Cosmetic Plastic Surgery Updates
Inferior Pedicle Autoaugmentation Mastopexy After Breast Implant Removal
Journal Aesthetic Plastic Surgery
Johannes Franz Hönig1, 2 , Hans Peter Frey3, Frank Michael Hasse1 and Jens Hasselberg1 21 February 2010 Abstract A new method of autoaugmentation mammaplasty is presented to correct ptosis and to increase the projection and volume of the breast in patients who would like a reposition augmentation mammaplasty after breast implant removal but do not want a new implant. Methods Between 1999 and 2007, a total of 27 patients (age = 54 ± 7.3 years) underwent mammaplasty using an inferior-based flap of deepithelialized subcutaneous and breast tissue modularized to its pedicle which was inserted beneath a superior pedicle used for correction of ptosis and to increase the projection and apparent volume of the breast. Results The results confirmed that autoaugmentation mammaplasty of the breast following removal of the implant yields longstanding results. It corrects ptosis and increases the projection and apparent volume of the breast when mastopexy is planned without use of a new implant. Twelve months after surgery the degree of descent of the inframammary fold generally parallels that of the nipple. The mean level of the inframammary fold was below the mean level of the nipple. Postoperatively, the optimum distance had been largely achieved. Conclusion The advantages of the technique presented here are that it minimizes the skin scar in cases using vertical mammaplasty techniques and optimizes the breast shape after breast implant removal in patients who do not want a new implant. Keywords Capsular contracture - Breast implant - Autoaugmentation mammaplasty - Mastopexy Note: I have done a number of implant removals with mastopexy performed at the same time. There are many patients who look fine after removal without implants. Sometimes people gain weight, get pregnant, or hormonally change resulting in larger breasts then anticipated. Perky breasts are routinely achieved with breast lift or mastopexy. Larry Weinstein.MD FACS www.docweinstein.com www.drlarryweinstein.com
Fleur-de-lis Abdominoplasty: A Safe Alternative to Traditional Abdominoplasty for the Massive Weight Loss Patient
Friedman, Tali MD,MHA; Coon, Devin MD; Michaels, Joseph V. MD; Purnell, Chad BS; Hur, Seung BA; Harris, Diamond N BS; Rubin, J. Peter MD
Background: Traditional abdominoplasty techniques often fail to adequately correct the complex contour deformities in the massive weight loss (MWL) patient. To correct these deformities, addition of a vertical skin resection to the traditional horizontal excision has become a popular procedure. We analyzed the impact of vertical (fleur-de-lis) excision on complications when compared to traditional transverse excision.
Methods: A review of MWL patients enrolled in an IRB-approved prospective registry was performed on consecutive patients undergoing abdominoplasty by a single surgeon. Patients were included if they underwent at least 50 lbs of weight loss. Demographic, procedural data and outcome measures were studied. Logistic regression and t-tests were performed to analyze differences in complication rates for both procedures and identify risk factors for complications.
Results: Four hundred ninety nine patients met inclusion criteria, of whom 154 (31%) had a fleur-de-lis (FDL) vertical component. The overall abdominal complication rate for all patients was 26.3% with a 5.6% rate of major complications. Transverse-only and FDL abdominoplasty had similar rates of complications with the exception of a higher rate of wound infection in the FDL group on multivariate analysis. Risk factors for abdominal wound complications with either procedure included male gender, seroma, high BMI, concurrent component separation and previous subcostal scars.
Conclusion: FDL abdominoplasty can be safely performed with complication rates comparable to traditional abdominoplasty techniques. Ideal candidates are patients with upper abdominal skin laxity who may not achieve an adequate aesthetic result with transverse-only excision. Note: In my website at www.drlarryweinstein.com I have several examples of patients who have had just lower abdominal incisions for tummy tuck. However there are a select group of patients who need the fleur de lis incision to control the extra skin or relieve tension on the lower abdominal wound. Larry Weinstein, MD FACS (C)2010American Society of Plastic Surgeons
Subfascial Breast Augmentation: A Comprehensive Experience
Aesthetic Plastic Surgery, 02/11/10 Joseph P. Hunstad1 and L. Shayne Webb2
Background Subfascial breast augmentation, first performed in 1998, places the implant above the pectoralis muscle but below the pectoralis fascia. Graf documented that this approach resulted in less capsular contracture than subglandular implant placement and a more natural shape while eliminating implant animation with arm movement. In addition, implant edge visibility was decreased compared with subglandular implantation in all but the extremely thin patient. Because of the described benefits and high patient satisfaction, the authors began to perform this technique in 2006.
Methods This report presents a comprehensive review of the aforementioned technique by describing a large series of subfascial augmentations (inframammary, periareolar, and endoscopic transaxillary) as primary procedures, secondary procedures, and operations with concurrent use of mastopexy performed by a single surgeon using multiple approaches. A patient satisfaction questionnaire was used in addition to a detailed clinical assessment.
Results The results of this procedure were reproducible, controllable, and predictable. The study demonstrated a high degree of patient and surgeon satisfaction with few complications, a low rate of capsular contracture, no evidence of breast animation with arm movement, excellent lower pole coverage, and a brief recovery period.
