Cosmetic Plastic Surgery Updates

Advances in Facial Rejuvenation: Botox, Hyaluronic Dermal Fillers, and Combinations--Consensus Recommendations.

COSMETIC  Plastic & Reconstructive Surgery. 121(5) SUPPLEMENT:5S-30S, May 2008.

Carruthers, Jean D. A. M.D.; Glogau, Richard G. M.D.; Blitzer, Andrew M.D., D.D.S.; the Facial Aesthetics Consensus

Background: Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures, and patient demographics.

Clinicians can tailor treatments to individual patients, treating multiple facial areas, and using combinations of products to optimize outcomes.

Methods: A multidisciplinary group of aesthetic people convened to review the uses of botulinum toxin type A (BoNTA) and hyaluronic acid fillers and to update consensus recommendations for facial rejuvenation using these two types of products. The group considered paradigm shifts in facial aesthetics; optimal techniques for using BoNTA and hyaluronic acid fillers alone and in combination; the influence of patient sex, ethnicity, cultural ideals, and skin color on treatment; general techniques; patient education and counseling; and emerging trends and needs in facial rejuvenation.

Results: The group provided specific recommendations by facial area, focusing on relaxing musculature, restoring volume, and recontouring using BoNTA and hyaluronic acid fillers alone and in combination. For the upper face, BoNTA remains the cornerstone of treatment, with hyaluronic acid fillers used to augment results. These fillers are central to the midface because of the need to restore volume. BoNTA and hyaluronic acid in combination can improve outcomes in the lower face.

Conclusions: Optimal outcomes in facial aesthetics require in-depth knowledge of facial aging and anatomy, an appreciation that rejuvenation is a three-dimensional process involving muscle control, volume restoration, and recontouring, and thorough knowledge of properties and techniques specific to each product in the armamentarium.

Note: This appears to be an Allergan picked panel. radiesse and Artefil are other alternatives for fillers that offer advantages over hyaloronics in some cases. Surgical ablation of muscles that cause wrinkles is ignored but very effective in many cases. Resurfacing by peels via acids or LASER are another alternative to help control wrinkles.

Larry Weinstein, MD FACS board certified plastic surgeon Chester, New Jersey

 

The Influence of Forehead, Brow, and Periorbital Aesthetics on Perceived Expression in the Youthful Face.

COSMETIC Plastic & Reconstructive Surgery. 121(5):1793-1802, May 2008.

Knoll, Bianca I. M.D.; Attkiss, Keith J. M.D.; Persing, John A. M.D.

Abstract:

Background: The purpose of this study was to characterize the relative influence of eyebrow position and shape, lid position, and facial rhytides on perceived facial expression as related to blepharoplasty, with a specific focus on the perception of tiredness.

Methods: A standardized photograph of a youthful upper face was modified using digital imaging software to independently alter a number of variables: brow position/shape, upper/lower lid position, pretarsal show, and rhytides. Subjects (n = 20) were presented with 16 images and asked to quantify, on a scale from 0 to 5, the presence of each of seven expressions/emotions as follows: "surprise," "anger," "sadness,"

"disgust," "fear," "happiness," and "tiredness."

Results: Statistically significant values for tiredness were achieved by changes of increasing and decreasing the pretarsal skin crease, lowering the upper eyelid, and depressing the lateral brow. Happiness was perceived by elevation of the lower lid or the presence of crow's feet. Brow shape had a greater influence than absolute position on perceived expression. Elevation of the lateral brow was perceived as surprise, whereas depression of the medial brow and rhytides at the glabella were perceived as anger and disgust. Elevation of the medial brow elicited a minimal increase for sadness.

Conclusions: This study showed that the perception of tiredness is most affected by the length of pretarsal lid height (e.g., ptosis).

Surprisingly, simulating the skin resection of an upper blepharoplasty results in a paradoxical increase in the perception of tiredness as well. Modifications of brow contour elicit profound changes in perceived facial mood to a greater degree than absolute brow position.(C)2008American Society of Plastic Surgeons

Note: Extreme elevation of the brow is to be avoided, it gives a surprised look. However hooding can be corrected with a brow lift.

Finesse in this operation is critical to a well received outcome.

Larry Weinstein,MD FACS board certified plastic surgeon Chester, New Jersey www.drlarryweinstein.com

Treating the Abdominotorso Region of the Massive Weight Loss Patient: An Algorithmic Approach.

