Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery

Published by SAGE Publications
Online ISSN: 1527-330X
Publications
Article
The prostaglandin F2a (PGF2a) analogue bimatoprost 0.03% (Allergan, Inc, Irvine, California) has been employed for the treatment of hypotrichosis since it gained Food and Drug Administration approval as Latisse in 2008. In this report, the authors retrospectively review the cases of 7 patients who presented to their outpatient ophthalmology clinic with glaucoma. These patients had periorbital hollowing due to fat atrophy as a side effect of topical ophthalmic bimatoprost therapy. The series of patients described in this report emphasizes the small but significant risk of periocular fat changes associated with bimatoprost 0.03%, which is the exact formulation marketed as Lumigan for glaucoma treatment. Patients using Latisse for its cosmetic enhancement of eyelash length should be warned of this potentially disfiguring side effect, since the cosmetic and ophthalmic preparations are identical. Such changes can be irreversible, and the implications of the decision to prescribe this drug either in the form of an eyelash application or for topical ophthalmic use should be clearly understood by both clinicians and patients alike. Level of Evidence: 4
 
Article
We present a case of a delayed seroma with a fibrous capsule formation after insertion of a textured silicone gel-filled implant for the surgical correction of Poland syndrome, in spite of an uneventful intraoperative and early postoperative course. The result achieved after treatment of the seroma without reinsertion of an implant was aesthetically satisfactory.
 
Article
Since the introduction of fourth- and fifth-generation silicone gel implants, manufacturers have conducted several prospective, multicenter trials to examine their safety and efficacy. However, these studies were not standardized with regard to surgeon skill, pocket placement, operative technique, adjunct therapies, or postoperative management. The purpose of this study was to examine the surgical outcomes of a single surgeon (WGS) in a consecutive series of breast augmentation cases using a fourth-generation cohesive silicone MemoryGel breast implant (Mentor, Santa Barbara, CA). A retrospective chart review was conducted to identify all patients who underwent silicone breast augmentation within the Mentor Adjunct Silicone MemoryGel breast implant by a single surgeon (WGS) within a single free-standing outpatient surgical center over a 13-year period (1992 to 2006). For each patient, demographic information, comorbidities, and surgical information (implant size and concomitant surgery) were recorded. In addition, outcomes were analyzed to identify complications and the need for surgical revision. A total of 1012 fourth-generation, textured, cohesive silicone gel implants were placed in 511 patients during the 13-year study period. The overall complication rate per implant was 5.5% (n=56 implants in 43 patients). The most common complication was capsular contracture (n=26; 2.6 %) followed by abnormal scarring (n=11; 1.1%). The overall revision rates per patient and per implant were 8.0% (n = 41 patients) and 6.8% (n = 69 implants), respectively. The average time interval between initial implantation and revision was 18.5 months (range, 2 weeks to 26 months). The most common indication for surgical revision was patient desire for implant size change (n=15 patients) followed by Baker class III or IV capsular contracture (n=13 patients). The presence of previous surgery for capsular contracture was not statistically correlated to the need for revision (P= .326). Age (P= .568), previous history of breast surgery (P= .704), and history of smoking (P= .138) were also not statistically correlated to revision. Placement of the implant in the subglandular position (n=30 implants), however, was statistically correlated with need for revision (P< .01). Mentor fourth-generation cohesive silicone gel implants possess a complication and revision profile that is superior to earlier-generation silicone gel implants. Implantation with MemoryGel implants, when standardized with regard to surgeon and operative technique, can have significantly reduced complication and revision rates compared to the Mentor Core Data.
 
Article
Background: Controversy persists regarding the optimal procedure to rejuvenate the aging neck. More invasive procedures carry increased risks of complications, whereas less invasive approaches may deliver marginal results. The challenge is selecting the appropriate procedure for delivering consistent, durable results meeting both the patient’s and surgeon’s expectations. Objectives: The authors describe their trampoline platysmaplasty (TPP) approach, a percutaneous suture suspension necklift that constitutes a less invasive approach for neck rejuvenation. Methods: A retrospective study was conducted of 105 consecutive patients who underwent TPP. Age, sex, procedure(s) performed, complications, and patient satisfaction were recorded. Cadaver studies were conducted to compare the tensile strength of the ligaments that anchor the TPP to the tensile strength of the sutures placed to approximate the medial platysma borders. In addition, the accuracy of light transillumination to determine depth of travel of the light-emitting diode (LED) lighted rod was evaluated. Results: Patients underwent either TPP alone (18 women, 24 men) or TPP with a facelift (35 women, 28 men) between October 2007 and June 2009. The average age of the patients was 52 years, and average length of follow-up was 33 months. Patient satisfaction was high. Three early patients underwent immediate revision to improve results secondary to the suture matrix being too loose. Six additional patients had recurrent banding around one year postoperatively, but correction was achieved in all six by replacing the matrix with the help of the lighted rod. The results of the cadaver study revealed that the tensile strength of the retaining ligaments was statistically identical to the medial platysma borders, and the light transillumination feedback was accurate with regard to the depth of travel of the illuminated rod tip. Conclusions: The TPP approach for neck rejuvenation is effective and durable in properly-selected patients. It works well as a stand-alone procedure and in conjunction with facelift procedures. It also offers younger patients a less-invasive option to improve neck contours inherited through genetics. After nearly three years of follow-up of the patients in this report, the results appear to be long-lasting. Level of Evidence: 4.
 
Article
Background: Controversy persists regarding the optimal procedure to rejuvenate the aging neck. More invasive procedures carry increased risks of complications, whereas less invasive approaches may deliver marginal results. The challenge is selecting the appropriate procedure for delivering consistent, durable results meeting both the patient’s and surgeon’s expectations.Objectives: The authors describe their trampoline platysmaplasty (TPP) approach, a percutaneous suture suspension necklift that constitutes a less invasive approach for neck rejuvenation.Methods: A retrospective study was conducted of 105 consecutive patients who underwent TPP. Age, sex, procedure(s) performed, complications, and patient satisfaction were recorded. Cadaver studies were conducted to compare the tensile strength of the ligaments that anchor the TPP to the tensile strength of the sutures placed to approximate the medial platysma borders. In addition, the accuracy of light transillumination to determine depth of travel of the light-emitting diode (LED) lighted rod was evaluated.Results: Patients underwent either TPP alone (18 women, 24 men) or TPP with a facelift (35 women, 28 men) between October 2007 and June 2009. The average age of the patients was 52 years, and average length of follow-up was 33 months. Patient satisfaction was high. Three early patients underwent immediate revision to improve results secondary to the suture matrix being too loose. Six additional patients had recurrent banding around one year postoperatively, but correction was achieved in all six by replacing the matrix with the help of the lighted rod. The results of the cadaver study revealed that the tensile strength of the retaining ligaments was statistically identical to the medial platysma borders, and the light transillumination feedback was accurate with regard to the depth of travel of the illuminated rod tip.Conclusions: The TPP approach for neck rejuvenation is effective and durable in properly-selected patients. It works well as a stand-alone procedure and in conjunction with facelift procedures. It also offers younger patients a less-invasive option to improve neck contours inherited through genetics. After nearly three years of follow-up of the patients in this report, the results appear to be long-lasting.Level of Evidence: 4.
 
