Cosmetic Plastic Surgery Updates
"Immediate Breast Reconstruction with Implants After Skin-Sparing Mastectomy: A Report of 96 Cases"
Aesthetic Plastic Surgery, 05/19/10 Fa-Cheng Li1 , Hong-Chuan Jiang2 and Jie Li2
Abstract
Background: Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has become increasingly popular as an effective treatment for patients with early-stage breast cancer requiring mastectomy. This study aimed to evaluate the clinical outcomes of IBR using permanent gel breast implants and Becker expandable breast implants after SSM.
Methods: A review of 96 patients undergoing IBR with Beck expandable or permanent gel breast implants after SSM from July 2002 to December 2006 was performed. Of the 96 patients, 30 had IBR after SSM with conservation of the nipple–areola complex (NAC). The mean patient age was 42 years (range, 29–57 years). Aesthetic outcomes were assessed according to the breast volume, shape, and symmetry with the opposite breasts after a mean follow-up period of 44 months.
Results: The aesthetic outcomes were graded as excellent for 29 patients, good for 47 patients, fair for 12 patients, and poor for 8 patients. The overall complication rate was 11.5% (11/96). The complications included prosthesis loss after skin flap necrosis subsequent to hematoma formation (n = 1), skin necrosis (n = 2), partial necrosis of preserved NAC (n = 1), capsular contracture (Baker 4, n = 2), wound infection not involving the prosthesis (n = 2), inversion of the injection port (n = 2), and seroma (n = 2).
Conclusion: This study demonstrates that prosthetic breast reconstruction is a safe, reliable method with minimal complications and good to excellent aesthetic results for the majority of patients with early-stage breast cancer. For selected patients, NAC-sparing mastectomy can be performed without increasing the risk of local recurrences. Success depends on patient selection, proper incision for SSM, total coverage of the prostheses with muscles, and careful intra- and postoperative management.
Keywords Breast implants - Breast neoplasms - Mammaplasty - Mastectomy
"Key Points in Mastopexy"
Aesthetic Plastic Surgery, 06/04/10 Javier De Benito1 and Kyrenia Sánchez1
Abstract Breasts represent femininity and any change of shape may affect their appearance. Breast ptosis may be caused by several factors, including significant weight loss, pregnancy, long breastfeeding periods, and involution of the postmenopausal breast tissue. Breast ptosis may be associated with breast hypoplasia; thus, in case of a mastopexy with or without the use of implants being indicated, several considerations have to be taken into account: the wishes of the patient, age of the patient, degree of ptosis, parenchymal volume, covering tissue, quality of the tissue, pocket implant, shape and content of the implant, and resulting scars.
Keywords Breast augmentation - Mastopexy Note: Breast ptosis or saggy baggies can be corrected with a breast lift - Mastopexy or sometimes with replacement of volume with an implant. An implant can be used with degrees of lifting that include a crescant lift, periareola lift, lollypop or inverted T. There is a high degree of patient satisfaction with this procedure.
Larry Weinstein,MD FACS
"A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction" Obesity Surgery, 06/10/10
Abstract
The transversus abdominis plane (TAP) block acts on the nerves localised in the anterior abdominal wall muscles. We evaluated the efficacy on post-bariatric (PB) patients undergoing body-contouring abdominoplasty. We retrospectively evaluated PB patients undergoing abdominoplasty with flank liposuction and compared results to a matched group of TAP aesthetic patients. Outcomes evaluated were the analgesic requirements during the early postoperative days. Fifty-one patients (PB n?=?27, aesthetic n?=?24) were assessed. No complications were observed. All PB patients required analgesia until the second postoperative day contrarily to most aesthetic ones. Patients with greater flap resected and higher pre-abdominoplasty BMI had greater morphine consumptions. In PB patients, the larger amount of tissues resected corresponded to a greater stimulation of pain fibres that cannot be paralleled by a concomitant increase of the local anesthetic administered. This partially invalidates TAP’s efficacy on PB patients.
Keywords Transversus abdominis plane - Pain - Locoregional analgesia - Abdominoplasty - Body contouring - Obesity surgery - Bariatric surgery
Note: My patients with abdominoplasty usually go home the same day of surgery. They do well with oral pain medications. Larry Weinstein,MD FACS
www.drlarryweinstein.com
"No significant difference in benefit for longer surgical procedure... Comparison of Morbidity, Functional Outcome, and Satisfaction Following Bilateral TRAM Versus Bilateral DIEP Flap Breast Reconstruction Plastic and Reconstructive Surgery, 06/17/10"
Background: The potential for donor site morbidity associated with bilateral pedicled TRAM flap breast reconstruction has led to the popularization of DIEP flap reconstruction. This study compares post-operative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction.
Methods: One-hundred and five women with bilateral pedicled TRAM flaps were compared to 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Post-operative follow-up data was obtained through Short Form-36, FACT-B, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys.
Results: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data was otherwise similar. Abdominal hernias occurred in 3 TRAM patients (2.9 %) and in no DIEP patients, whereas abdominal bulges occurred in 3 TRAM patients (2.9 %) and 4 DIEP patients (6.9 %); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Post-operative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the SF-36 subjective energy category (p = 0.01) and mean FACT-B score (p = 0.01).