COSMETIC Plastic & Reconstructive Surgery. 121(4):1431-1441, April 2008.

Wallach, Steven G. M.D.

Abstract:

Summary: There has been tremendous growth in the number of patients seeking body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore there have been many surgical options proposed based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. An algorithm for treatment is presented to simplify the decision-making process.

Patient examples are also shown to demonstrate the usefulness of the algorithm.

(C)2008American Society of Plastic Surgeons

Note: Assessing the skin texture, underlying fascia and adjacent tissue components are critical to acceptable results. Taking into account proportions, excess adjacent skin and planning appropriate length procedures are critical to safe results. The real risk of deep venous thrombosis ( leg clots) and pulmonary emboli must be explained to these patients.

The algorithm as explained is an acceptable method that may help some junior surgeons approach these cases.

Larry Weinstein,MD FACS board certified plastic surgeon Chester, New Jersey

Breast Augmentation After Reduction Mammaplasty: Getting the Size Right.
Breast Surgery

Annals of Plastic Surgery. 60(4):372-374, April 2008.

Colwell, Amy S. MD *+; Slavin, Sumner A. MD +; May, James W. Jr MD *

Abstract:
Although patients are typically satisfied after reduction mammaplasty, a subgroup later deems the volume of remaining breast tissue inadequate and presents for breast enhancement. Our purpose was to identify patient and procedural risk factors that may contribute to an over-reduced breast and the desire for breast augmentation after initial reduction. Seven patients were identified who had breast augmentation an average of 13 years after breast reduction. Four patients were satisfied with breast size immediately after reduction mammaplasty but lost breast volume subsequent to weight loss or childbearing. Three patients with a body mass index of 18 to 20 were dissatisfied immediately after reduction. Body image improved in 100% of patients after enhancement. Getting the size right depends upon thorough discussion with the patient regarding desired size, insurance requirements, and potential for decreased size after weight loss or childbearing. Breast augmentation may improve body image in patients with small breasts after reduction.
(C) 2008 Lippincott Williams & Wilkins, Inc.

Note: The Harvard group are not alone in finding patients who find themselves smaller then anticipated after surgery. Sometimes insurance criteria and requirements for reimbursement create an adverse environment for patient care. In New Jersey with the governor tax, do we collect cosmetic tax for those who have breast reduction without insurance coverage? I elect not to, in those with back shoulder or neck pain. I have done breast augmentation and lift on two patients who lost a great deal of weight after breast reduction by other surgeons.

Larry Weinstein,MD FACS

The "Rising-Sun-Technique" in Abdominoplasty.
Annals of Plastic Surgery. 60(4):343-348, April 2008.
Momeni, Arash MD; Heier, Matthias MS; Bannasch, Holger MD; Torio-Padron, Nestor MD; Stark, G Bjorn MD
Abstract:
A multitude of studies has been published focusing on different technical aspects of abdominoplasty. However, rarely has attention been drawn to skin closure techniques and its implications on postoperative scar length and complication rate. A retrospective analysis was conducted comparing a new comprehensive approach to skin closure with conventional techniques. Patients in each study group were matched for race, body mass index, gender, medical history, and smoking habits. We focused on postoperative scar length and rate of wound healing problems. Forty-six patients were included in each study group. Patients in whom wound closure was achieved via the technique presented here displayed a mean scar length of 33.68 cm (vs. 49.92 cm) and wound healing problems in 8.7% (vs. 23.9%). A marked reduction of scar length and postoperative wound healing problems is achievable with application of the technique presented in this article.
Note: The smile incision I have used for 20 years is hidden very well in the panty line. The length of the incision varies on the amount of tissue to be removed. A tension free closure is more important to get a barely visible scar then any other factor. Refraining from smoking is very important to get a reasonable result. Larry Weinstein, MD FACS Cosmetic plastic surgeon - Chester, New Jersey