Article
Perioperative hypothermia has been associated with increased rates of infection, prolonged recovery time, and coagulopathy. The authors assessed the impact of hypothermia on patient outcomes after plastic surgery and analyzed the impact of prewarming on postoperative outcomes. The medical charts of 1062 patients who underwent complex plastic surgery typically lasting at least 1 hour were reviewed. Hypothermia was defined as a temperature at or below 36°C. Postoperative complication data were collected for outcomes including infection, delayed wound healing, seroma, hematoma, dehiscence, deep venous thrombosis, and overall wound problems. Odds ratios (ORs) were estimated from 3 multivariate logistic regression models of hypothermia and one model of body contouring procedures that included prewarming as a parameter. Perioperative hypothermia was not a significant predictor of wound problems (OR = 0.83; P = .28). In the stratified regression model, hypothermia did not significantly impact wound problems. The regression model measuring the interaction between hypothermia and operating time did not show a significantly increased risk of wound problems. Prewarming did not significantly affect perioperative hypothermia (P = .510), and in the model of body contouring procedures with prewarming as a categorical variable, massive weight loss was the most significant predictor of wound complications (OR = 2.57; P = .003). Prewarming did not significantly affect outcomes (OR = 1.49; P = .212). Based on univariate and multivariate models in our study, mild perioperative hypothermia appears to be independent of wound complications. LEVEL OF EVIDENCE 4: Risk. © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.
 
Article
The use of the laser as an auxiliary tool has refined the traditional technique for lipoplasty. During laser lipolysis, the interaction between the laser and the fat produced direct cellular destruction before the suction, reduced bleeding, and promoted skin tightening. This study sought to perform a comparative histologic evaluation of laser lipolysis with the pulsed 1064-nm Nd:YAG laser versus a continuous 980-nm diode laser. A pulsed 1064-nm Nd:YAG (Smart-Lipo; Deka, Italy) and a CW 980-nm diode laser (Pharaon, Osyris, France) were evaluated at different energy settings for lipolysis on the thighs of a fresh cadaver. The lasers were coupled to a 600-microm optical fiber inserted in a 1-mm diameter cannula. Biopsy specimens were taken on irradiated and non-irradiated areas. Hematoxylin-erythrosin-safran staining and immunostaining (anti-PS100 polyclonal antibody) were performed to identify fat tissue damage. In the absence of laser exposures (control specimens), cavities created by cannulation were seen; adipocytes were round in appearance and not deflated. At low energy settings, tumescent adipocytes were observed. At higher energy settings, cytoplasmic retraction, disruption of membranes, and heat-coagulated collagen fibers were noted; coagulated blood cells were also present. For the highest energy settings, carbonization of fat tissue involving fibers and membranes was clearly seen. For equivalent energy settings, 1064-nm and 980-nm wavelengths gave similar histologic results. Laser lipolysis is a relatively new technique that is still under development. Our histologic findings suggest several positive benefits of the laser, including skin retraction and a reduction in intraoperative bleeding. The interaction of the laser with the tissue is similar at 980 nm and 1064 nm with the same energy settings. Because higher volumes of fat are removed with higher total energy, a high-power 980-nm diode laser could offer an interesting alternative to the 1064-nm Nd:YAG laser.
 
Article
Internal lipoplasty (iLAL) represents an evolving procedure that depends on delivery of sufficient and controlled thermal energy for lipolysis and collagen denaturation. Of the two outcomes, the particular advantage of iLAL may exist in its capability to selectively denature, remodel, and contract collagen and elastin fibers for eventual skin contraction. Despite the practice of sound laser principles and clinical outcomes, laser lipolysis has not been readily accepted because of its yet unproven advantages over other liposuction devices. This limited clinical research study on the lower abdomen of three female subjects provides objective data by Vectra 3D analysis (Canfield Scientific, Fairfield, New Jersey) of significant skin contraction (average, 9.1% at three months; average, 7.6% at six months) as a consequence of the application of sequential wavelengths of 8 W 1064 nm/8 W 1320 nm within the shallow but not the deep subdermal layers. The application of sustained and confluent thermal injury within the targeted 4 x 10-cm rectangular panel (zone 5) was continually monitored by an internal temperature-sensing cannula (45-47 degrees C) and by an external surface temperature-sensing infrared camera, recording surface skin temperatures to 40-42 degrees C threshold levels. Minimal skin contraction was measured at three months in panels that were treated by tumescence (1.1%, zone 1) and cannulation (1.5%, zone 2). Of interest, the slight increase in skin contraction in zones treated by volume reduction after liposuction (3.6%, zone 3) or deep lasing plus liposuction (3.6%, zone 4) may be due more to skin accommodation than active skin contraction. The second highest amount of skin contraction was observed in zone 6 (4.2%), which was treated by shallow lasing, liposuction, and deep lasing. Further quantitative clinical studies will be needed to validate these findings.
 