Conclusions Subfascial breast augmentation is a safe, effective procedure allowing for predictable results with excellent shape and longevity. For the properly selected patient, this approach provides the benefits of subglandular and submuscular placement without the disadvantages associated with each. Keywords Breast augmentation - Implant - Subfascial Note: I have used this technique many times for small breast augmentations it is good alternative. The results fail to show adequate cleavage, the implants are centered on the nipple and have more of an axillary placement then most patients desire. www.drlarryweinstein.com www.docweinstein.com Larry Weinstein, MD FACS
Malposition Implant treated with capsular Flap
Gyeol Yoo1 and Paik-Kwon Lee2
(1) Department of Plastic Surgery, College of Medicine, The Catholic
University of Korea, # Yeouido-dong, Yeoungdeungpo-gu, Seoul, Korea
31 December 2009
Abstract Among the reasons for reoperation after augmentation mammaplasty is the malpositioned implant, especially a lowered inframammary fold or symmastia, which is difficult to repair. The peri-implant capsule, a physiologic response to a foreign body, is naturally formed and suitable for use as a flap because of its high vascularity. In addition, it is sufficiently tough for suspension of the implant. The authors introduce the idea that the capsular flap is very useful for the correction of symmastia or a lowered inframammary fold. In such situations, the capsular flaps are used to prevent migration of the implant after raising of the inframammary fold or defining of the midline with capsulorrhaphy. This technique successfully corrected the malpositioned implants in this study, and all the patients were satisfied. There was no recurrence of a lowered inframammary fold or symmastia. These findings suggest that the capsular flap should be considered an option for the management of malpositioned implants.
Keywords Breast augmentation - Capsular flap - Implant malposition
Note: Implant malposition can often be treated with external manipulations and bandages. On a rare occasion is the surgical option needed. Capsulorraphy or adjusting the capsule with Contour thread sutures is a quick effective method of controling lateralization or double bubble problems. Flaps are an alternative for the tougher cases.
Larry Weinstein,MD FACS www.drlarryweinstein.com
Management of Mons Pubis and Labia Majora in the Massive Weight Loss Patient
Gary J. Alter MD
The high incidence of female obesity and weight loss has resulted in common complaints of a large, protuberant mons pubis and labia majora (outer labial lips) related to unsightly fat deposits and skin ptosis. The author presents a technique to correct the protuberant mons and pubic descent by performing a pubic lift, fat excision, and liposuction, and then tacking the superficial fibrofatty tissue to the rectus fascia. The labia majora enlargement is treated by fat excision and/or liposuction and skin excision. These techniques eliminate difficulties with sexual intercourse, poor hygiene, and discomfort, while also improving self-esteem. (Aesthet Surg J;29:432-442) Note: Most often I treat these problems at the same time as an extended abdominoplasty. A proper abdominoplasty addresses this issue but can be dealt with at a secondary procedure. Dr. Larry Weinstein www.docweinstein.com www.drlarryweinstein.com
Combination Hand Rejuvenation Procedures
Ava T. Shamban, MD1 Accepted 22 May 2009. Although the hands age at the same rate as the face, the aging process differs and requires a combination treatment approach for optimal rejuvenation. Photoaging causes epidermal changes such as lentigines, actinic keratoses, fine wrinkles, and crepe-like textural change. Thinning of the dermis and subcutaneous fat occurs as a result of both ultraviolet light exposure and intrinsic aging. This process can lead to a skeletal appearance of the hands, with prominent veins and bulging tendons. The combination approach addresses all of these issues, employing lasers, intense pulsed light devices, fractional devices, fillers, peels, vein sclerotherapy, and an effective at-home skin care program as indicated for individual needs and concerns.
Note; Hand Rejeuvenation is a procedure I have done for years with LASER with very good results
Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 919-925
doi: 10.1097/PRS.0b013e3181b0389e Cosmetic: Original Articles
Local Complications after Cosmetic Breast Augmentation: Results from the Danish Registry for Plastic Surgery of the Breast
Hvilsom, Gitte B. M.D.; Hölmich, Lisbet R. M.D., D.M.Sc.; Henriksen, Trine F. M.D., Ph.D.; Lipworth, Loren Sc.D.; McLaughlin, Joseph K. Ph.D.; Friis, Søren M.D.
Background: Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially.
Methods: The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/displacement of the implant, hematoma, and infection.
Results: During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant.
Conclusions: Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up.
Note: Incidence of complications with Dr. Weinstein is less. Hematoma 0.02%, none requiring surgery. Reoperation rate is less than 1% per year. www.docweinstein.com www.drlarryweinstein.com <http://www.drlarryweinstein.com> Larry Weinstein, MD FACS
Plastic and Reconstructive Surgery:
October 2009 - Volume 124 - Issue 4 - pp 1304-1311
doi: 10.1097/PRS.0b013e3181b455d0 Cosmetic: Original Articles
Intraoperative Use Bupivacaine for Tumescent Liposuction Failey, Colin L. M.D.; Vemula, Rahul M.D.; B, Gregory L. M.D.; Hsia, Henry C. M.D.
Background: Bupivacaine anesthetic is commonly used as a wetting solution additive in tumescent liposuction, but its routine use remains controversial because of a lack of evidence in the current literature.
Methods: In accordance with local institutional review board regulations, a retrospective chart review was conducted of liposuction cases performed from 1997 to 2007 at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. The primary endpoint was adverse perioperative events. Secondary endpoints included length of postanesthesia care unit stay and length of total postoperative hospital stay.
Results: Eighty-seven cases were analyzed and two subsets of patients were identified. In group 1, 24 patients were compared who underwent liposuction as the primary procedure and received bupivacaine, lidocaine, or no additive in their wetting solution. No adverse events were encountered and the average length of stay was not significantly different. In group 2, 20 patients were compared who underwent abdominoplasty and liposuction and received bupivacaine or no additive in their wetting solution. No adverse events occurred and patients receiving bupivacaine had a significantly shorter average length of stay, 19 hours versus 36 hours, compared with controls (p = 0.015).