Conclusion: This study suggests no significant differences in donor site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction. (C)2010American Society of Plastic Surgeons Note; The extended surgical time, inherent risk factors in a longer procedure and lack of significant benefit may preclude the use of this flap in most patients. Larry Weinstein, MD FACS
Aesthetic Breast Augmentation and Thoracic Deformities
Aesthetic Plastic Surgery, 05/03/10
P. Wolter3 , S. Lorenz2 and C. Neuhann-Lorenz1
(1) Praxis für Plastische und Aesthetische Chirurgie, Theatinerstrasse 1, 80333 München, Germany
(2) Department of Plastic, Reconstructive, Hand and Burn Surgery, Klinikum Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany
(3) Department of Plastic Surgery, Hand Surgery, Burn Center, University Hospital of the RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
Abstract
To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.
Keywords Aesthetic breast augmentation - Thoracic deformities - Silicone breast implants - Breast asymmetry - Poland's syndrome - Retrospective study Note: Many patients have thoracic problems with their chest wall which are enhanced with breast implants. Many more patients with real problems with their chest walls or breast maldevelopment have breast augmentation then movie stars or dancers. Larry Weinstein, MD FACS www.drlarryweinstein.com
Correlation Between Scoliosis and Breast Asymmetries in Women Undergoing Augmentation Mammaplasty <http://www.mdlinx.com/readArticle.cfm?art_id=3118000>
Aesthetic Plastic Surgery, 04/28/10
Background: Breast asymmetries and scoliosis influence the results of augmentation mammaplasty. Although a variety of methods have been proposed to resolve breast asymmetries, to date, no simple preoperative algorithm has been proposed for predicting the breast volume and decreasing breast asymmetries in the place of subjective or expensive evaluation. The relationship between the scoliosis and breast volume asymmetry was further analyzed statistically in this study.
Methods: The study enrolled 60 scoliotic patients from 780 patients undergoing augmentation mammaplasty between January 2000 and March 2008. The average follow-up period was 2 years. The inclusion criteria required hypoplastic breasts, a difference in bilateral breast volumes greater than 20 ml, and scoliosis with a Cobb angle greater than 10°. The authors’ surgical algorithm demonstrated an anthropomorphic equation for predicting breast volume and selecting the correct implant size.
Results: Pearson regression analysis showed that the breast volume asymmetry difference was significantly correlated with the severity of scoliosis (Cobb angle) (correlation coefficient, 0.901). No correlation between the difference in pre- and postoperative nipple and inframammary levels and the severity of scoliosis was noted. Augmentation mammaplasty significantly decreased the breast asymmetry differences (volume and nipple level) (p < 0.001). The average preoperative estimated breast volume was 45.3 ml for the smaller breast and 88.4 ml for the larger breast.
Conclusion: This study found that the severity of scoliosis showed significant correlation with the breast volume asymmetry differences. Augmentation mammaplasty for breast asymmetries decreased not only the volume difference but also the difference in nipple levels. Keywords: Augmentation mammaplasty - Breast asymmetries - Implant - Scoliosis Note: Breast asymmetry can be secondary to spinal and chest bone deformities. Scoliosis is a special case which can give more significant abnormalities of the breast on a developmental and aging process. I have had good success with improvement in patients with scoliotic related breast asymmetry. Larry Weinstein, MD FACS www.drlarryweinstein.com
Botox reduces wrinkles even in less frequent doses: OHSU research shows patients can reduce frequency of Botox Cosmetic treatments over time, saving money while still reducing dynamic wrinkles
PORTLAND, Ore. – Patients can decrease the frequency of Botox© Cosmetic injections after approximately two years and still receive most of the same wrinkle-smoothing cosmetic benefits, according to new research at Oregon Health & Science University.
"After two years of treatment at recommended intervals, patients can potentially cut the frequency, and thus the cost, of their Botox© treatments by half," said Roger A. Dailey, M.D., F.A.C.S., professor and Lester Jones Endowed Chair of oculofacial plastic surgery in the OHSU School of Medicine. The results of Dailey's work were presented at a meeting of American Society of Aesthetic Plastic Surgeon on April 24 in Washington, D.C. The research was sponsored by an unrestricted educational grant from Allergen, Inc., the maker of Botox© Cosmetic.
The Botox© research effort also demonstrated that the injections have a wrinkle preventing – or prophylactic – effect. Patients who begin receiving injections between their 30s and 50s are able to prevent wrinkles from forming and eliminate existing wrinkles, said Dailey, head of the Casey Aesthetic Facial Surgery Center, which opened in 1991 as part of Casey Eye Institute.
Based on previous studies, doctors advised patients who wished to reduce wrinkles in the glabellar region – the area between the eyebrows – that they needed to have Botox© Cosmetic injections every three months to maintain the cosmetic wrinkle-smoothing benefits. Such frequent treatment, however, deterred some patients, Dailey said.
Dailey studied 50 women ages 30 to 50, who received regular Botox© injections for two years. "We found that after the patient receives Botox© Cosmetic injections every four months for two years, the frequency of the injections can be changed to every six months and still achieve good results," Dailey said. "This demonstrates patients have the ability to achieve good results with broader treatment schedules and ultimately at a lower overall treatment cost.