Article
By early afternoon on September 11, New York was a different city than it had been just hours before, and lower Manhattan was a different world. A thick cloud of smoke from the devastation at the World Trade Center filled the sky and could be seen from almost every corner of the city. Sidewalks were filled with stunned throngs of people who had been directed to walk north. The shrill sirens of fire trucks and ambulances could be heard blaring as they raced in the opposite direction. Lines formed around hospitals and other facilities where blood donations were being collected, and rescue volunteers assembled in front of armories where armed guards in full combat gear were stationed. For me, the day had started out like most others. I had planned on a full schedule of elective surgery in the morning, new patients …
 
Article
Background: Despite the increasing popularity of the combined augmentation mastopexy procedure among patients, the safety and efficacy of this surgery have been questioned by many surgeons. Objective: The authors investigated the safety and efficacy of the combined augmentation mastopexy procedure. Methods: The authors retrospectively reviewed the medical records of 615 consecutive patients who underwent combined augmentation mastopexy procedures at a single outpatient surgery center from 1992 through 2011. Patient demographics, operative and implant details, and long-term outcomes were analyzed. Rates of complications and revisions were calculated. Results: The most common complications were poor scarring (5.7%), wound-healing problems (2.9%), and deflation of saline implants (2.4%). Of the 615 patients evaluated, 104 (16.9%) elected to undergo revision surgery: 54 revision procedures were secondary to implant-related complications, and 50 were secondary to tissue-related complications. Our data compare favorably with previously reported revision rates for breast augmentation alone and mastopexy alone. Conclusions: With a skilled surgeon and proper patient selection, the combined augmentation mastopexy procedure can be safe and effective. Level of Evidence: 4
 
Article
Polyacrylamide hydrogel (PAHG) is widely used in biomedical research and industry and has been used as a soft tissue filler in some countries for more than a decade. The author evaluated the results of malar area augmentation with PAHG. Results from 1306 patients who were treated with PAHG for soft tissue augmentation of the malar area from 2000 to 2006 were retrospectively assessed. Follow-up ranged from 3 months to 6 years. Patients were initially satisfied in 95% of cases (1241 patients). In 5% of cases (65 patients), patients were not satisfied with the result because the injected volume was insufficient. Adverse events occurred in 8.4% of cases (111 patients) with lumps, gel displacement, and pain being the most frequent complications. In our experience, PAHG has proven to be a safe material for achieving facial soft tissue augmentation with minimal side effects. A follow-up study is necessary to evaluate longer-term results and possible side effects of augmentation with PAHG.
 
Article
Preferred techniques for rejuvenation and contouring of the neck region have evolved over the past 40 years. A slender neckline is recognized as an attractive feature of youth, whereas aging of the lower face often includes ptosis of the soft tissues of the chin and banding or cording of the muscles of the anterior and lateral neck. Aesthetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. The authors review their 14-year experience with a technique incorporating standard submental liposuction with a method of triple suturing the medial platysmal bands associated with lateral plication of the superficial muscular aponeurotic system (SMAS)-platysma. Between 1994 and 2008, 507 patients (451 women and 56 men) were treated with this technique which consisted of placing a first line of sutures distributing tension between the medial platysmal bands and the anterior belly of the digastric muscles, a second single suture at the distal medial borders of the platysma, and a third running suture starting at the level of the thyroid cartilage up to the supramental region. In most cases, a lateral plication of the SMAS-platysma and a "stair-like" SMAS plication were performed in order to define the cervicomandibular line and treat midface flaccidity, respectively. Mean follow-up was eight years. Complications included hematomas (4.6%) and seromas (3.6%). Four percent of patients underwent a second procedure approximately seven years after their primary procedure. Overall the majority of patients exhibited long-lasting results satisfactory to both patients and surgeons. The triple-suture technique for neck contouring creates a median vertical vector of traction, whereas lateral plication produces a lateral posterior oblique vector. The combination of these two procedures is an easily reproducible and reliable option for surgeons when patients are seeking a more youthful appearance of the neck.
 
Article
In my opinion, there are four holy grails of cosmetic surgery that the baby boomer generation has been actively pursuing over the last 20 years: noninvasive skin tightening, localized noninvasive fat reduction, stretch mark improvement, and treatment of cellulite. In his study, Dr. DiBernardo introduces an interesting, novel, and promising new approach to the last of these goals. As the author points out, his study is limited by a small number of patients (10). However, this study is well designed as a prospective controlled model. The clear strengths of the study include the full year of follow-up, the clearly-demonstrated photographic improvement, and the objective measurements of skin elasticity and thickness. One of the most confusing areas of laser surgery is the area of optimal wavelength utilization. Anderson et al outlined the optimal wavelengths for fat absorption.1 However, that study actually outlined fat absorption from external laser radiation and did not examine the effectiveness of absorption when the laser was fired into the hypodermis in direct contact with the fat itself. Many wavelengths are utilized in the melting of fat (eg, 920 nm, 975 nm, 1064 nm, 1320 nm, and 1440 nm), and the characteristics of each are beyond the scope of this commentary. However, the 1440-nm wavelength—the one administered in Dr. …
 
Article
Background: Historically, treatments for cellulite have not been able to address all of its physiological components and require multiple sessions. Objective: The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite. Methods: Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the ability of blinded evaluators to distinguish baseline photos from those taken at 3 and 6 months posttreatment, as well as their rating of the results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to those taken at 2, 3, and 6 months posttreatment. Patient and physician satisfaction was assessed based on completion of a satisfaction survey at 2, 3, and 6 months posttreatment. Adverse events (AE) were recorded throughout the study. Results: At 6 months posttreatment, blinded evaluators rated at least a 1-point improvement in the appearance of cellulite in 96% of treated sites. Blinded evaluators were also able to correctly identify baseline versus posttreatment photos in 95% of cases. At least 90% of patients and physicians reported satisfaction with the results of treatment throughout 6 months. AE were mild in intensity and transient to treatment. Conclusions: A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 6 months posttreatment. Level of Evidence: 2
 
Article
Cellulite is characterized by a thickened hypodermal fat layer, along with hypodermal fat lobules that extend upward into the dermis, expanding and stretching the fibrous septae that separate the fat lobules. Eventually, the septae sclerose, contract, and harden, holding the skin at an inflexible length while the surrounding tissue continues to expand. The author evaluates the efficacy, safety, and duration of clinical benefit associated with a pulsed laser that delivers 1440-nm energy to the dermal-hypodermal interface for the treatment of cellulite. The changes in the dermal structure that affect the appearance of cellulite are also examined. Ten healthy women with cellulite on their thighs enrolled in a prospective Institutional Review Board-approved study conducted in the author's private plastic surgery clinic. Patients received a single treatment with a 1440-nm pulsed laser. Energy was delivered to the subdermal tissue through a fiber that was designed for side firing and enclosed in a cannula. Treatment addressed the thickened hypodermal fat layer, hypodermal fat lobules that extended upward into the dermis, and fibrous septae by thermal subcision. The mean age of the patients was 47 years ± 5.4 years. Mean skin thickness (as shown by ultrasound) and skin elasticity were shown by objective measurements to increase significantly at one, three, six, and 12 months. Subjective physician and subject evaluations indicated improvement, high subject satisfaction, and minimal adverse effects. In this study, a single treatment with the 1440-nm pulsed laser improved the appearance of cellulite, an improvement that persisted through at least one year of follow-up with minimal adverse effects.
 