Conclusions: A review of the experience at Robert Wood Johnson University Hospital reveals that the intraoperative use of bupivacaine for tumescent liposuction in 27 cases appeared to be as safe as other tumescent additives. There did not appear to be a significant difference in the incidence of adverse events or postoperative length of stay for patients who underwent liposuction with bupivacaine compared with other wetting solutions. Among a subset of patients who underwent concurrent abdominoplasty and liposuction procedures, patients who received bupivacaine spent significantly less time in the hospital postoperatively than those who did not receive it. Conducting future prospective studies involving larger samples among multiple centers is an essential next step to confirm these findings.
Note: I have been using Bupivicaine a longer acting anesthetic for 20 years with minimal pain for most patients postoperatively. Larry Weinstein, MD FACS www.docweinstein.com <http://www.docweinstein.com> www.drlarryweinstein.com <http://www.drlarryweinstein.com>
Plastic and Reconstructive Surgery:
October 2009 - Volume 124 - Issue 4 - pp 1285-1293
doi: 10.1097/PRS.0b013e3181b455b Cosmetic: Original Articles
Lateral Orbicularis Oculi Muscle Plasty in Conjunction with Face Lifting for Periorbital Rejuvenation Cabbabe, Samer W. M.D.; Andrades, Patricio M.D.; Vasconez, L, O. M.D.
Background: The purpose of this study was to evaluate the lateral orbicularis oculi muscle plasty as an alternative periorbital rejuvenation technique during face lift.
Methods: The authors conducted a retrospective review of patients who underwent face lifts between 2004 and 2007. Postoperative follow-up, complications, aesthetic outcome, and patient satisfaction were recorded. The patients were further divided into four groups for the analysis: lateral orbicularis oculi muscle plasty with lower blepharoplasty (group 1), lower blepharoplasty without lateral orbicularis oculi muscle plasty (group 2), lateral orbicularis oculi muscle plasty without lower blepharoplasty (group 3), and neither lateral orbicularis oculi muscle plasty nor lower blepharoplasty (group 4).
Results: A total of 76 patients were identified as having had a midface lift with or without lateral orbicularis oculi muscle plasty in the study period. Sixty-eight percent of the patients had a lateral orbicularis oculi muscle plasty procedure. Group 3 showed the lowest complication rate followed by group 4, but there were no statistical differences in complication rates among the study groups. The higher aesthetic result and patient satisfaction were obtained by groups 3 and 4 (p < 0.01). Group 2 had the highest complication rate and lowest overall outcomes.
Conclusion: The authors have been able to demonstrate that lateral orbicularis oculi muscle plasty is a safe technique that may be considered a good alternative for periorbital rejuvenation and may help in avoiding lower lid incisions or extensive dissections during face lifting in some cases.
Note: I have been using a lateral suspension procedure for many years, patient outcomes have been very acceptable. Larry Weinstein, MD FACS www.docweinstein.com <http://www.docweinstein.com/> www.drlarryweinstein.com <http://www.drlarryweinstein.com/>
Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 722-736
doi: 10.1097/PRS.0b013e3181b179d2
Breast: Special Topics
Partial Breast Reconstruction: Current Perspectives
Losken, Albert M.D.; Hamdi, Moustapha M.D., Ph.D.
Summary: The popularity of breast conservation therapy for the management of women with breast cancer continues to rise. To preserve cosmesis or broaden the indications for breast conservation therapy in some situations, plastic surgeons are now being challenged with the reconstruction of partial mastectomy defects. Numerous techniques exist, either at the time of resection or following radiation, and the decision of which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects in smaller breasts will often benefit from volume replacement techniques, such as local fasciocutaneous or myocutaneous flaps, without the need for a symmetry procedure. Women with moderate or larger breasts (with or without ptosis) and the potential for an unfavorable result also have the option for volume displacement procedures using local tissue rearrangement techniques to reshape the breast mound. As these are volume reduction procedures, they often require a contralateral procedure for symmetry. The extent of resection (lumpectomy versus quandantectomy) will also influence the type of reconstruction. Patient selection, surgical technique, margin status, and appropriate follow-up are crucial to maximize both oncological safety and cosmesis. The reconstruction of partial mastectomy defects will likely gain popularity as we continue to demonstrate safe and effective treatment algorithms with larger series and longer follow-up in an attempt to minimize locoregional disease and maximize cosmetic outcome.
Note: I have been doing partial breast reconstructions for years using implants, fat injections, latissimus flaps and small TRAM flaps with acceptable results. I am not a puris, I will use what I feel is best for the patient be it implant or autologous tissue. Larry Weinstein, MD FACS Chester NJ USA
Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 826-835
doi: 10.1097/PRS.0b013e3181b03749
Reconstructive: Head and Neck: Original Articles
Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?
McCluskey, Paul D. M.D.; Constantine, Fadi C. M.D.; Thornton, James F. M.D.
Background: A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat.
Methods: The authors conducted a retrospective analysis of 55 consecutive patients who underwent reconstruction of lower third nasal defects with full-thickness skin grafts between 2002 and 2007 performed by the senior author (J.F.T.). All of the patients in this review underwent skin cancer ablation by means of Mohs' micrographic surgery.
Results: Good aesthetic results, based on preoperative and postoperative photographic analysis of contour and pigmentation, have been achieved in both the recipient and donor sites in 52 of 55 patients. Three patients, all of whom were smokers, experienced loss of the skin graft requiring alternative reconstructive techniques.
Conclusions: Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color.