Abdominoplasty Can Be Performed Successfully as an Outpatient Procedure With Minimal Morbidity.
Annals of Plastic Surgery. 60(4):349-352, April 2008.
Chattar-Cora, Deowall MD *; Okoro, Stanley A. MD +; Barone, Constance M. MD +
Abstract:
Since abdominoplasty has been shown to have a positive impact on patient's self-image and quality of life, it is no surprise that the annual number of these procedures performed has continued to increase. Historically, because of concerns with patient safety the majority of these operations have been performed on an inpatient basis. The breast reduction experience has shown that with proper patient selection and operative technique, this procedure can be performed on an outpatient basis without compromising safety. We retrospectively reviewed the senior author's experience to see if abdominoplasties can be safely performed as an outpatient procedure. Forty-five patients underwent abdominoplasties as an outpatient with only 1 patient required operative reexploration; the other complications were minor wound problems that did not require operative intervention. Proper patient selection and operative technique can allow a successful abdominoplasty with minimal morbidity.
Note: I have been doing Abdominoplasty or tummy tucks on an outpatient basis for 20 years with no mortality and minimal secondary problems. Larry Weinstein, MD FACS cosmetic Plastic surgeon Chester, New Jersey
 
EMLA Cream Application Without Occlusive Dressing Before Upper Facial Botulinum Toxin Injection: A Randomized, Double-Blind, Placebo-Controlled Trial.
Annals of Plastic Surgery. 60(4):353-356, April 2008.
Kashkouli, Mohsen Bahmani MD; Salimi, Shabnam MD; Bakhtiari, Pejman MD; Parvaresh, Mohammad Mehdi MD; Sanjari, Mostafa Soltan MD; Naseripour, Masood MD
Abstract:
A randomized, double-blind, placebo-controlled clinical trial was conducted among 44 subjects to assess the efficacy of EMLA cream application without occlusive dressing on pain on needling (PN) and pain on injection (PI) felt during multiple botulinum toxin type A (BTA) injections for correction of hyperkinetic upper facial lines. Mean PN score was less than PI score with high correlation and no significant difference. Although both PN and PI scores (visual analog) were less in the EMLA than placebo group, the difference was only statistically significant for PN score. Time intervals between the cream application and BTA injections beyond 60 minutes did not show lower pain score in either type of the pain.
Note: I have been using ice packs and EMLA or liocaine cream for over 10 years with strong patient appreciation. Larry Weinstein, MD FACS Cosmetic Plastic surgeon Chester NJ

Landmark Five-Year Data
Artes Medical recently announced the publication of positive data from a long-term safety and efficacy study of ArteFill in the December 2007 "Special Issue: Fillers" of Dermatologic Surgery, a peer-reviewed publication of the American Society for Dermatologic Surgery.

Results from the study, led by Steven R. Cohen, MD, Clinical Professor, Division of Plastic Surgery, University of California, San Diego School of Medicine, showcase the safety and aesthetic outcomes over a five-year period in patients treated with ArteFill for nasolabial fold wrinkles. This 5-year follow-up study evaluated 145 patients who were treated with ArteFill in Artes Medical's U.S. pivotal clinical trial.

In addition to demonstrating the safety profile of ArteFill, the study showed statistically significant (p less than 0.001) improvement in patient wrinkle correction 5 years after the patient's last ArteFill treatment, and a statistically significant (p=0.002) improvement in wrinkle correction at the 5-year point compared to the 6-month evaluation period.

Larry Weinstein,MD FACS

Mammographic findings after breast augmentation with autologous fat injection

Jenny Carvajal MD<<^1, <<and Jairo H. Patiño MD
Accepted 22 November 2007.  Available online 29 March 2008.

Background

Conventional film-screen mammography is a highly effective tool for the early diagnosis of breast cancer. Although the mammographic spectrum of fat necrosis has been well documented, and many postsurgical findings mimic carcinoma in clinical examination or imaging studies, the evolution of the mammographic appearance has not previously been reported in patients with a history of breast lipoinjection.

Barbed Sutures: A Review of the Literature.

COSMETIC - FACELIFT - NECKLIFT - JOWLLIFT - FACE LIFT

Plastic & Reconstructive Surgery. 121(3):102e-108e, March 2008.

Villa, Mark T. M.D.; White, Lucile E. M.D.; Alam, Murad M.D.; Yoo, Simon S. M.D.; Walton, Robert L. M.D.

Background: Despite substantial mention in the popular press, there is little in the plastic surgery or dermatology literature regarding the safety, efficacy, longevity, or complications of barbed suture suspension procedures. The authors review the literature to estimate several clinical parameters pertaining to barbed thread suspensions.