Article
Although there is an abundance of data in the literature regarding the safety of breast reduction and augmentation, nearly all of the literature concerning mastopexy describes techniques. There are few studies regarding revision and complication rates for mastopexy procedures. A retrospective review was performed on a series of 150 consecutive patients who underwent a mastopexy procedure. Operations were performed by one of two surgeons (W.G.S. or D.A.S.) in an outpatient surgery center over a 6-year period (1999-2005), with an average follow-up of 36 months. Patients were identified as being either primary (no previous breast surgery) or secondary (history of at least one previous breast surgery). The type of mastopexy design was recorded (inverted-T or vertical), and trends were examined. Complication and revision rates were observed, and their rates were calculated. One hundred forty-eight women underwent bilateral and two underwent unilateral mastopexy for a total of 150 women and 298 breasts. There were 119 primary and 31 secondary patients. Mastopexy incision designs were as follows: 86% inverted-T and 14% vertical. There were no major complications. The most common complications were poor scarring (6%) and seroma formation (2.7%). The revision rate was 8.6%; 75% of revisions were for poor scarring. Some of these were performed with the patients under local anesthesia or at the time of a subsequent unrelated surgery. Our series of 150 consecutive patients, with no major complications and a revision rate of 8.6% over an average of 36 months, indicates that mastopexy may be considered a safe and effective procedure.
 
Article
Current striae treatments are limited in their ability to deliver long-lasting improvements for all skin types. The success of fractional nonablative lasers for surgical scars has been attributed to the controlled wound-healing response stimulated by microscopic columns of epidermal and dermal thermal damage. The authors describe the safety and efficacy results of treatment with a fractional nonablative 1540-nm erbium:glass laser in patients with Fitzpatrick skin types II to IV for both striae rubra and striae alba. A 51-person clinical study was conducted on striae ranging in duration from one to 40 years. Nine different anatomical locations were treated, including the breasts, hips, and abdomen. Treatment parameters included two to three passes with the 1540-nm laser, with energy settings from 35 to 55 mJ/mb with the 10-mm optical tip or 12 to 14 mJ/mb with the 15-mm optical tip. Two to four total treatments were performed at four- to six-week intervals. Nonblinded efficacy evaluations were performed on all 51 patients; blinded evaluations were conducted by three independent clinicians on 14 randomized sets of pre- and posttreatment images on a 0% to 100% quartile improvement scale. Skin reactions were assessed by the treating physician and recorded at multiple time points, and histology was conducted with hemotoxylin and eosin as well as Orcein-Giemsa staining. Nonblinded clinical assessments rated overall improvement as 50% or greater for all patients at six months or longer after the last treatment. Blinded evaluators reported an overall mean improvement score of 51% to 75% on properly selected images taken at least three months after treatment (n = 11). In all patients examined at either 18 or 24 months after treatment, there was no recurrence of striae. Typical side effects included transient erythema and edema. A small minority of patients experienced transient cases of trace postinflammatory hyperpigmentation (PIH), which all resolved. Histologic observations showed thickening of the epidermis and dermis, neocollagenesis, and increased elastin deposition one month after the last treatment. Positive safety and efficacy results with the fractional nonablative 1540-nm erbium:glass laser for the treatment of striae rubra and striae alba ranging in maturation age from one to 40 years was demonstrated in Fitzpatrick skin types II to IV.
 
Article
Pulmonary embolism (PE) represents the third most frequent cause of postoperative death in the United States. In recent years, there has been an increasing demand among plastic surgeons for patient safety guidelines that specifically address the complications of deep venous thrombosis (DVT) and PE in relation to aesthetic surgery. In this study, we review 3871 consecutive major body contouring procedures performed over the last 8 years in our surgery center in an attempt to identify common factors that could have contributed to the onset of DVT/PE in 17 of these patients. We conducted a retrospective chart review to identify common factors associated with the occurrence of DVT/PE in high risk patients who undergo aesthetic surgery. Among these patients, we calculated the following incidence rates: 0.46% for DVT and 0.08% for PE. We discovered that a culmination of factors working synergistically play a significant role in the development of DVT/PE. We conclude that a carefully planned, comprehensive, appropriately enforced protocol is necessary to reduce the rate of thromboembolic events. Practical safety measures and technical recommendations are presented that strongly encourage the use of thromboprophylaxis during the pre-, intra-, and postoperative phases of aesthetic surgical procedures. We feel that DVT and PE prevention should involve a partnership between patient and surgeon.
 
Article
The combination of liposuction and abdominoplasty has been slow to be accepted, primarily due to a perceived higher incidence of complications associated with the procedure. There has also been extensive debate about the combined procedure's effects on flap vascularity and viability and the extent to which liposuction may be performed in conjunction with surgical abdominoplasty. The authors present data from their four-year experience supporting lipoabdominoplasty as a safe and effective procedure for body contouring. The authors retrospectively reviewed a case series of lipoabdominoplasties performed between 2004 and 2008 by the senior author (KK). A total of 173 consecutive patients who presented for abdominal contouring were included in the study. Each patient underwent a combined procedure beginning with liposuction utilizing the superwet technique, followed by an inverted V-pattern abdominoplasty. Of the patients included in this study, 171 (98.8%) were women and two (1.2%) were men. The average age of the patients was 41.53 years, and the average body mass index was 26. The average amount of total lipoaspirate from the flanks was 2166.09 mL, and the average specimen weight resected was 972.80 g. Complications included partial dehiscence/skin necrosis (12 patients; 6.9%), infection requiring antibiotic therapy and/or intervention (13 patients; 7.5%), suture spitting (one patient; 0.5%), seroma (six patients; 3.4%), major fat necrosis requiring local debridement (one patient; 0.5%), and skin flap necrosis requiring readvancement of the abdominal flap (two patients; 1.1%). There was a revision rate of 8.0%: two patients required additional liposuction to smooth out unevenness, five patients required scar revision, and seven patients had dog-ears requiring intervention. All revisions were performed under local anesthesia. There were also five instances of confirmed deep vein thrombosis (2.8%) and two cases of pulmonary embolism requiring hospitalization (1.1%). The senior author's (KK) lipoabdominoplasty technique, combined with his current preoperative and postoperative protocols, is believed to be a safe procedure that results in excellent cosmetic results. In contrast to some of the current literature, the data show a reduction of overall complications as compared to historical norms.
 