Note: It is critical with grafts or flaps to get buy in from the patient to stop smoking. I have used full thickness skin grafts, alar wedge grafts, flaps, bone and cartilage grafts for nose reconstruction.
Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 926-933
doi: 10.1097/PRS.0b013e3181b03880
Cosmetic: Original Articles
National Bariatric Surgery and Massive Weight Loss Body Contouring Survey
Warner, Jeremy P. M.D.; Stacey, D Heath M.D.; Sillah, Nyama M. M.D.; Gould, Jon C. M.D.; Garren, Michael J. M.D.; Gutowski, Karol A. M.D.
Background: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons.
Methods: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed.
Results: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery.
Conclusions: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified.
Note: Abdominoplasty, buttock lifts, arm lifts, breast lifts and augmentation have all been used with some amazing results. Options should be offered to patients by competent plastic surgeons.
Plastic and Reconstructive Surgery:
August 2009 - Volume 124 - Issue 2 - pp 356-363
Breast: Original Articles
Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis: A 13-Year Experience Using Timed Excision with Continued Expansion
Antony, Anuja K. M.D.; Mehrara, Babak M. M.D.; McCarthy, Colleen M. M.D.; Zhong, Toni M.D.; Kropf, Nina M.D.; Disa, Joseph J. M.D.; Pusic, Andrea M.D.; Cordeiro, Peter G. M.D.
Background: Mastectomy flap necrosis after immediate tissue expander placement can have profound implications, resulting in prosthetic infection necessitating tissue expander removal. The purpose of this investigation was to evaluate the safety and efficacy of timed, surgical excision during continued serial expansion in the setting of mastectomy flap necrosis and to identify an algorithm for surgeons faced with the management of this difficult problem.
Methods: Consecutive patients in whom documented mastectomy flap necrosis developed following immediate tissue expander placement from 1995 to 2008 were identified. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database. Medical records were then retrospectively reviewed to further characterize the extent of mastectomy flap necrosis and its management.
Results: Over the 13-year study period, 178 patients with documented mastectomy flap necrosis following immediate tissue expander were identified. In 58 patients (33 percent), surgical excision of the mastectomy flap necrosis was performed. Surgical excision occurred a mean 36 days (range, 8 to 153 days) after tissue expander placement. Mean surface area of eschar excised was 42.5 cm 2 (range, 2.5 to 240 cm2). In nine (15.5 percent) of the 58 patients, resection of such an extensive area of mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure (local advancement flaps, n = 8; latissimus flap, n = 1). Of the remaining patients, only three (6 percent) developed a subsequent infection necessitating the premature removal of a tissue expander.
Conclusions: Timed excision with continued expansion is a straightforward procedure associated with a low incidence of failure. This approach allows for salvage of a significant percentage of threatened tissue expanders and may be coordinated with adjuvant oncologic therapy without excessive delays.
Plastic and Reconstructive Surgery:
July 2009 - Volume 124 - Issue 1 - pp 134-143
Reconstructive: Head and Neck: Original Articles
Liposuction and Lipoinjection Treatment for Congenital and Acquired Lipodystrophies in Children
Giugliano, Carlos M.D.; Benitez, Susana M.D.; Wisnia, Pamela M.D.; Sorolla, Juan Pablo M.D.; Acosta, Silvana M.D.; Andrades, Patricio M.D.
Background: The purpose of this clinical study was to establish liposuction and lipoinjection as a noncosmetic procedure in children to correct lipodystrophies.
Methods: Liposuction, fat injection, or a combination of both was performed on 30 patients between 1994 and 2006 at Roberto del Rio Hospital or Clinica Alemana, Santiago, Chile. Liposuction was indicated in patients with excessive amounts of fatty tissue or tumor-like swelling. Combined liposuction and lipoinjection was performed on patients with deficit and excess in soft tissues. Lipoinjection was used for patients with soft-tissue insufficiencies. Samples of fat obtained by liposuction were submitted to histopathologic examination. Traditional tumescent technique was used for liposuction. The supernatant obtained by simple filtration was used for fat injection. Short- and long-term postoperative follow-up included registration of complications and assessment of aesthetic and functional outcome. The kappa test was used for statistical analysis.
Results: Thirty patients, nine boys and 21 girls, were operated on, with an average age of 11 years (range, 4 to 17 years). A total of 43 procedures were performed: 27 liposuctions, 10 lipoinjections, and six combined procedures. Average hospital stay was 1.1 days. Of a total 20 patients who underwent liposuction, six required revision. Histopathologic study showed 19 lipomatoses and one lipoblastomatosis. Cosmetic outcomes based on Strasser scale were as follows: six excellent, 19 good, four mediocre, and one poor.
Conclusions: Liposuction and lipoinjection as sole or combined procedures are safe methods for the pediatric population. They are well tolerated, with a low rate of complications and satisfactory aesthetic results.
Shaping the Breast in Aesthetic and Reconstructive Breast Surgery: An Easy Three-Step Principle. Part III-Reconstruction following Breast Conservative Treatment
Hijjawi, John; Depypere, Herman; Roche, Nathalie; Van Landuyt, Koenraad; Blondeel, Phillip N.
Plastic and Reconstructive Surgery. 124(1):28-38, July 2009.