Methods: The authors performed a MEDLINE search using the keywords "barbed and suture," "thread and suspension," "Aptos," "Featherlift,"
and "Contour Thread."

Results: The authors identified six studies that met their criteria of addressing midface elevation with barbed thread suspension. These detected some adverse events, but most of these were minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect. Objective outcome measures and long-term follow-up data were not provided in a systematic manner in the few available studies.

Conclusions: Suspension of the aging face with barbed sutures offers the promise of a minimally invasive technique with diminished adverse events. The technique is in its infancy, but it has potential to be a useful and effective clinical tool as further innovations are made in the clinic and laboratory.

(C)2008American Society of Plastic Surgeons

Note: My experience with thread lifts has been positive. It is helpful in elevating nasolabial folds, cheeks, jowls and neck areas. It will never replace the results of SMAS facelift.

Larry Weinstein,MD FACS

Reduction Mammaplasty: A Review of Managed Care Medical Policy Coverage Criteria.

BREAST - BREAST REDUCTION - BACK PAIN - SHOULDER PAIN - NECK PAIN

Plastic & Reconstructive Surgery. 121(4):1092-1100, April 2008.

Nguyen, Jesse T. B.S.; Wheatley, Michael J. M.D.; Schnur, Paul L. M.D.; Nguyen, Tuan A. M.D., D.D.S.; Winn, Shelley R. Ph.D.

Background: Insurance companies evaluate the medical necessity for breast reduction surgery based on internal company medical policies, but the correlation of insurance company criteria to the scientifically established indications for reduction mammaplasty has never been studied. The authors obtained 90 insurance company medical policies for reduction mammaplasty to determine whether the criteria on which coverage determinations are made are consistent with published data regarding the indications for this procedure.

Methods: The authors reviewed the medical literature on reduction mammaplasty and identified what conclusions can reasonably be drawn  from this literature on the common insurance criteria used to determine medical necessity for reduction mammaplasty. Conclusions based on the medical literature regarding volume of reduction, symptom presentation, conservative therapy, obesity, presence of bra strap grooving and intertrigo, and age at time of reduction were formulated, and these conclusions were compared with the criteria of 90 different health insurance reduction mammaplasty medical policies.

Results: The authors were unable to identify any medical policies that could be supported in entirety by the medical literature and many that are completely unfounded based on the medical literature.

Conclusions: Insurance company medical policy requirements with respect to reduction mammaplasty are, in many cases, arbitrary and without scientific basis. Requirements for a specific volume of reduction, a minimum age, a maximum body weight, and a trial of conservative therapy are required by the majority of managed care medical policies, even though scientific support for any of these requirements is not evident in the medical literature.

(C)2008American Society of Plastic Surgeons

Note: I am very careful in my documentation of back, shoulder and neck pain secondary to severe breast hypertrophy. Lordotic spines and ulnar nerve dysesthesias ( hand numbness) are more common then the literature would suggest, Liz has been good with putting the documentation together for approvals from insurance companies that have ridiculous criteria.

Larry Weinstein,MD FACS

 

Hockey-Stick Vertical Dome Division Technique for Overprojected and Broad Nasal Tips C. W. David Chang, MD; Robert L. Simons, MD Arch Facial Plast Surg. 2008;10(2):88-92.

Objectives

To discuss overprojected and broad nasal tips, to overview treatment options, and to relate our experience with the hockey-stick technique.

Design A retrospective review (1975-2005) was conducted. Patients were selected from a computerized rhinoplasty database of operative cases.

The database was used to extract a subset population that had received the hockey-stick tip procedure and had follow-up data for 1 year or more after surgery. Medical records and photographs were also analyzed in this review of results and complications.

Results

The hockey-stick modification of vertical dome division was used in 137 patients (9.9% of the rhinoplasties in the computerized database). Of these, 64 patients had 1 year or more of follow-up.

Complications referable to the nasal tip (eg, bossae, persistent tip projection, and alar asymmetry) were seen in 8 patients (13%).

Revisions for tip-related problems were performed in 4 patients (6%).

Conclusions

The hockey-stick technique is an effective method for nasal tip deprojection and narrowing via an endonasal approach. The length of follow-up in this patient population allows good long-term evaluation of this technique.

Author Affiliations: Departments of Otolaryngology–Head and Neck Surgery, University of Missouri, Columbia (Dr Chang), and University of Miami, Miami, Florida (Dr Simons); and MIAMI Institute for Age Management and Intervention, Miami (Dr Simons).