Article
Background: Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. Objective: The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. Methods: A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. Results: A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. Conclusions: Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making. Level of Evidence: 3
 
Article
Plastic surgeons and manufacturers of breast implants have been examining the complication and reoperation rates of primary breast augmentations for more than 18 years. The seemingly high rates reported by the manufacturers to the United States Food and Drug Administration (FDA) were the impetus for this multicenter study. This paper reports on data pooled from three plastic surgery practices that were geographically distributed across the United States and examines the reoperation rate, time to reoperation, the reason for reoperation, and specific complications in 177 consecutive primary breast augmentation patients. These data are statistically compared to the manufacturers' 2005 and 2008 FDA data. In addition, the significance of selected variables from our data are examined as predictors for reoperation. Data were retrospectively collected from 177 consecutive primary breast augmentations performed between 2001 and 2004 from three surgical practices. Direct physician-to-patient follow-up periods ranged from 12 to 58 months, with 100% of patients having at least one year of follow-up. Each practice extracted chart data on variables and complications, including reoperations. These data were independently collated and sent to an independent biostatistician for analysis. Our three year Kaplan-Meier (KM) reoperation rate (8%) and capsular contracture rate (2%) were both lower than the manufacturers' KM 3-year rates for reoperation (13%-21%) and capsular contracture (8.2%-9%). Logistic regression identified only simultaneous mastopexy and preexisting ptosis as predictors of reoperation.
 
Article
Reconstruction of the suprapalpebral fold (SPF) to create a double eyelid is a popular procedure in many East Asian countries. However, the traditional long-incision, double-eyelid blepharoplasty procedure can result in eyelid swelling that lasts for months, resulting in the temporary appearance of an excessively high SPF. The author describes 18 years of experience using a short-incision technique for Asian blepharoplasty in 6215 patients. A short incision to minimize eyelid trauma and surgical scarring was made on only the middle one-third of the upper eyelid. The dissection was extended far enough superiorly, medially, and laterally above the levator aponeurosis to obtain maximum upward movement of the globe. Three anchoring sutures were placed for the creation of the permanent SPF, with inverted stitches between either the levator aponeurosis or the lower border of the stripped orbital septum, to either the dermis or the dermomuscular junction of the lower margin of the incised skin. Intraoperative adjustment of the curvature and the lateral flare of the SPF was accomplished by changing or releasing the point of the anchoring suture in four different ways: to either the upper or lower dermal or dermomuscular junction of either the lower or upper margin of the incised wound or, on rare occasions, by a small elliptical excision of the upper skin flap. In 70% of patients, changing the medial anchoring suture to the proper position resulted in the creation of suprapalpebral outside fold, without any need to perform epicanthoplasty. The average operative time was 33 minutes. Most patients did not need to refrain from attending work or school. The postoperative complication rate was 3.8%. The most common temporary unfavorable results were minimal swelling, bruising, and eversion of the eyelid margin. Minor complications included asymmetrical fold, fading of the fold, depressed scar, and drooping of lateral eyelid skin. All of the minor complications were treated successfully. There were no severe complications. The short central incision is a semi-open blepharoplasty technique for creating the double eyelid that is suitable for all patients without loose upper eyelid skin.
 
Article
Although some authors have reported that 1-stage breast augmentation with mastopexy does not increase the risks of surgery, recent literature has raised the question of whether better results might be achieved by staging the procedures. The authors evaluated the safety and efficacy of 1-stage breast augmentation with mastopexy in their own patients by analyzing long-term complication and revision rates. A retrospective chart review was performed of 186 consecutive patients who underwent primary 1-stage breast augmentation with mastopexy at a single outpatient facility. Patient data recorded included age, body mass index, smoking status, degree of breast ptosis, and any preoperative asymmetry. Operation-related data recorded included type of mastopexy performed, operating surgeon, length of surgery, American Society of Anesthesiologists level, and concomitant procedures. Data on implant type, volume, and position were also collected. Complication and revision rates were recorded and calculated. Ninety-six patients (44%) received saline implants; 104 (56%) received silicone implants. In most cases, textured implants were placed in submuscular pockets. The mean implant volume was 320 cc. Inverted T mastopexy was performed in 60% of cases, circumareolar in 24% of cases, and vertical or crescent accounted for most of the remainder. No severe complications occurred, although 1 patient developed a late infection that required removal of the breast implant. The most common complication was saline implant deflation (5.9%), although saline implants were used in less than half of cases. Thirty-one patients (16.7%) underwent some form of revision surgery within the average 42-month follow-up period. Our review of 1-stage breast augmentation with mastopexy procedures revealed no severe complications. Although the overall revision rate of 16.7% is significant, it is comparable to rates for breast augmentation alone and is significantly lower than the 100% reoperation rate required for a staged procedure. In our experience, it is a safe and effective procedure, although one that is not easy to perform. Patients should be advised of the possibility that a second procedure may be necessary.
 
Article
The current technique of “tumescent anesthesia,” popularized by Dr. Jeffrey A. Klein, has evolved from the developments of local anesthetic agents and various infusion devices over the last 110 years. “Tumescent anesthesia” is really a variation of a much older technique known as “massive infiltration” or “hard infiltration.” By 1915 “massive infiltration analgesia with weak analgesic solutions” was a well-developed and widely used form of analgesia. Various pressurized or motorized devices for the propulsion of the solutions, flexible needles, multiple formulas, and many applications of the technique were described and illustrated in several standard American surgical textbooks of the 1920s and 1930s. The goal was to render a large field anesthetic and relatively bloodless by use of only regionally injected solutions. In our current era, Dr. Ed Hamacher et al. and Dr. Klein deserve credit for reintroducing this old technique and for establishing new parameters for lidocaine toxicity. It is important for us to remember that the current technique of “tumescent anesthesia” really evolved over the last 110 years as the synthesis of the ideas of many individuals throughout the world.
 
Article
Although "tumescent anesthesia" has been described as a new technique, historical references reveal that in reality it has been used for decades all over the world. In "The History of Tumescent Anesthesia, Part I: From American Surgical Textbooks of the 1920s and 1930s" (Aesthetic Surg J 1998;18:353-357), Dr. Welch reported on early references to tumescent anesthesia in works published in the United States. In Part II, the authors report that tumescent anesthesia is very similar to a local anesthesia method, "Vishnevsky Local Anesthesia," widely known and used in Russia since the 1930s. (Aesthetic Surg J 2002;22:46-51.).
 