Botox© has been approved for cosmetic use for eight years. In 2008, more than 5 million patients in the United States received cosmetic Botox© treatments, according to Allergen, the manufacturer. About 313,000 of those patients were men.
Note: I have been using Botox for over 15 years for my staff and patients. Different strokes for different folks. Some patients require every 3 month treatment, some may have residual effects for as long as 6 months, I suspect some patients may eventually experience muscle atrophy from disuse and may need less as time goes on. However some patients develop taxyphylaxis which is a resistence to the medication that might require an increased dose or a slightly different compound; such as Dysport. Larry Weinstein,MD FACS
www.drlarryweinstein.com
Upper Body Reshaping for the Woman with Massive Weight Loss: An Algorithmic Approach <http://www.mdlinx.com/readArticle.cfm?art_id=3106686>
Aesthetic Plastic Surgery, 04/22/10
Abstract
Background
Body contouring after massive weight loss represents a rather new surgical field. Many areas of the body are affected such as the back, the upper arms, and the breasts in the upper body. Combining more than one such area in a single operative step can yield many advantages. The author proposes a single-step approach to the upper body of the woman with massive weight loss and offers an algorithm to simplify the operative plan.
Methods
Based on the characteristics of the individual, each adjacent region is analyzed for the potential of surgical improvement. Several lifting techniques can be used to restore the shape of each region. The breast represents a rather unique entity in which three basic types can be recognized. Accordingly, a surgical plan is formulated and discussed with the patient.
Results
The presented algorithm was used successfully for 17 consecutive women after massive weight loss. Although the time for these combined operations was increased, patient safety was not reduced nor were the number of complications increased compared with multiple smaller operations. The overall treatment plan for this patient group was greatly enhanced and simplified with this approach and resulted in great patient satisfaction.
Conclusion
Body contouring after massive weight loss presents a steadily increasing surgical field. Typically, multiple operative steps are required to achieve the patient’s ultimate goal. The author offers a surgical algorithm that aids in the operative planning for the upper body of such patients that simplifies this operation and yields great patient satisfaction.
Note: I have been using an extended abdominoplasty with thigh lift for some years with very nice results in most patients. see www.drlarryweinstein.com <http://www.drlarryweinstein.com> tummy tucks.
LASER removal of fat cells.
Mary K. Caruso-Davis1, Thomas S. Guillot2, Vinod K. Podichetty3, Nazar Mashtalir4, Nikhil V. Dhurandhar4, Olga Dubuisson4, Ying Yu4 and Frank L. Greenway4
Published online: 15 April 2010
Abstract
Background
Low-level laser therapy (LLLT) is commonly used in medical applications, but scientific studies of its efficacy and the mechanism by which it causes loss of fat from fat cells for body contouring are lacking. This study examined the effectiveness and mechanism by which 635–680 nm LLLT acts as a non-invasive body contouring intervention method.
Methods
Forty healthy men and women ages 18–65 years with a BMI <30 kg/m2 were randomized 1:1 to laser or control treatment. Subject's waistlines were treated 30 min twice a week for 4 weeks. Standardized waist circumference measurements and photographs were taken before and after treatments 1, 3, and 8. Subjects were asked not to change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceride release.
Results
Data were analyzed for those with body weight fluctuations within 1.5 kg during 4 weeks of the study. Each treatment gave a 0.4–0.5 cm loss in waist girth. Cumulative girth loss after 4 weeks was ?2.15 cm (?0.78 ± 2.82 vs. 1.35 ± 2.64 cm for the control group, p < 0.05). A blinded evaluation of standardized pictures showed statistically significant cosmetic improvement after 4 weeks of laser treatment. In vitro studies suggested that laser treatment increases fat loss from adipocytes by release of triglycerides, without inducing lipolysis or cell lysis.
Conclusions
LLLT achieved safe and significant girth loss sustained over repeated treatments and cumulative over 4 weeks of eight treatments. The girth loss from the waist gave clinically and statistically significant cosmetic improvement.
Keywords Cold laser - Fat reduction - Low-level laser therapy - Non-invasive laser
This study was supported by Meridian Medical, Inc., Vancouver, BC, Canada V6K 4L9.
Saturday, April 24, 2010
Alex Colque, M.D. , The Methodist Hospital, Houston, TX
Michael Eisemann, MD , Eisemann Cosmetic Daysurgery Center, The Methodist Hospital, Houston, TX
Goals/Purpose: Breast augmentation has been performed under local anesthesia and intravenous sedation for 30 years. The senior author (M.L.E.) has observed, during over 20 years of practice, less intra-operative bleeding and post-operative nausea using intravenous sedation and intercostal nerve blocks than with general anesthesia. General anesthesia is only used when breast augmentation with or without mastopexy is combined with large liposuctions, body contouring procedures, obese patients or surgery expected to last over 4.5 hours. The described protocol can be administered by the surgeon and the circulating nurse. It deliberately avoids the use of propofol which should be used only by a nurse anesthetist or anesthesiologist. Patients, when given the option of monitored sedation with intercostal nerve block generally have preferred this technique over general anesthesia due to its safety, efficiency, and cost savings. We present our experience with using intercostal nerve blocks and intravenous sedation to perform breast augmentation with and without simultaneous mastopexy. We also compare these two groups of patients.