Summary: Of the relatively few studies that exist regarding the cosmetic satisfaction of patients following breast conservation therapy, several indicate significant dissatisfaction in many patients. Breast conservation often results in some of the most challenging and complex reconstructive problems. Indeed, even defining the problem or analyzing the defect can be difficult for the junior surgeon. For the more seasoned reconstructive surgeon, analyzing the problem and applying solutions may be less difficult, but clearly communicating the defects typically seen after an aggressive lumpectomy and radiotherapy can be difficult, especially with trainees or junior surgeons. The goal of this article, the third in a four-part series, is to provide a template for the analysis and surgical reconstruction of defects resulting from breast conservation therapy utilizing a systematic three-step method. Part I of this series described the three main anatomical features of the breast-the footprint, the conus of the breast, and the skin envelope-and how they interact. By systematically analyzing the breast with this three-step method, a "problem list" based in specific anatomic traits of the breast can be generated, allowing the surgeon to then generate an appropriate surgical plan for reconstruction. Surgical approaches based on the percentage of breast parenchyma resected are suggested, with a focus on glandular rearrangement, breast reduction techniques, and locoregional flaps. The three-step method of breast analysis, evaluating the anatomical deformation of the breast footprint, conus, and skin envelope, remains the fundamental "fall-back" principle of this approach.
(C)2009American Society of Plastic Surgeons
The Impact of Partial Breast Reconstruction Using Reduction Techniques on Postoperative Cancer Surveillance
Losken, Albert; Schaefer, Timothy G.; Newell, Mary; Styblo, Toncred M.
Plastic and Reconstructive Surgery. 124(1):9-17, July 2009.
Abstract:
Background: Partial breast reconstruction using reduction techniques has recently increased in popularity. Some fear that combining breast conservation therapy with partial breast reconstruction alters the architecture and will affect patterns of local recurrence and make postoperative cancer surveillance more difficult. The purpose of this series was to evaluate long-term postoperative cancer surveillance.
Methods: The authors retrospectively reviewed the charts and mammograms of patients (n = 17; average follow-up, 6.3 years) who underwent the oncoplastic reduction technique before 2004. Mammography sensitivity was determined by measuring breast density, qualitative changes, and time until mammographic stabilization was determined. These data were compared with those of a control group from the same time period who underwent breast conservation therapy alone (n = 17; average follow-up, 5.9 years).
Results: Typical mammographic findings, including architectural distortion, cysts, and calcifications, were similar between the two groups. There was no significant difference in breast density scores. The oncoplastic reduction group had longer times to mammographic stabilization (21.2 versus 25.6 months, p = 0.23). There was a trend toward a greater number of postoperative mammograms and ultrasounds in the study group when indexed per follow-up year. The rate of tissue sampling in the study group was significantly higher (53 percent) than that in the control group (18 percent).
Conclusions: The oncoplastic reduction technique remains safe and effective, without significantly affecting postoperative surveillance. Mammographic findings were similar to those observed in patients with breast conservation therapy alone, and sensitivity was not affected. It takes longer to achieve mammographic stability and more patients in the oncoplastic group will require additional diagnostic testing.
(C)2009American Society of Plastic Surgeons
SURVEY REVEALS INJECTABLE PROCEDURES ARE MAINSTREAM AND ACCEPTED MEDICAL AESTHETIC TREATMENT OPTIONS
Survey Shows Majority of Respondents Openly Discuss Use of BOTOX® Cosmetic and Hyaluronic Acid Dermal Fillers
NEW YORK, NY (June 1, 2009) — Despite what some may think, people aren’t hiding their use of BOTOX® Cosmetic and hyaluronic acid dermal fillers. In fact, according to survey statistics released today by The Aesthetic Surgery Education & Research Foundation (ASERF), the research arm of the American Society for Aesthetic Plastic Surgery (ASAPS), nearly nine out of 10 respondents (87 percent) openly discuss their BOTOX® Cosmetic and hyaluronic acid dermal filler treatments with others, with seven out of ten (70 percent) receiving support from the people they told.
“In a similar survey issued four years ago, we dispelled the myth that Hollywood and corporate wives were the typical BOTOX® Cosmetic patient,” says ASERF President Laurie Casas, MD, a plastic surgeon practicing in suburban Chicago. “Now, demographic and perception data trends show us that aesthetic injectable treatments have continued to evolve into mainstream and accepted options for the everyday woman.”
Survey results found that the typical aesthetic injectable patient is a married, working mother between 41-55 years of age with a household income of under $100,000. The survey also found that women receiving aesthetic injectable treatments are health-conscious and philanthropy minded, with the majority incorporating exercise (95 percent) and healthy eating habits (78 percent) into their lives, and many volunteering with charitable organizations that matter to them (32 percent). In addition, nearly seven out of 10 respondents believe that BOTOX® Cosmetic (72 percent) and hyaluronic acid dermal fillers (65 percent) are important parts of their aesthetic routine.
“Interestingly, among BOTOX® Cosmetic patients, nearly seven out of 10 respondents also received treatment with hyaluronic acid fillers,” says Dr. Casas. “Most people have great success with BOTOX® Cosmetic and dermal fillers; however, we need to make patients aware that even though injectables are not ‘surgery,’ their administration is a medical procedure with risks that depend on the training and experience of the clinician, the clinical setting and the technique used.”
Additional findings of the survey found that 72 percent of respondents received BOTOX® Cosmetic injections to treat their glabellar lines – also referred to the “11” – the frown lines in between the brows, while 63 percent of those surveyed received hyaluronic acid dermal filler injections to treat their nasolabial folds – also known as the “parentheses” – the lines around the nose and mouth. A few of the most frequently cited reasons to receive treatment with BOTOX® Cosmetic was “to look more relaxed, less stressed” while patients reported choosing treatment with hyaluronic acid dermal fillers to “look more rejuvenated.”