Article
In recent years, aesthetic surgeons performing breast augmentations have focused increasingly on improving patient outcomes and reducing reoperation rates.1 In doing so, emphasis has been placed on the entire “process” of breast augmentation, from consultation and preoperative education, to patient evaluation and operative planning, to surgical technique and standardized postoperative care.1-3 When assessed as a whole, each section of the process has become better defined in terms of its contribution to the overall goal of improved outcomes.4,5 On the basis of comprehensive approaches to the breast augmentation process, several authors have published individual series with low reoperation rates ranging from 0% to single digits.6-10 When we recognize the necessity of a comprehensive approach applied to the entire process, it is hard to imagine how a single minor subset of this process could be heralded as yielding a straightforward cause-and-effect phenomenon—for example, the placement of a specific sizer in combination with an implant that has not gone under multicenter trials, in an article with limited reference to the other essentials steps in the process, such as the one by Drs. Gore and Lamberty (“PERTHESE Implant-Identical Cohesive-Gel Sizers in Breast Augmentation: A Prospective Report on 200 Consecutive Cases and Implications for Treatment of Breast Asymmetry”). Furthermore, the structure of the study investigating this device is a concern; the authors combined augmentation mastopexy procedures and aesthetic breast revisions in the same group with primary augmentations. More challenging procedures (such as revisions …
 
Article
The insertion of sizers in breast augmentation surgery is a common method of predicting the final volume of prosthesis required. However, saline-filled sizers may not accurately represent the shape of the cohesive-gel-augmented breast. PERTHESE cohesive-gel breast implants are produced with matching sets of reusable (sterilizable) cohesive-gel-filled sizers that accurately predict the form of the augmented breast. The authors assess the efficacy of PERTHESE sizers and implants in 200 consecutive patients who presented for breast augmentation. Data were prospectively collected for all patients who underwent bilateral breast augmentation between 2003 and 2010 with the senior author (BGHL), during which time he inserted PERTHESE implants exclusively in his clinical practice. The 200 patients included in this series were analyzed according to demographic details, preoperative findings (including the presence of breast asymmetry), surgical approach, postoperative patient and surgeon satisfaction scores, and complications. Less than 2% of patients in this series experienced complications such as hematoma, seroma formation, or infection. Capsular contracture developed in 7% of patients, but there were no visible or painful capsules. Only 2% of patients elected to undergo surgical revision for aesthetic reasons. A high proportion (87%) of the 27 patients who had significant preoperative breast asymmetry were satisfied with the aesthetic outcome of their surgery. Likewise, a significant percentage (92%) of the 148 patients who had preoperative breast symmetry were satisfied with their outcome. Application of intraoperative form-stable cohesive-gel sizers can enhance the surgeon's ability to predict the final appearance of the augmented breast. The placement of these form-stable sizers and implants is a particular advantage in cases of established breast asymmetry.
 
Article
Background: Transaxillary augmentation mammaplasty (TAM) is an option for patients who wish to avoid a visible breast incision from breast augmentation (BA). Objectives: The authors compared TAM outcome data for gel and saline implants and evaluated patient satisfaction using the BREAST-Q patient-reported outcome measure (BQ). Methods: In this 10-year retrospective, comparative, and cross-sectional study, the authors reviewed results of saline implants placed with TAM in a surgeon’s practice during the final 5 years of the moratorium of the US Food and Drug Administration (phase 1) and compared them with results for gel and saline implants placed with TAM during the 5 years after the moratorium (phase 2). Outcomes were assessed for the entire BA study population (n = 2430 for primary BA; 4860 implants); 670 patients completed and returned the BQ, from which postoperative satisfaction was evaluated. Results: BQ responses demonstrated a high rate of patient satisfaction, with outcomes comparable to those of other studies. The differences between the median BQ-assessed breast satisfaction and outcome satisfaction scores in the axillary and nonaxillary surgical groups were statistically significant, favoring axillary over nonaxillary. The difference in mean satisfaction scores was marginally significant between the 2 types of implants, favoring silicone gel. The incidence of surgical revision was 7.5% for the entire BA study population and 6.8% for the patients who underwent TAM. Conclusions: TAM produces long-term patient satisfaction as measured by the BQ. Complication rates are similar to those of other studies. In the present study, patients who underwent TAM and thus had hidden incisions were more satisfied than patients whose incisions were visible. Level of Evidence: 3
 
Article
Fractionated carbon dioxide (CO(2)) laser resurfacing combines the concept of fractional photothermolysis with an ablative 10,600-nm wavelength. This technology allows for the effective treatment of rhytides, photodamage, and scars, with shorter recovery periods and a significantly reduced side effect profile as compared to traditional CO(2) laser resurfacing. In this article, the authors review the concept of fractional photothermolysis, the expanding array of indications for use of fractionated CO(2) lasers, and their preferred treatment technique.
 
Article
Background: Ultrasonic surgery systems present the surgeon with a host of control parameters and design choices that may directly affect clinical outcome. These include amplitude setting, probe/cannula tip design, probe/cannula diameter, vibration frequency, and mode of energy delivery. Currently, no commonly accepted objective means of measurement (or measurements) exists that can be used to assess the impact of these control parameters, to compare different systems/designs, or to provide a common basis for interpreting clinical outcomes. Objectives: The goals of this study were to develop the following as functions of the surgeon's choice of control parameters: (1) a measure of the vibratory power that could potentially be applied to the subcutaneous tissues, and (2) a measure of the effectiveness of the applied vibratory power. Methods: The vibratory power produced by 4 commercially available ultrasonic surgery systems was quantified on the basis of a measured temperature rise in a known volume of water with various combinations of ultrasonic probes/cannulas. The data were normalized to develop a measure of energy efficiency. Results: The data show that ultrasonic surgical probes/cannulas have zones of high and low efficiency, that the vibratory power and energy efficiency that may be applied to tissues varies widely over the range of the possible control parameters, and that zones of optimal efficiency may be developed. Conclusions: Two simple measurements referred to as H2O power and energy efficiency provide a basis for objective comparison of different ultrasonic instrumentation. These measurements will assist in standardizing clinical observations. (Aesthetic Surg J 2001;21:233-241.).
 