Note : tip projection is a simple problem to reduce, increasing tip projection is more involved. The authors are commended for there work.

Larry Weinstein,MD FACS

 

Copyright © 2008 American Society for Aesthetic Plastic Surgery, Inc.

Published by Mosby, Inc.

Outpatient reduction mammaplasty: An eleven-year experience

W. Grant Stevens MD1, , Andrew J.L. Gear MD, David A. Stoker MD, Elliot M. Hirsch MD, Background

In the last 15 years, reduction mammaplasty has been increasingly performed on an outpatient basis. Despite this evolution, few outcome studies have been published regarding outpatient breast reduction surgery.

Objective

The authors documented clinical outcomes of reduction mammaplasty performed in an outpatient setting over an 11-year period and compared these results with published normative values in the plastic surgery literature.

Methods

A retrospective review was undertaken of 884 reduction mammaplasties in 444 patients at a single outpatient surgical center performed by the senior author (W.G.S.) from 1995 through 2006. In all cases, a laser-assisted, inferior pedicle, Wise pattern, reduction mammaplasty was performed. In addition to demographic and surgical data, complication frequency and type were recorded. Complication data were further stratified into minor and major categories. Potential minor complications included seroma, hematoma, soft tissue infection, dog-ears requiring revision, and small incisional breakdowns or delayed healing of less than 2 cm. Potential major complications included large incisional breakdowns or delayed healing of greater than 2 cm, nipple/areolar necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death.

Results

The mean patient age was 38 years (range, 16 to 73 years). Mean body-mass index was 27 (range 17 to 47). The reported preoperative brassiere cup sizes ranged from a 34 C to a 38 K, with a DD being the most common size. The mean preoperative sternal notch-to-nipple distance was 29 cm (range 22 to 54 cm). Forty patients smoked (9%).

Mean clinical follow-up was 13 months. Mean total resection weight of breast tissue was 1228 g (range 100 to 5295 g). Mean operative time for reduction mammaplasty was 115 minutes (range 50 to 195 minutes).

Nineteen percent of patients underwent multiple procedures, including abdominoplasty, lipoplasty, and facial procedures, with a mean operative time of 132 minutes (range 75 to 345 minutes). The overall complication rate was 14%, with 70 minor complications occurring in 62 patients. Specific minor complications included one seroma, four hematomas, eight soft tissue infections, two of which required a short course of intravenous antibiotics, one patient with dog-ears requiring surgical revision, and 56 small incisional wound breakdowns (< 2 cm).

The small incisional breakdowns, which represented the largest group of complications, were further subdivided into 44 minor T-zone wounds, 3 nipple-areolar complex wounds, and 9 wounds of the vertical and horizontal incisions. Three major complications (0.67%) were recorded.

Two patients had development of partial nipple/areolar necrosis. A third patient required anticoagulation for a pulmonary embolus diagnosed 10 days after surgery. Statistical analysis of the complication data revealed one significant relationship. Patients with a body mass index above the mean had a 21% complication rate as compared with a 12% rate for those below the mean. Of note, there was no increase in complication rate in the context of multiple procedures.

Conclusions

This retrospective series is the largest to date involving outpatient reduction mammaplasty. Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility.

Note: Since 1988 I have performed bilateral breast reduction on an outpatient basis. Rare minor complications have presented and only one tissue necrosis has been treated with improvement over time. It is a safe alternative for most patients.

Larry Weinstein,MD FACS

 

 

 

 

Impact of Cosmetic Facial Surgery on Satisfaction With Appearance and Quality of Life

Jason A. Litner, MD, FRCSC; Brian W. Rotenberg, MD, FRCSC; Maureen Dennis, BA, RN; Peter A. Adamson, MD, FRCSC

Arch Facial Plast Surg. 2008;10(2):79-83.

Objectives  To assess perioperative quality-of-life (QOL) changes in a facial plastic surgery patient population and to ascertain factors determinative of QOL changes. A notable paucity of objective scientific measurements of QOL exists within the facial plastic surgery literature.