Methods/Technique: We used the following anesthesia technique: Patients were administered the first dose of intravenous sedation by the surgeon starting with 1mg midazolam (FDA schedule IV), 50mcg fentanyl (FDA schedule II), and 10 mg ketamine (FDA schedule III) and then additional doses as necessary by the circulating nurse. Local anesthesia solution consisting of equal parts of 0.25% bupivicaine and 1% xylocaine with 1:100,000 epinephrine was then injected into intercostal spaces 3-7 at the mid-axillary line. 2ml were used in each costal interspace. The solution was then injected at the lateral sternal boarder in varying amounts.
A retrospective review was done on 171 patients who underwent bilateral breast augmentation and augmentation- mastopexy from January 1st, 2007 to October 30th, 2009 at an AAAA accredited outpatient surgery center by the senior author (M.L.E.) using the protocol described above. All procedures were performed for cosmetic purposes. We excluded patients that had any other additional procedures including liposuction. All breast implants were placed in a subpectoral pocket. The two groups were then analyzed for age, BMI, operative time, total sedation used, total local anesthesia used, recovery room length of stay, and complications.
Results/Complications: A total of 171 patients were included in the study, 132 underwent breast augmentation and 39 breast augmentation-mastopexy. In the augmentation group the means were: age 31.7 (range: 17-66), BMI 21.5 (16.4-28.7), operative time 63.8 min (42-120), ketamine used 19.3mg (0-60), midazolam used 5.7mg (0.5-11), fentanyl used 160.5mcg (25-300), total local solution used 79.6ml (25-120), recovery room length of stay 49.9min (16-116), and 14 had post-operative nausea (10.6%). In the augmentation-mastopexy group the means were: age 34.5 (range: 20-54), BMI 22.8 (17.2-32.0), operative time 134.7min (56-210), ketamine used 18.2mg (0-40), midazolam used 7.3mg (4-10), fentanyl used 180.8mcg (100-300), total local solution used 90.9ml (45-144), recovery room length of stay 52.9min (17-107), and 5 had post-operative nausea (12.8%). There were no deaths, deep venous thromboses, pulmonary emboli, hematomas, reoperations, pneumothoracies, intubations, and none of the patients required admission to the hospital.
Conclusion: After reviewing our experience, we conclude that breast augmentation with and without mastopexy can be performed safely and with minimal discomfort under local anesthesia with intravenous sedation with minimal complications when performed by ACLS certified personnel in an AAAA certified facility. Although augmentation with mastopexy procedures requires a longer operative time than augmentation alone, this does not lead to a longer recovery room length of stay. This is likely due to the effectiveness of the intercostal nerve block for post-operative pain control.
Saturday, April 24, 2010
Alberto di Giuseppe, pastic, maxillo, surgeon , ASAPS, Ancona, Italy
Goals/Purpose: Give a 360 degree perspective of safe and aestheticre modeling of the thigh
Methods/Technique: Superficial and deep ultrasound liposculture of anterior thigh through patellar and inguinal incisions.
Results/Complications: Significant improvement of aesthetic results of the thigh remodeling, due to a real 360 degree sculpturing . no complications in our series with 2 years follow up.
Conclusion: The analysis of the proportions rules proposed by leonardo da vinci, kept in evidence that only 2 dimensions of the thigh have been evaluated even with photographic approach in te last decades. profile and 3/4 view give reason of the need of treatment also of the anterior thigh, when necessary, to complete and enhance the aesthetic outcome of the entire thigh. These concepts are realized through vaser superficial and deep ultrasound liposculture.
In the last decades, when planning a liposuction or liposculpture of the thigh, the analysis of the areas and zones to be corrected has always been taken from anterior and posterior views, and the surgical techniques have been addressed to correct flanks, trocanter deformities, banana fold, inner side of the thigh, inner side of the knees, etc.
I reviewed the story of the studies on body proportions by LEONARDO DA VINCI, starting from his paintings of nude man,1503,1509, exposed at the WINSOR CASTEL ROYAL LIBRARY, where he started studying the body figure and proportions from 2 standards views, frontal and dorsal ,or anterior and posterior, as we have been instructed through all these years by our masters.
LEONARDO DA VINCI introduced hid antropometric studies of body proportions and parts, simplifying the absolute criteria of VITRUVIO (1siecle a.c.) based on a Greek measurement scheme.
And finally introduced the third dimension, as indicated in his drawings analysis of leg proportion. Leg is measured with Greek letters at different distances, and comparison between upper, middle lower third of the leg are done in absolute and relative terms. The lateral view of the thigh appears finally, after frontal and dorsal view have been the only considered in the previous period .
In his drawing on study of proportions of the body standing, sitting, and on his knees ( Windsor Castle 1490) clearly indicated the correct way to approach and evaluate the body symmetry and evaluate body contouring.
The lost third dimension tells me of a different criteria to evaluate and thus correct body deformity mainly in the thigh area, which has been considered for long time assort of “forbidden area “. This relative hostility was due to the difficulty of sculpturing and mastering the anterior and antero medial part of the thigh, and for the fear to damage with secondary irregularities and depressions.