Article
Background: Over the past 10 years, there has been significant fluctuation in the yearly growth rates for cosmetic surgery procedures in both the United States and the United Kingdom. Objectives: The authors compare cosmetic surgical procedure rates in the United Kingdom and United States with the macroeconomic climate of each region to determine whether there is a direct relationship between cosmetic surgery rates and economic health. Methods: The authors analyzed annual cosmetic surgery statistics from the British Association of Aesthetic Plastic Surgeons and the American Society for Aesthetic Plastic Surgery for 2002-2011 against economic indices from both regions, including the gross domestic product (GDP), consumer prices indices (CPI), and stock market reports. Results: There was a 285.9% increase in the United Kingdom and a 1.1% increase in the United States in the number of procedures performed between 2002 and 2011. There were significant positive correlations between the number of cosmetic procedures performed in the United Kingdom and both the GDP (r = 0.986, P < .01) and CPI (r = 0.955, P < .01). Analysis of the US growth rates failed to show a significant relationship with any indices. UK interest rates showed a significant negative correlation (r = −0.668, P < .05) with procedures performed, whereas US interest rates showed a significant positive correlation. Conclusions: Data from the United States and United Kingdom suggest 2 very different growth patterns in the number of cosmetic surgeries being performed as compared with the economy in each region. Economic indices are accurate indicators of numbers of procedures being performed in the United Kingdom, whereas rates in the United States seem independent of those factors.
 
Article
The reader is presumed to have a basic understanding of the use of lasers in plastic surgery and laser physics. After reading this article, the participant should be able to: Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination on the basis of material covered in this article. The examination begins on page 435. Nonablative resurfacing, also referred to as subsurface or dermal remodeling, is a recently introduced technology for restoring damaged collagen without injuring or removing the overlying epidermis. To date there have been no published comparisons or reviews of these laser systems. The authors review the mechanisms of action of currently available nonablative laser technologies and published data on their performance. Literature concerning nonablative laser technology published between 2000 and 2002 was reviewed by use of Medline searches. Data on technical specifications were obtained from the manufacturers. Significant improvement in skin elasticity and photodamage with few or no complications was noted after treatment with most of the systems reviewed. However, the results were generally more subtle than those achieved with ablative lasers. Nonablative technology is currently at the forefront of skin rejuvenation. Data on long-term results must await several more years of accumulated clinical treatment. Improvement in skin quality, tone, and texture can be expected, but patients and physicians who expect nonablative laser treatment results to be similar to those achieved by ablative techniques may be disappointed. (Aesthetic Surg J 2002;22:427-434.).
 
Article
Background: Reduction mammaplasty is an established and effective technique to treat symptomatic macromastia. Variable rates of complications have been reported, and there is a continued need for better outcome assessment studies. Objective: The authors investigate predictors of postoperative complications following reduction mammaplasty using the National Surgery Quality Improvement Program (NSQIP) data sets. Methods: The 2005–2010 American College of Surgeons NSQIP databases were reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Two complication types were recorded: major complications (deep infection and return to operating room) and any complication (all surgical complications). Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. A multivariate regression analysis was used to identify independent predictors of complications. Results: A total of 3538 patients were identified with an average age of 43 years and body mass index of 31.6 kg/m2. Most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes. The incidence of overall surgical complications was 5.1%. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01). The incidence of major surgical complications was 2.1%. Factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). Conclusions: This study demonstrates overall incidence of complications in 1 in 20 patients and a 1 in 50 incidence of a major surgical complication. Noteworthy findings include the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. These data can assist surgeons in preoperative counseling and enhance perioperative decision making. Level of Evidence: 3
 
Article
During the "Hot Topics" seminar at The Aesthetic Meeting 2006, authors polled participants to gain insight into how plastic surgeons evaluate current hot topics. Here are the results as well as the authors' notes on additional presentations.
 
Article
Background: As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. Objective: The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. Methods: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ2 tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. Results: Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). Conclusions: Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes. Level of Evidence: 3
 
Article
I commend the authors for performing a unique epidemiological study of surgical outcomes in the elective breast surgery population. This study represents an innovative approach using the National Surgical Quality Improvement Program (NSQIP) database to evaluate surgical outcomes across different providers and a variety of health systems. Large database analyses are important benchmarking techniques to provide general information on surgical outcomes that are not specific to one particular surgeon or technique. This type of epidemiological study gives greater insight into what is most effective, not just efficacious, under real-world conditions that are usually less than ideal. Difficulties arise when attempting to use large administrative or claims-based databases to evaluate surgical outcomes in plastic surgery as often the data of interest are not collected or collected in the wrong patient population. For example, many databases are claims based and therefore …
 
Article
On March 12, 2013, the American Society for Aesthetic Plastic Surgery (ASAPS) released its 16th annual Cosmetic Surgery National Data Bank multispecialty procedural statistics.1,2 The overall results of the ASAPS survey of board-certified plastic surgeons, dermatologists, and otolaryngologists (projected to reflect nationwide statistics) show that cosmetic surgical procedures in 2012 were up 3.1% from the previous year, with nearly 1.7 million procedures performed. Nonsurgical procedures increased 10.4%, exceeding 8.4 million. These figures are encouraging and consistent with what many of us are seeing in our practices: a steady increase in the number of patients seeking both surgical and nonsurgical cosmetic procedures. ASAPS released its first groundbreaking statistics early in 1998, providing detailed data on cosmetic procedures performed during the previous year. From the beginning, ASAPS recognized the value of collecting data from multiple specialties so that a more accurate picture could be painted regarding the frequency of the full range of cosmetic procedures. This concept was, at the time, somewhat foreign to organized plastic surgery. Plastic surgeons had previously promoted statistics developed by the American Society of Plastic and Reconstructive Surgeons (ASPRS; now the American Society of Plastic Surgeons [ASPS]) as generally representative of the total number and scope of procedures performed. Yet ASPRS obtained its data solely from board-certified plastic surgeons. ASAPS, however, recognized the changes occurring in cosmetic surgery and the need to educate the public not only about plastic surgery but also the core specialties' specific areas of expertise. With so many practitioners entering the cosmetic arena, it was imperative that the public be able to separate qualified from unqualified providers. Sixteen years later, this insight has proved invaluable, particularly with regard to cosmetic medicine, where the core specialties all play an important role in treatment options within our communities. In the past 16 …
 