Based on its annual survey of U.S. physicians performing cosmetic procedures, ASAPS recently reported that BOTOX® Cosmetic injections have remained the most frequently performed procedure since FDA approval of the product in 2002. Hyaluronic acid dermal fillers ranked as the third most popular procedure performed last year. ASERF conducted this follow-up survey to quantify the characteristics and opinions of the patients who receive the treatment to help its members and the public obtain a better understanding of these important modalities.
Survey Methodology
To conduct this survey, ASERF, the charitable, not-for-profit research arm of American Society for Aesthetic Plastic Surgery (ASAPS), retained the services of Industry Insights, Inc. an independent research and consulting firm headquartered in Columbus, Ohio.
In March 2009, a two-page questionnaire, designed by ASERF in conjunction with Industry Insights, was distributed to 1,818 ASAPS members to distribute to their BOTOX® Cosmetic and/or hyaluronic acid dermal filler patients. A total of 687 completed and useable forms were received in time for processing and analysis. Based on 687 presumably random responses, this study has a +/- 3.7% margin of error at a 95% level of confidence. A margin of error of +/- 5% is typically accepted as the “standard” in association research, so this study’s +/-3.7% figure indicates a stronger than typical level of statistical integrity.
Abdominoplasty with Direct Resection of Deep Fat.
COSMETIC Plastic & Reconstructive Surgery. 123(5):1597-1603, May 2009.
Brink, Robert R. M.D.; Beck, Joel B. M.D.; Anderson, Catherine Michelle; Lewis, Anne Christine
Abstract:
Background: Suction-assisted lipectomy is an integral component of abdominoplasty for many surgeons. Its potential to affect the vascularity of the abdominal flap is usually offset by limiting the extent of undermining and not suctioning the central flap. The authors address whether these guidelines apply to direct excision of subscarpal fat and whether direct excision provides aesthetically superior abdominoplasty results with fewer complications.
Methods: A 10-year review of consecutive abdominoplasty patients (n = 181) was conducted. Undermining was done to the xyphoid and just beyond the lower rib margins superiorly and at least as far as the anterior axillary line laterally. Fat deep to Scarpa's fascia was removed by tangential excision in all zones of the abdominal flap, including those considered at high risk for vascular compromise if subjected to liposuction after similar undermining. Concurrent liposuction of the abdominal flap was not done. Thirty patients had concurrent flank liposuction. Results: No patients experienced major full-thickness tissue loss. The incidence of limited necrosis at the incision line requiring subsequent scar revision was 0.7 percent in the 151 patients having abdominoplasty and 6.7 percent in the 30 patients having abdominoplasty combined with flank liposuction. Erythema and/or epidermolysis was seen in 4.8 percent of the abdominoplasty patients and 10 percent of the abdominoplasty/ flank liposuction group. The rate of seroma formation in both groups was approximately 16.5 percent. Conclusions: Direct excision of subscarpal fat does not subject any zone of the abdominoplasty flap to increased risks of vascular compromise. It is a safe technique that provides excellent abdominoplasty results. (C)2009American Society of Plastic Surgeons Note : I have been perforrming tummy tuck with liposuction and or direct resection of fat for years with minimal complications.Dr. Larry Weinstein Chester, NJ, USA
Satisfaction with and psychological impact of immediate and deferred breast reconstruction
J. Fernández-Delgado1, M. J. López-Pedraza2, J. A. Blasco2, E. Andradas-Aragones3, J. I. Sánchez-Méndez4, G. Sordo-Miralles1 and M. M. Reza2,* Background: The present work assesses the effect of immediate breast reconstruction (IBR), deferred breast reconstruction (DBR), and no breast reconstruction on the psychological impact. Patients and methods: Standard questionnaires were used to determine the psychological impact suffered by patients who underwent IBR, DBR and no reconstruction, their degree of satisfaction with the results achieved, and their postprocedure opinions regarding reconstruction options. Results: A total of 526 women underwent mastectomy. The response rate to the questionnaires was 71.67%. A significantly greater proportion of the women who underwent no reconstruction suffered psychological problems than those who underwent reconstruction of some type (P = 0.01). Some 94.77% of the women who underwent IBR maintained a postprocedure preference for this option; in contrast, some 87.27% of the DBR and 56.14% of the no-reconstruction patients declared a postprocedure preference for IBR. In all, 63.49% of the women who underwent reconstruction were moderately very satisfied with the aesthetic results achieved, while only 22.80% of the no-reconstruction patients declared such satisfaction (P = 0.0001). Conclusions: The women who underwent no breast reconstruction suffered more emotional problems than those who underwent a reconstruction procedure. In general, all groups reported a postprocedure preference for IBR in their questionnaire answers. The aesthetic results achieved by IBR seem to be those best accepted. Key words: breast neoplasm, breast/surgery, mammaplasty, mastectomy, patient satisfaction, plastic surgery
Note: Since my Sloan Kettering New York New York days I have been acutely aware of the need for breast reconstruction in the breast cancer patient. The job is not finished until the patient is satisfied. Larry Weinstein, MD FACS Chester New Jersey. www.docweinstein.com
Correction for the Iatrogenic Form of Banana Fold and Sensuous Triangle Deformity
Aesthetic Plastic Surgery, 07/31/08 Luiz Haroldo Pereira1 and Aris Sterodimas
Abstract
The “banana fold,” or the infragluteal fold, is a fat deposit on the posterior thigh near the gluteal crease and parallel to it. The “sensuous triangle” is found at the junction of the lateral buttocks, the lateral thigh, and the posterior thigh. The iatrogenic forms of banana fold and sensuous triangle deformity are produced by excessive liposuction. The authors’ experience using autologous fat transplantation to treat tissue defects led them to use this technique for correcting iatrogenic forms of banana fold and sensuous triangle deformity. The simplicity of the procedure, the low incidence of complications, and the high satisfaction rate makes autologous fat transplantation an attractive option for correcting iatrogenic complications of liposuction.