TRIDIMENSIONAL PLANNING
TECHNIQUE, CIRCUMFERENTIAL THIGH VASER CONTOURING
Scope of the anteromedial approach to the thigh is to thin the subcutaneous fat of the thigh in areas considered to be risky for the approach with classic liposuction. At the same time, the undermined tissues rises and represents a substantial benefit for the final contouring of the leg. Of course the approach to the anterolateral part is the final step of a circumferential sculpturing of the thigh. A tridimensional vision of the full area is mandatory to model the different sides in harmony in between them.
Infiltration of tumescence is vital in ultrasound assisted lipoplasty.
1. The tumescent infiltration initially distends the tissue, allowing vasoconstriction which diminishes bleeding, compacting the tissues which become uniform .The fluids are distributed superficially first and deeper, to follow.
2. The superficial superwet technique of infiltration really distends the tissue and allows a precise undermining by the 2,9 mm or 3,7 mm one or two rings probe. With the power tunneled at 70 per cent of power, the probe is directed parallel to the skin axis, as indicated in the diagram, in order to allows careful undermining of the tissue from underlying fat. This maneuver is essential for the final contouring of the area of the thigh, as will allow the reduced tissues to adhere to the new, reduced and shaped body. This selectivity distinguishes vaser ultrasound from whatever other technique in terms of protection of the subcutaneous vascular plexus.
3. Once completed the undermining, which may require 5, 6 minutes of delicate vaser action, always respecting the skin superficial layers, the probe is directed in the deeper layers of the thigh.
4. The emulsification ends when there is no more resistance in the deep layers of fat.
5. Once this phase is completed, the surgeon starts the most delicate part of the contouring, the removal of emulsified fat from the deeper layer, the superficial spreading of the skin, the careful aspiration in respect of the shape of the body. Aspiration in the superficial layer has to be very conservative This part of the sculpting of the body allows the plastic surgeon to express his own talent and artistry, and is the unique part of the technique which cannot be taught, but just shown.
6- Sculpturing the body, recreating lines of natural convexity or concavity is the fascinating and creative part of surgery. I utilize a 2,8 mm fine cannula to shape the superficial planes, with virtually no aspiration. And a 3,7 mm cannula to aspirate in the deeper planes.
CLINICAL CASES
Saturday, April 24, 2010
Alessandra Haddad , Disciplina de Cirurgia Plástica UNIFESP Universidade Federal de São Paulo, São Paulo, Brazil
Daniel Regazzini , Campinas Obesity Surgery Center, São Paulo, Brazil
Vanessa Contato Lopes Resende, Resident , Disciplina de Cirurgia Plástica UNIFESP Universidade Federal de São Paulo, São Paulo, Brazil
Lydia Masako Ferreira, MD, PhD , Disciplina Cirurgia Plástica UNIFESP - Universidade Federal de São Paulo. Departamento de Cirurgia, São Paulo, Brazil
Goals/Purpose: The purpose of this paper is the analyze the safety in the use of Hyaluronic Acid based filling substances of in the treatment of aesthetic imperfections of the face.
Methods/Technique: The aging process leads to facial outline alteration and global volume reduction due to dermal alterations and skin tissue reduction. Several substances have been used to minimize theses alterations and to compensate the wrinkle tissular volumetric form through dermal filling.
Because it’s an absorbable substance of non – animal origin, the Hyaluronic Acid have been greatly used as a facial filling. Hyaluronic Acid is a glycosaminoglycan polysaccharide present in dermis and other organic tissues that assists cellular growth and acts in membrane receptors and cellular adhesion.
The use of hyaluronic acid as a dermal filling presents many advantages, due to its non-animal origin and absorbability (less capacity of imunogenicity). Because of its characteristics, it was chosen as the filling material of this study, for facial wrinkles, lips contour, scar depressions and facial lipoatrophy.
This is a retrospective study on the application of hyaluronic acid with on 1366 patients, based on photographs right before application, 30 days afer and the 180 days application.
The selected patients were the ones with indication for dermal filling to treat deep wrinkles, scars in the fce, facial lipoatrophy, deep nasolabial fold and thin lips.
The criteria for exclusion are: patients with history of allergy to hyaluronic acid, presence of skin patologies at the local of application or decompensated systemic pathology, pregnancy, presence of scarring disturbances, previous treatments with non-biodegradable substances at the local to be treated or the use of anticoagulant for any pathology.
The patients were treated with 0,7ml and 1,4ml applications of hyaluronic acid, sterilized and with concentration of 20mg/ml, injected in mid-reticular dermis, deep reticular dermis and papillary dermis, on pre-determined spots, using 13x0,7 (27G) needle.
The markings were made with the patients seated, to highlight the spots that needed filling. Topic local anesthesia and /or anesthetic block may be used according with the indication of anesthetics local infiltration. The volume injected should be enough for the local to be treated. The aesthetic result is immediate and there should not be hypercorrection. The application technique used was retroinjection. After application, cold compress for 10 minutes and local massage are done.
The patients returned on the 7th and 15th day after the application, when they are evaluated, after the improvement of initial edema. At this point, if necessary, touch up can be made as complements on spots with hipocorrection or assimetry. Then they should return on the 30th and 180th day after application for new evaluation.