Methods  A 3-year prospective cohort study. The patient population, which comprised a consecutive series of patients 16 years or older, undergoing cosmetic nasal or facial surgery, was obtained from the senior author's (P.A.A.) private surgical practice. All patients presenting for surgery were offered participation. The main outcome measure was the 59-item Derriford Appearance Scale (DAS59), a valid and reliable instrument assessing psychological distress associated with self-consciousness of facial appearance. Three patient score subgroupings were established: group 1, the DAS59 scores for all patients; group 2, the DAS59 score according to sex; and group 3, the DAS59 score according to the main surgical procedure. Surveys were administered to eligible patients at the final preoperative clinic visit and at 3 months after surgery. Data from the case-control groups were analyzed by a blinded statistician with appropriate t tests.

Results  A total of 93 patients were enrolled with a 100% response rate (82 females [88%] and 11 males [12%]). The most common procedures were rhinoplasty (49%) and surgery for the aging face (51%). Marked differences in perioperative QOL were noted across all DAS59 domains for group 1 and for all females in group 2. Male patients in group 2 analysis experienced QOL improvement only from DAS59 domain 2 (General Self-consciousness of Facial Appearance). Rhinoplasty and surgery for the aging face improved patients' QOL but differed with respect to which DAS59 domains were affected.

Conclusions  Quality of life was enhanced by facial plastic surgery in this patient population. Male and female patients seem to have different needs to be met from facial cosmetic surgery and correspondingly different areas of improvement in QOL. Rhinoplasty and surgery for the aging face act on different domains of QOL.

^{Note: Quality of life is a major factor and reason for proceding with facial rejeuvenation.                                 Larry Weinstein, MD FACS Chester, New Jersey}

Hematoma Rates in Drainless Deep-Plane Face-lift Surgery With and Without the Use of Fibrin Glue

Richard Zoumalan, MD; Samieh S. Rizk, MD

Arch Facial Plast Surg. 2008;10(2):103-107.

Objective  To determine the rate of hematoma formation in drainless deep-plane rhytidectomy and compare it with the rate using the same technique with the use of fibrin glue.

Methods  This is a retrospective review of 605 patients (78 male and 527 female) who, over a 6-year period, underwent deep-plane face-lift surgery (n = 544) or lateral superficial musculoaponeurotic system (SMAS)ectomy (n = 61) by the senior author (S.S.R.) without the use of surgical drains. One hundred forty-six consecutive patients underwent rhytidectomy without fibrin tissue glue, and the following 459 consecutive patients were sprayed with fibrin glue under the flap prior to flap closure. Pressure dressings were used on all patients for 24 hours.

Results  None of the patients in either group had major or expanding hematomas requiring operative intervention. In the group of patients treated without fibrin glue (n = 146), there were 5 minor, nonexpanding hematomas, all managed by needle aspiration. This is a minor hematoma rate of 3.4%. In the fibrin glue group (n = 459), there were 2 hematomas, for a rate of 0.4%. Using a Fisher exact test, we found a statistically significant decrease in the hematoma rate from 3.4% to 0.4% (P = .01). Male patients had a higher hematoma rate than female patients, and only men had significantly fewer hematomas when fibrin glue was applied (P = .01). All 7 hematomas were recognized in the first 24 hours after surgery. Of the 7 patients with hematomas, 2 (29%) had emesis in the recovery room despite medication.

Conclusions  The use of fibrin glue demonstrates a significant decrease in the rate of hematoma formation. Fibrin glue may benefit male more than female patients. If meticulous hemostasis and pressure dressings are used, drains are not necessary. The prevention and prompt treatment of postoperative nausea may also help prevent hematoma formation.

Note: Incidence in my practice of significant hematomas in facelift patient's has been zero. However hypertensive patient's are at increased risk and benefit from B blockers such as Inderal or nadolol. Male patients, smokers and high blood pressure patients are all at higher risk. Fibrin glue is effective slightly but increases the cost. Larry Weinstein, MD FACS Chester New Jersey

 

BBC Internet News

 