Liposuction - Banana fold - Sensuous triangle deformity - Fat transplantation Note: Indentation deformities, wavy skin, and indented areas can be treated under local anesthesia with a tiny incision to release them with a forked cannula. Fat deposition is sometimes helpful for this rarly seen problem in the USA. Larry Weinstein MD FACS Chester New Jersey USA www.drlarryweinstein.com www.docweinstein.com
Abdonminoplasty tummy tuck Panniculectomy Annals of Plastic Surgery. 61(2):188-196, August 2008. Cooper, Joshua M. MD *; Paige, Keith T. MD, FACS +; Beshlian, Kevin M. MD, FACS +; Downey, Daniel L. MD, FACS +; Thirlby, Richard C. MD, FACS
Abstract:
Background: We reviewed our experience with 3 operative techniques for abdominal panniculectomies to determine differences in complication rates and levels of patient satisfaction. Methods: This retrospective study included 92 consecutive patients who underwent abdominal panniculectomies over a 9-year period. Patients underwent one of 3 panniculectomy techniques: fleur-de-lis (n = 25), transverse incisions with minimal undermining (n = 30), or transverse incisions with extensive undermining (n = 37). Postoperatively, patient satisfaction surveys were completed. Results: Median pannus weight was 4.4 kg (range, 1.6-20.5). Sixty-eight patients (73.9%) had a previous gastric bypass. Median body mass index (BMI) was 38 kg/m2 (range, 22-66.9). Median follow-up for complications was 8.1 week (range, 1-235). Forty of 92 patients (43%) suffered wound complications. The reoperation rate was 13%. Postoperative complication rates were higher among hypertensive patients (61% vs. 36%; P = 0.04). There was a trend towards increased complications among those with higher BMI and pannus weights. There was not a significant relationship between operative technique and overall complication rate. Mean length of follow-up for patient questionnaire completion was 2 years, 11 months (range, 1-9 years). Eighty-one percent of those responding to the mailed questionnaire were satisfied with their operative results. There were no statistically significant differences between the technique used and patient satisfaction level. Concomitant hernia repair was performed in 47% of patients without increased wound complications. Conclusions: Patients were satisfied with the results of their panniculectomy, although complications were common. Higher BMI, larger pannus size, and hypertension were correlated with increased complication rates. The minimal undermining, extensive undermining, and the fleur-de-lis panniculectomy techniques result in similar patient satisfaction rates and complication rates.
Note: High satisfaction rate is the rule in my experience, the heavier the patient the rougher the recovery. Larry Weinstein MD FACS Chester New Jersey www.docweinstein.com
The Anatomic Replication Technique (ART): A New Approach in Saddle Nose Correction. Annals of Plastic Surgery. 61(2):169-177, August 2008. Mutaf, Mehmet MD
Abstract:
Correction of major saddle nose deformities is one of the greatest challenges in nasal surgery. Here, a new approach for the correction of major saddle nose deformities in which the missing parts of the nasal skeleton are replaced with their anatomic replicas sculptured from an autogenous osteocartilagineous rib graft is presented. Since 1998, this new technique has been used in 17 patients (11 females and 6 males) with major saddle nose deformities. The age range was between 19 and 37 years. The etiology of saddle nose deformity was iatrogenic in 11 and traumatic in 2 patients. In the remaining 4 patients, saddle nose was a part of ethnic facial features. During a mean follow-up of 2 years, the sculptured nasal frame maintained its form and resistance. There was no patient with recurrent nasal collapse or airway obstruction. The nasal tip was naturally mobile in all patients. Replacing the missing parts of the nasal skeleton with their anatomic replicas created from autogenous tissues, this new technique restores all anatomic and functional features of the nose. It efficiently corrects saddle nose deformity and eliminates associated functional deficiencies.
Note: I have had extensive experience with saddle nose reconstruction using cranial bone graft and ear cartilage with excellent results for traumatic, congenital and iatrogenic nose reconstruction.
Larry Weinstein, MD FACS Chester New Jersey www.docweinstein.com www.drlarryweinstein.com
Aesthetic Plastic Surgery, 07/28/08 Patrick P. G. M. Rooijens1 
, Hans-Peter Zweep2 and Werner H. Beekman2 Background Many techniques have been introduced for the surgical treatment of the aging neck. In this study the combination therapy of ultrasound-assisted liposuction and limited-incision platysmaplasty for cervicofacial rejuvenation is presented.
Methods Fifteen female patients (age = 43–75 years) were treated for grade II–III (n = 2), III (n = 6), and grade IV (n = 7) cervicomental angle deformity. The outcome of surgery was retrospectively evaluated by a panel.
Results Ultrasonic energy was applied for an average of 2 min (range = 45 s–6.5 min). The mean aspiration volume was 125 ml. No immediate or delayed adjuvant skin reduction was needed in any of the patients. No complications were encountered in this series. After treatment significant improvement of the cervicomental angle was observed.
Conclusion For treatment of all grades of the aging neck we advocate the combination of UAL and limited-incision platysmaplasty. This combination therapy has little morbidity and leads uniformly to significant improvement of the cervicomental angle.