Results/Complications: It was documented 1366 patients submitted to hyaluronic acid dual filling, between 1997 and 2007. The application sites were: nasolabial fold (48,2%), lips (25%), nasolabial fold and lips (19%), earlobe (1,2%), malar region (0,7%) and other region (6,1%). 32% of the patients needed touch up application after 15 days. There were complications in 8 patients (0,6%): palpable fibrous string (2), ectopia (2), front cellulite (1), strange body granuloma (1) and extrusion (2).
The adverse effects are described in literature and generally are self-limited.
Conclusion: The conclusion of this paper is that Hyaluronic Acid is an excellent filling, with low complication rate and high degree of patient satisfaction.
Tuesday, April 27, 2010: 11:24 AM
Oscar M. Ramirez, MD , Plastic Surgery, Sanctuary Plastic Surgery, Boca Raton, FL
Goals/Purpose: Previously designed chin implants failed to do the changes that the sliding osteotomy can do. We describe a newly designed chin implant and its corresponding technique that can be considered a substitute for the sliding geniality.
Methods/Technique: The implant is a two-piece adjustable wraparound device that provides augmentation of the genio-mandibular area in all dimensions. A wide subperiosteal dissection and detachment of the digastric/mylohyoid muscles with latter reattachment in a new and more anterior position is performed. These accomplish some of the effects of the sliding genioplasty: increase of vertical height of the anterior mandible, soft tissue remodeling of the lower mandible and chin and tightening of the suprahyoid muscles. Lower perioral musculature dynamics also improves.
Results/Complications: This method was used for 13 years in 142 patients some as a solo procedure and others as a part of a more comprehensive plan. Soft tissue anthropometric measurements in 20 patients showed an improved soft tissue/skeletal advancement ratio of 1.5 (0.8 for the sliding genioplasty). Complication rate has been minimal: 4.2% temporary neuropraxia of the marginal mandibular nerve. One patient required trimming of implant at the gingivo-buccal sulcus. In other patient paresthesias of the mental nerve required trimming of the implant. Three patients (2%) required size adjustments: one exchange for a smaller implant, one in situ trimming and the third a further augmentation with an overlay implant. Two patients (1.4%) requested removal of their implants
Conclusion: High patient satisfaction and good to excellent aesthetic results were obtained in 90% of patients. The subset with anthropometric data showed positive soft tissue/skeletal advancement ratio compared to those described for the sliding genioplasty patients. Many patients' candidates for sliding genioplasty were successfully treated with this implant and the described technique.
Tuesday, April 27, 2010: 1:31 PM
Douglas M. Senderoff, MD, FACS , Plastic Surgery, Park Avenue Aesthetic Surgery, PC, New York, NY
Goals/Purpose: The purpose of this study was to examine the results of a single surgeon in a consecutive series of buttock augmentations using solid silicone implants.
Methods/Technique: A retrospective chart review was conducted to identify all patients who underwent bilateral buttock augmentation using solid silicone implants over an eight year period. Demographic information, implant size, concomitant procedures and surgical information including the use of drains and implant position were recorded for each patient. Pre and postoperative photographs were taken. The data was analyzed to determine the rate of complications, need for surgical revision and aesthetic outcome. All patients in the series underwent buttock augmentation as an outpatient by the author in his AAAASF accredited office based surgical facility. Patients were positioned prone on the operating table after undergoing general or epidural anesthesia. A single dose of Cefazolin was given intravenously prior to skin incision. Solid silicone gluteal implants were inserted through a single midline intergluteal incision measuring 7 cm. in length. Implants were placed in either the subfascial (SF) or intramuscular (IM) position. Precise pocket dissection was accomplished through the use of a fiber optic retractor and long tip electrocautery in the subfascial plane. Intramuscular dissection was performed using a combination of electrocautery dissection and blunt dissection. Closed suction drains were used in select patients and removed when less than 25 ml. of fluid was obtained over a 24 hour period. Patients were discharged with oral analgesics and instructed to refrain from physical exertion for 4-6 weeks.
Results/Complications: A total of 400 solid silicone gluteal implants were placed in 200 patients during the 8-year study period. Of the 200 patients who underwent gluteal augmentation 26 (13%) were male and 174 (87%) were female. The average age was 34 years for the men and 30 years for the women. The implants were placed in the IM position in 46 patients and in the SF position in 154 patients. Concurrent aesthetic procedures were performed in 30% (n=59) of the patients and included liposuction of the back (n=51), breast augmentation (n=2), calf augmentation, (n=2), liposuction of the abdomen (n=1), liposuction of the thighs (n=1), scar revision (n=1), and sacral reduction (n=1). The overall reoperation rate was 13 % (n=26). Indications for reoperation were grouped by category which included: infection (n=11), seroma (n=6), aesthetic concerns (n=6), capsular contracture (n=1), hematoma (n=1), and wound healing (n=1). Seroma formation was the most common complication occurring in 28% (n=56) of patients. Seromas were treated successfully with serial aspiration in 80% (n=45) of the cases. Five patients were treated with drain reinsertion and six patients required surgery. The overall infection rate was 6.5% occurring in 13 of the 200 patients. The implant infection rate was 3.8% occurring in 15 of the 400 implants placed. Eleven patients required implant removal due to infection while 2 patients were successfully treated for buttock cellulitis with antibiotics alone. Three infections occurred in the IM group and 10 occurred in the SF group producing identical infection rates of 6.5%. Staphylococcus aureus was the most commonly isolated pathogen and was cultured from the buttock implant periprosthetic fluid in 11 of the 13 patients with infected buttocks. Escherichia coli bacteria were cultured from the buttock implant periprosthetic space in one patient requiring explantation. No fluid was available for culture in one of the patients with buttock cellulitis. Hematomas occurred in 2% (n=4) of patients and were treated with wound exploration in three patients and unilateral buttock aspiration in one. Wound dehiscence occurred in 1.5% (n=3) of patients. Two superficial wound separations were treated with local care only and one wound dehiscence which was limited to the deep subcutaneous layer was treated with debridement and closure in the operating room. Capsular contracture was noted in 1% (n=2) of the patients, both of which had postoperative seromas. Additional aesthetic procedures at the time of buttock augmentation did not affect the complication rate. There were no cases of sciatic nerve injury or gluteal muscle weakness. Keloid or hypertrophic scarring of the intergluteal incision did not occur although drain site scar hypertrophy did occur in several patients. IM patients required more time to recuperate and complained of more pain than SF patients. Final aesthetic results were evident more quickly in the SF patients than the IM patients. Satisfaction rates were very high in both SF and IM patients although IM patients more often complained of lack of inferior gluteal fullness.