Overseas ops 'harm one in five'
It may be cheaper, but it could cause you problems, the survey suggests People who combine a foreign holiday with an operation are frequently left to deal with unpleasant complications, a Which? magazine survey suggests. Nearly one in five (18%) of respondents had health problems following treatment, including infections, and 8% needed urgent NHS care on their return. An estimated 80,000 UK residents opted for cheaper surgery abroad in 2006. Many cosmetic surgeons say they have ended up repairing the damage botched surgery carried out overseas. Medical tourists should do their homework before jumping on the plane, and avoid rushing back too quickly if they want to avoid potential problems Neil Fowler Editor, Which? The comparatively low prices of surgery and dentistry abroad are fuelling the dramatic rise seen in the past decade. Which? said that a tummy tuck which would cost £4,000 in the UK could be carried out for half that price in Poland. However, specialists say that flying into a foreign city for an operation means that patients are not properly assessed prior to surgery - and not given the right support afterwards. The majority of the 299 people polled by Which? said they were very satisfied with their treatment, but more than a quarter said they had not received the right follow-up care after their procedure. Among the 18% who reported problems were one patient who developed a severe infection after a tummy tuck operation, and another who said that she had been left leaking fluid following liposuction. Which? is also concerned about the quality of advice offered to would-be patients - one firm called anonymously said a full knee replacement was not a risky procedure, and that the patient would not need to be followed up by a clinician on returning to the UK. However half of all knee replacement patients need physiotherapy and all are reviewed as part of standard practice. Safety net Neil Fowler, the Editor of Which?, said: "Medical tourists should do their homework before jumping on the plane, and avoid rushing back too quickly if they want to avoid potential problems. "Ask the right questions beforehand, speak to UK health professionals and don't assume you'll have a safety net if things don't go according to plan." More than half the members of the British Association for Aesthetic Plastic Surgery who answered a survey last year said they had seen three or more dissatisfied patients following surgery abroad. Its president Douglas McGeorge said: "My experience with patients is that counselling is inadequate - the individuals have no idea of the standards of care in the country they are visiting and no knowledge of the abilities or experience of the surgeon. "Follow-up is difficult - complications do occur and are usually left to the British system to treat." Michael Summers, the vice-chairman of the Patients Association, said that patients should think very carefully before going abroad to have major surgery such as hip and knee replacement. "There is a lot more to this than just saving money - frankly, a 50% satisfaction rate is just not good enough, and if you come back to this country with problems after surgery, the NHS doctor won't know exactly what has been done to you, won't have seen the x-rays. "It's a frightening prospect." The Which? survey was sent out to 200,000 people. Note: The BBC are not the only observors of cosmetic surgery done by less then stellar individuals with results that are less then acceptable. All surgery has risk, when it is done at one of the center's I operate in the risl is less with close to a 99% satisfaction ratio. Larry Weinstein, MD FACS Chester New Jersey

Locally Administered Ketorolac and Bupivacaine for Control of Postoperative Pain in Breast Augmentation Patients: Part II. 10-Day Follow-Up.

COSMETIC

Plastic & Reconstructive Surgery. 121(2):638-643, February 2008.
Mahabir, Raman C. M.Sc., M.D.; Peterson, Brian D. M.D.; Williamson, J Scott M.D.; Valnicek, Stan M. M.D.; Williamson, David G. M.D.; East, William E. M.D.

Abstract:
Background: Previously, it was shown that locally applied intraoperative ketorolac and bupivacaine significantly reduced pain in the recovery room. The objective of this study was to test the effectiveness of the same solution over the first 10 days.

Methods: This study was a prospective, randomized, double-blind clinical trial with ethical approval. Fifty submuscular breast augmentation patients were enrolled, and informed consent was obtained. Standard anesthetic and surgical protocols were followed. Either normal saline or ketorolac and bupivacaine (30 mg and 150 mg, respectively) were placed into the pocket. The power of this study to detect a 20 percent difference was 0.90, and values of p < 0.05 were considered significant. The primary outcome was pain measured with the visual analogue pain scale recorded in a take-home diary. The secondary outcome was codeine usage.

Results: Forty-five patients completed the study. Of the patients who did not, three were in the normal saline group (n = 22) and two were in the ketorolac-bupivacaine group (n = 23). The ketorolac-bupivacaine combination significantly reduced pain over the first 5 days. By the tenth day postoperatively, the effect had dissipated. These patients also used less codeine. There were no significant complications.

Conclusion: Locally applied, intraoperative ketorolac and bupivacaine significantly reduced pain for 5 days after surgery in women who had undergone primary breast augmentation.

" Of note in my practice, I use bupivicaine in all patients with minimal complaint of pain subsequent to surgery. Most patient's in my practice require only tylenol postop for pain control. However, younger patient's who have never had children are more needy of medication."