Article
Background: To avoid complications and improve patient satisfaction with lower lid blepharoplasty, a precise assessment of any preoperative eyelid asymmetry is essential. Objectives: The authors describe a method of assessing preoperative eyelid asymmetry through readily available software and classifying the resulting measurements. Methods: Digital images of 204 patients were analyzed using Photoshop CS3 Extended software (Adobe Systems, San Jose, California). The left eye was superimposed over the right eye using layers in the software program, and the lower eyelid margin and axis were outlined to obtain a diagram with the superimposed outlines of both eyes. Several measurements (ie, lateral canthal height, lower eyelid margin length and axis angle, and lower palpebral fissure surface area) were obtained for each patient. Differences between the right and left eyelids were recorded, and these data were compared between patients. Results: Of the 204 patients studied, 184 (90.2%) had some degree of asymmetry. Most (118; 64.13%) presented with the right lower eyelid at a more inferior position than the left (R–), while 66 (35.87%) presented with the right lower eyelid at a higher position than the left (R+), a difference that was highly significant (P < .001). Conclusions: This software is a powerful and precise tool to evaluate and measure eyelid asymmetries. The use of this method showed a large degree of eyelid asymmetry preoperatively (more than 90%), which proves the importance of detecting and adequately analyzing this condition prior to surgery. The authors' simple method may be an important adjunct to obtaining optimal results in patients who seek eyelid surgery.
 
Article
Since the National Surgical Adjuvant Breast and Bowel Project B06 (NSABP-B06) trial demonstrated equivalent survival outcomes between patients with breast cancer undergoing modified radical mastectomy versus lumpectomy and radiation, an increasing number of patients are seeking breast conservation therapy. Traditionally, only patients who have undergone total mastectomy have been referred for reconstruction. The purpose of the study was to determine the number of dissatisfied patients treated with breast conservation therapy who have suboptimal cosmesis and should be referred for reconstruction. After obtaining approval from the Institutional Review Board and patient consent, patients identified as more than 1 year posttreatment from breast conservation therapy (1999-2004) were interviewed and photographed. Data were gathered by use of a questionnaire that included patient aesthetic score, patient satisfaction, and change in body image. Photographs were shown to a surgical oncologist, a general surgeon, and a plastic surgeon for a physician aesthetic score. Thirteen of 46 patients (28.3%) were dissatisfied with their cosmetic result. Women who were dissatisfied with their cosmetic result were more likely to have a negative change in their body image when compared with patients who were satisfied with their cosmetic result (46.2 % vs 6.1%, P = .02). Additionally, dissatisfied patients were more likely to rate their cosmetic result as poor (15.4 % vs 0%, P = .007) and were more likely to consider reconstruction (46.2% vs 9.1%, P = .01) when compared with satisfied patients. Risk factors to predict dissatisfaction in our patient population included age younger than 52 years and the resection of tumor from the upper inner quadrant. Twenty-eight percent of patients in this study were dissatisfied with their cosmetic result. Furthermore, a large portion of these patients would consider reconstruction if it were offered. Although this study only identified a few broad risk factors for suboptimal cosmetic outcome, it confirms our hypothesis that many patients who have undergone breast conservation therapy should be referred for plastic surgery consultation.
 
Article
Both surgical and nonsurgical techniques, including soft tissue augmentation, are available to restore a youthful appearance to the face. Soft tissue augmentation with nonabsorbable fillers is increasingly important, as a growing number of patients are seeking aesthetic improvement without the downtime and cost of major surgical procedures. Polymethylmethacrylate (PMMA), an injectable implant composed of a suspension of microspheres in different media, is one such soft tissue filler. Because the application of PMMA into the pericartilage of the ear is becoming a more common practice among plastic surgeons, the authors offer a systematic analysis of its effects. They believe this information to be of paramount importance to prevent injuries and deformities. Twenty-one patients who presented to the lead author's clinic with prominent ears during a period of 16 months between 2007 and 2008 were retrospectively reviewed. The authors analyzed PMMA's effects on each patient's ear shell cartilage, which was extracted during correction without causing any kind of injury or deformity to the participants in this study. The histopathologic study from the excised skin and cartilage samples showed a granulomatous inflammation in all patients. There was no association between the incidence of tissue alterations and the mean length of PMMA on the conchal cartilage. The potential consequences of PMMA injection in close proximity to cartilage cannot be predicted and the possibility of myxomatous cartilage degeneration is a serious potential adverse event because it can cause permanent deformities of the cartilaginous skeleton.
 
Article
Background: Micro-ribonucleic acids (miR) are small, noncoding RNA molecules 19 to 25 nucleotides in length that typically function as negative regulators of expression for many target genes involved in cell proliferation, differentiation, and apoptosis. However, the effects of miR-21 on keloid fibroblasts are currently unknown. Objectives: The authors investigate whether miR-21, a specific miR implicated in multiple aspects of keloid fibroblasts, affects the expression of Fas ligand (FasL) in the presence of transforming growth factor (TGF)-β1. Methods: The relationship between TGF-β1 and miR-21 expression was investigated by TaqMan quantitative real-time polymerase chain reaction (Life Technologies, Grand Island, New York). FasL protein was determined by Western blotting, and regulation of cell proliferation/migration/apoptosis ability by TGF-β1 inhibitor or plasmid was evaluated respectively by EdU incorporation, Transwell assay, and flow cytometry analysis. Results: Fibroblasts from keloid tissue were confirmed to express high levels of TGF-β1 and miR-21 compared with normal skin fibroblasts. Expression of TGF-β1 and miR-21 was positively correlated in fibroblasts. In addition, cells transfected with TGF-β1 inhibitor or miR-21 inhibitor showed significant increases in FasL protein levels and number of apoptotic cells compared with control cells, whereas cell growth and migration significantly decreased. The opposite results could also be confirmed when TGF-β1 was upregulated in normal skin fibroblasts. Conclusions: TGF-β1 could effectively influence cell proliferation, apoptosis, and migration via its control of miR-21. These findings also identify a novel mechanism of interaction between TGF-β1 and miR-21 in the regulation of FasL protein, which is involved in keloid formation.
 
Article
The author uses the concepts of preserving the pretarsal orbicularis muscle and anchoring the preseptal muscle to the lateral orbital rim suture as the basis for a cheek lift/eyelid correction. Refinements in his technique have evolved over a period of 24 years and with treatment of more than 1000 patients.
 
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W. Grant Stevens
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Emmanuel Delay
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Allen Gabriel
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Raphael Sinna
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