Conclusion: Buttock augmentation with solid silicone implants is a safe and satisfying procedure. The most common complication in this series was seroma formation which was treated with serial aspiration in the majority of cases. Gluteal implants can be successfully placed in either the subfascial or intramuscular position with no significant difference in complications. SF implant placement can produce better aesthetic results in patients requiring inferior gluteal fullness.
Tuesday, April 27, 2010: 1:47 PM
Joseph Hunstad, MD, FACS , Plastic surgery, The Hunstad Center, Charlotte, NC
Roderick Urbaniak, MD , The Hunstad Center, Charlotte, NC
Bill Kortesis, MD , The Hunstad Center, Charlotte, NC
Goals/Purpose:
This report describes a new method of providing buttocks augmentation with exceptional projection achieved using an innovative purse-string technique. This method of providing autologous augmentation and lifting of the ptotic buttock can be used as a stand-alone procedure for primary augmentation and lifting, as salvage after suboptimal prosthetic or fat augmentation, or most commonly, in concert with a circumferential body lifting.
Methods/Technique:
There are three main techniques for buttocks augmentation: large-volume autologous fat transfer, prosthetic implant-based augmentation, and augmentation with dermo-adipose flaps. Each technique has unique characteristics. The highly popular method of autologous fat transfer requires the availability of suitable donor sites, is technique dependent and, has variable survival rates. While it remains an attractive option for patients with ample donor sites and desire for hip, thigh, or abdominal volume reduction, it may not be available for thin patients or many after significant weight loss. Prosthetic buttocks augmentation can add volume by placing silicone implants in the subfascial, intramuscular, or submuscular position. Although most results are acceptable, complications such as infection, rotation, visibility, palpability, surgical site dehiscence, extrusion, and appearance of stretch marks have been noted. Autologous flap augmentation is the method of choice for buttocks augmentation when excess tissue exists. Buttocks lifting is also achieved with this technique. This method of gluteal rejuvenation is ideal for patients with significant weight loss who exhibit significant skin laxity with variable residual adiposity.
Described initially in 2009, our purse-string gluteoplasty procedure provides lifting as well as exceptional projection and we have used it as a primary method for autologous augmentation gluteoplasty since 2006. It creates a buttock that is lifted and augmented with centrally based autologous dermo-adipose flap with completely preserved vascularity. The amount of added volume can be controlled with the design of the flap. Similarly, projection is adjustable and can be varied intraoperatively. We will present technical details, refinements, and our experience in sixteen consecutive patients.
Results/Complications:
Sixteen female patients underwent autologous gluteal augmentation with purse-string gluteoplasty from December 2006 until August 2009. A retrospective chart review was performed. Complications were recorded and divided into major and minor categories.
All procedures were performed by the senior surgeon (JPH) in a fully-accredited (AAAASF) surgical center. 4 of 16 were African American, 1 of 16 was Hispanic, and the rest were Caucasian. The average age was 41.8 years and the average BMI 24.5 (18-34). 50% (8/16) were massive weight loss patients and all of which were at stable weight and at least 18 months after their bariatric operation. 12 patients had their gluteoplasty as part of a circumferential body lift, and 2 patients who had a prior abdominoplasty elected to have a gluteoplasty to complete their circumferential body contouring procedure. Interestingly, two other patients had a gluteoplasty as a stand-alone procedure. One had a salvage operation after removal of a rotated palpable silicone implant initially used for augmentation, and second one had a Purse-String Gluteoplasty after fat grafting to buttocks failed to provide adequate volume.
Average follow up in this series is 12 months ranging from 3 to 32 months. Eight patients developed complications for an overall complication rate of 50%. Two of these were major (12.5 %) and six were minor (37.5 %). One patient developed a non-fatal pulmonary embolus 14 days post-op despite a regimen including intraoperative sequential compression devices, early and frequent ambulation, and peri-operative lovenox (2 doses of 30 mg, first dose in recovery). She was treated with systemic anticoagulation and recovered without further sequelae. The other major complication occurred in a patient who had simultaneous liposuction of the upper back and subsequently developed a 10 by 5 cm area of fat and skin necrosis. Closure was achieved in a secondary fashion with interval revision of resulting scar.
