Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery

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

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.

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.

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.

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.

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.

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.

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.

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 …

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

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.

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.

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. …

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.

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

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.

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.

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.

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.

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

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.

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.

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.