Larry Weinstein, MD FACS 

(C)2008American Society of Plastic Surgeons

COSMETIC

Gender and Nasal Shape: Measures for Rhinoplasty.

COSMETIC

Plastic & Reconstructive Surgery. 121(2):629-637, February 2008.
Springer, Ingo N. M.D., D.M.D., Ph.D.; Zernial, Oliver M.D., D.M.D.; Nolke, Frederike D.M.D.; Warnke, Patrick H. M.D., D.M.D., Ph.D.; Wiltfang, Jorg M.D., D.M.D., Ph.D.; Russo, Paul A. J. M.D.; Terheyden, Hendrik M.D., D.M.D., Ph.D.; Wolfart, Stefan D.M.D., Ph.D.

Abstract:
Background: Gender-specific nasal shapes are recommended for rhinoplasty. This study was conducted to clarify whether there truly are gender-related differences and to determine optimal nasal shapes in a Caucasian population.

Methods: The authors created female and male composite photographs of "average" (n = 128 each), "optimal" (n = 16 each), and "most unpleasant" (n = 8 each) noses stratified on the basis of each photographed subject's (n = 311) own evaluation of the attractiveness of her or his nose, using a visual analogue scale. These composites were also assessed by 308 independent judges.

Results: Optimal female noses showed a horizontally and vertically lower nasion and were concave to straight in profile as compared with optimal male noses, which had a vertically and horizontally higher nasion and a straight profile. A supratip break was not found in any of the composites. At least half of the judges rated average and optimal male composite noses as female. A significant majority mistook the composite of the most unpleasant female noses as male (frontal view, 62.0 percent; lateral view, 72.4 percent; p < 0.001). Optimal and average female and male noses were found to be independently significantly more attractive than the most unpleasant ones (p < 0.001, n = 308 judges). Women and men with a straight or concave profile were significantly (p = 0.017 and p = 0.006, respectively) more satisfied with the appearance of their nose than those with nasal humps.

Conclusions: Gender-related differences in nasal shape appear to be subtle, with nasion position being one of the main factors. A nasal hump and a supratip break are not desirable.

(C)2008American Society of Plastic Surgeons

Male and female noses are different and require different methods for correction. A male nose should have a straight line a female nose should have a softer profile. Larry Weinstein, MD FACS

Secondary Malar Implant Surgery.
Plastic & Reconstructive Surgery. 121(2):620-628, February 2008.
Yaremchuk, Michael J. M.D.

Abstract:
Background: Iatrogenic problems may occur after malar implant surgery. These include asymmetry, displeasing contours (too wide, too large, too low, or too prominent) with time, and symptoms related to infraorbital nerve damage.

Methods: Implant removal at the time of secondary surgery leaves depressions in the cheek resulting from implant-induced bone erosion and soft-tissue contracture. Secondary surgery requires implant removal, implant replacement with appropriately positioned and sized implants, and cheek resuspension (subperiosteal midface lift) to mask and redistribute implant-induced soft-tissue distortions.

Results: Twenty of the 22 patients were satisfied with their secondary operation. One patient requested another revision and, later, implant removal. Another patient who had been previously treated for infection developed another infection requiring implant removal.

Conclusion: Malar implant-related midface deformities can be corrected by implant removal, deficiency-specific implant replacement, and subperiosteal midface resuspension.

(C)2008American Society of Plastic Surgeons

Endoscopic Periosteal Brow Lift: Evaluation and Follow-Up of Eyebrow Height.

COSMETIC

Plastic & Reconstructive Surgery. 121(2):609-616, February 2008.
Graf, Ruth M. M.D., Ph.D.; Tolazzi, Andre R. D. M.D.; Mansur, Alexandre E. C. M.D.; Teixeira, Viviane M.D. Abstract:
Background: Endoscopic brow lift has become widely accepted as a method for rejuvenation of the upper third of the face, mainly to achieve eyebrow elevation. In this study, the authors quantified eyebrow elevation after videoendoscopic subperiosteal technique and followed up the heights of the eyebrows at different postoperative intervals.

Methods: Seventy-two patients were submitted to endoscopic subperiosteal brow lift, and photographic evaluation was performed preoperatively and at different intervals postoperatively. From an interpupillary line, three different measurements on each side were obtained up to the superior border of both eyebrows. The distance between the medial eyebrows was also measured. Results were analyzed statistically by using the t test.

Results: C