Conclusion: Purse string gluteoplasty is a highly effective method to augment and lift a ptotic, volume deficient buttock. It produces the most reproducible, most harmonious, full and natural-appearing buttock. It can be used in combination with circumferential body lift, as a completion procedure after anterior abdominoplasty, as salvage of failed augmentation, or as a stand-alone procedure. It affords unparalleled vascularity far above any undermined rotational flaps with virtually no risk for necrosis. Flap position and projection are precisely controlled. Patient and surgeon satisfaction has been universally high and complication rate has remained low with average follow-up of 12 months. It remains our method of choice for gluteal augmentation and correction of buttock ptosis.
Tuesday, April 27, 2010: 4:02 PM
Juan Pablo Maricevich, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Natale Gontijo, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Rodrigo Duprat, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Franciele Freitas, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Marco Maricevich, MD , Visiting Resident from the Department of Surgery, Rochester, MN
Ivo Pitanguy, MD , Plastic Surgery, Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Goals/Purpose: Prominent ears are a relatively common anomaly that presents as an instantaneously recognizable deformity. Numerous studies report psychological distress, emotional trauma, and behavioral problems prominent ears can inflict on children. The multitude of different approaches indicates that there is not a clearly definitive technique to correct all the prominent ears. Surgeons must be able to correctly and precisely analyze the deformity, then establish and implement a surgical plan based on the current available techniques. The goal of this study is to endorse the Pitanguy’s Island technique previously described by the senior author of this paper as an effective, simple, and reliable approach to correct prominent ears. This technique consists in creating a cartilaginous island to reconstruct the antihelix and the triangular fossa in addition to correct the conchascaphal angle.
Methods/Technique: We retrospectively reviewed the charts of all patients who underwent otoplasty using the Island technique at the Ivo Pitanguy Clinic from July of 1990 to July of 2008. Patients operated with any variation of the Island technique or using any other technique were excluded from our study.
Results/Complications: Using the Island technique, 111 patients underwent otoplasty from July of 1990 to July of 2008. There were 80 female (72%) and 31 male (28%) patients, aged from 5 to 65 years old (mean age of 28.2 years). The majority of patients operated belonged to the 11-20 years age group in both genders. The most common etiology for prominent ears was a combination of overdeveloped concha and underdeveloped anti helical fold present in 76 patients (69%). Only a minority (4%) of our patients had unilateral prominent ear. Other combined facial aesthetic procedures were simultaneously performed in 54 (49%) patients, an interesting new trend especially in the older age groups. Early complications occurred in 2 patients (1.8%) in the form of hematoma or wound dehiscence. Late complications were observed in 12 patients (10.8%), and that includes a residual deformity present in 6 patients (5.4%) causing surgical stigma that we named marked anti helical fold. All complications were addressed without any consequence to the final surgical outcome. No recidivism was observed in our study.
Conclusion: The Island technique is an effective, simple, and reliable surgical option to correct prominent ears. The greatest advantages of this technique are the absence of recidivism and minimal incidence of complications.
Salem Samra, MD , Yale University School of Medicine, New Haven, CT
Rajendra Sawh-Martinez, BS , Yale University School of Medicine, New Haven, CT
Yuen-Jong Liu, MD , Yale University School of Medicine, New Haven, CT
Fares Samra, BA , New York University School of Medicine, New York, NY
John Persing, MD , Plastic Surgery, Yale School of Medicine, New Haven, CT
Goals/Purpose: Brachioplasty has become a popular procedure to rejuvenate the upper arm. The major complication of the procedure is undesirable, visible scarring. An ongoing, unresolved debate in the brachioplasty literature is the optimal placement of the brachioplasty scar. This study attempts to resolve the question of where and how to place the scar based on population surveys.
Methods/Technique: Photographs were taken of a model with her arm progressively abducted at the shoulder to a level of 90 degrees, with the elbow progressively flexed to 90 degrees and the arm externally rotated. A brachioplasty scar was digitally created and placed on the arm first medially in the bicipital groove, then posteriorly in the brachial sulcus. An online survey was then created and distributed and included multiple variables: position of the scar, length of scar vs residual deformity, and acceptability based on phase of scar in time (early vs late result).
Results/Complications: Electronic surveys were distributed to and completed by the general public (n=117), local plastic surgery residents and attendings (n=10), and patients who had undergone or were seen in consultation for brachioplasty (n=9). Across age groups, gender, plastic surgeons, and patients, the medially based straight brachioplasty scar is more acceptable than the posteriorly based straight scar (4.00 vs. 3.14, p < 0.001). If the scar shape is made sinusoidal, a posteriorly based scar is favored over a medial one (2.61 vs. 2.03, p<0.001), yet this is still not as aesthetically pleasing as a medial straight scar (4.00 vs. 2.61, p<0.001). Furthermore survey participants accepted a longer scar over a residual deformity (58.8% vs 41.2%).
Conclusion: Based on the preferences of the populations surveyed, we conclude that the medially based straight scar is the most aesthetically acceptable option when performing a brachioplasty.
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 occu