Keywords Aging neck - Liposuction - Ultrasonic - Platysmaplasy
Note: Limited procedures on the neck will give limited results and less likely to give long term results. We have the ultrasonic liposuction machine available at Morristown Memorial in Morristown New Jersey. I have performed multiple fat reductions of fatty necks with excellent results in younger patients. However in older patients a facelift necklift or string suspension is often necessary for optimal results. Larry Weinstein, MD FACS Chester, New Jersey www.drlarryweinstein.com www.docweinstein.com
Outcomes After Breast Reduction: Does Size Really Matter?
Annals of Plastic Surgery. 60(5):505-509, May 2008.
Spector, Jason A. MD *; Singh, Sunil P. BA +; Karp, Nolan S. MD ++
Abstract:
There is no doubt that reduction mammoplasty (RM) results in significant improvement in a myriad of patient macromastia-related symptoms and other macromastia-related quality of life factors. Whether this improvement is correlated with the amount of tissue resected remains unknown because no previous study of RM has stratified patients by the amount of breast tissue resected. In this study, all patients were given a custom-designed questionnaire designed to evaluate their macromastia-related symptoms and other macromastia-related quality of life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery. A total of 188 patients completed pre- and postoperative surveys. Before the initiation of this study, patients were stratified by the total weight of breast tissue resected into the following cohorts: 1000 g or less (66 patients), 1001 to 1500 g (55 patients), 1501 to 2000 g (30 patients), and greater than 2000 g (37 patients). RM resulted in significant improvement in all macromastia-related symptoms and quality of life factors analyzed (P < 0.000001). There were no significant differences (P > 0.05) in pre- and postoperative macromastia-related symptoms across our 4 groups with the exception of lower back pain (preoperative P = 0.026), shoulder pain (preoperative P = 0.014), and painful bra strap grooves (preoperative P = 0.0059). Analysis of the symptomatic burden of macromastia on several quality of life factors showed no significant differences (P > 0.05) in either the pre- or postoperative symptom scores across all groups in any of the categories assessed. This study demonstrates that women seeking breast reduction have a similar preoperative symptom burden across a wide range of breast sizes. Furthermore, the symptomatic improvement derived from RM is not significantly different between women of different breast sizes.
Improving Esthetics and Safety in Abdominoplasty With Broad Lateral Subcostal Perforator Preservation and Contouring With Liposuction.
Annals of Plastic Surgery. 60(5):491-497, May 2008.
Kolker, Adam R. MD, FACS
Abstract:
Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.
Should a Panniculectomy/Abdominoplasty After Massive Weight Loss Be Covered by Insurance?
Annals of Plastic Surgery. 60(5):502-504, May 2008.
Sati, Shawkat MD; Pandya, Sonal MD
Abstract:
Body contouring after massive weight loss (MWL) is a rapidly growing area in Plastic Surgery. Panniculectomy/abdominoplasty is primarily a cosmetic procedure with some functional benefits (a large pannus may hamper mobility, prevent further weight loss, and cause recurrent skin infections) and hence many insurance companies are changing their guidelines to include this as a medical procedure. This study assesses reimbursements for a large academic institution in Massachusetts for panniculectomies/abdominoplasties performed in MWL patients. We performed a retrospective review of charges and reimbursements for panniculectomy/abdominoplasty in MWL patients performed at Lahey Clinic. Records for patients who underwent a "medical" panniculectomy by a single surgeon from August 2002 to August 2006 were reviewed with special emphasis on the charges, reimbursements, insurance carriers, and prior preauthorizations. Fifty-two patients underwent a medical panniculetomy/abdominoplasty (Current Procedural Terminology code 15831) for laxity of skin/pannus as a result of MWL. All patients except Medicare required and obtained precertification for the procedure. Patient ages ranged from 35 to 59 years, which included 42 females and 10 males (n = 52). Forty-three underwent bariatric surgery; their procedures were performed between 13 and 62 months after their initial surgery. Weight loss ranged from 65 to 345 pounds. Body mass index at the time of the surgery ranged from 22 to 48. The standard surgical charge for a medical panniculectomy at Lahey Clinic is $3,086. The range of reimbursements was zero to the full amount with the mean reimbursement of $615 and the median being $899. Reimbursements for panniculectomies are remarkably low and in many instances (35% in our series) absent despite obtaining prior precertification of medical necessity. Although insurance companies have extended their indications for panniculectomy/abdominoplasty, we think that it is a cosmetic procedure. Plastic surgeons must bear these reimbursements in mind when faced with a patient requesting this. (C) 2008 Lippincott Williams & Wilkins, Inc.
Power of the Pinch: Pinch Lower Lid Blepharoplasty.
Annals of Plastic Surgery. 60(5):532-537, May 2008.
Kim, Elizabeth M. MD; Bucky, Louis P. MD, FACS
Abstract:
Lower lid blepharoplasty is performed with great variation in technique. Conventional lower lid blepharoplasty with anterior fat removal via the orbital septum has a potential lower lid malposition rate of 15% to 20%. Lower lid malposition and the stigma of obvious lower lid surgery have led plastic surgeons to continue to change their approach to lower lid rejuvenation. In recent years, some surgeons have come to rely on alternative procedures like laser resurfacing alone or in conjunction with transconjunctival fat removal and canthopexy in an effort to avoid such complications. The pinch blepharoplasty technique removes redundant skin without undermining. This allows for more controlled wound healing, predictable recovery, and potential for simultaneous laser resurfacing. The combination of pinch blepharoplasty with transconjunctival fat removal leaves the middle lamella intact and reduces the chance of scleral show or ectropion. The p