Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases.

BACKGROUND: Modern rhinoplasty is not just a reduction procedure. An optimal nasal esthetic result occasionally requires augmenting the nasal tip, the dorsum or the lateral wall with autografts or alloplasts. A large number of nasal implant types have been reported in the medical literature. OBJECTIVE: The goal of this article is to demystify the role and indications of nasal implants in rhinoplasty. As well, it offers both the novice and experienced nasal surgeon a basic, simplified and organized approach to the use of soft and firm nasal implants in rhinoplasty. METHODS: This article presents the authors experience with 311 rhinoplasties using both soft and firm alloplastic implants. The indications for both types of alloplasts are discussed, the surgical technique detailed and the outcomes analyzed. RESULTS: A total of 311 nasal implant cases were reviewed. This series revealed a low incidence of postoperative infection (5.57% for soft implants and 0.1% for the firm ones). The revision rate was 2.7% for the soft implants group and 7.1% for the firm implants group. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Enhanced recovery programme reduces opiate consumption in hip hemiarthroplasty.

INTRODUCTION: The enhanced recovery programme (ERP) is used to improve patient experience before, during and after an operation. Initially designed for colorectal surgery, it has now been adopted by many other disciplines, including orthopaedics. Where applicable, ERP has shown to be associated with less pain, reduced length of hospital stay and increased patient satisfaction in elective orthopaedic procedures. There is, however, a paucity of data regarding the use of ERP in fractured neck of femur (NOF) operations. Our aim was to investigate the effect of ERP on analgesic requirements and hospital length of stay during hemiarthroplasty. METHOD: Consecutive notes of 100 patients who received a hemiarthroplasty for a fractured NOF were reviewed retrospectively. In one group (n = 50), patients received routine pre- and post-operative care; the second (n = 50) were on the ERP. All patients were previously mobile with an abbreviated mental test score of more than eight and lived in their own home. RESULTS: With ERP, oral opiate consumption fell dramatically in the first three post-operative days (4.7 vs. 14.0 mg, p > 0.005). The use of patient-controlled analgesia (PCA) was also significantly reduced (odds ratio 0.16, p > 0.05). Although ERP had no statistically significant effect on length of stay (7 vs. 8.5 days, p = 0.2), it saw a greater proportion of patients being discharged back to their own home (25 vs. 19 patients, p < 0.05). CONCLUSION: The ERP reduces post-operative oral opiates and PCA requirements in fractured NOF cases and by inference reduces pain. It does not appear to affect length of hospital stay in an acute unit.

Treatment of Keloid Scars with Botulinum Toxin Type A versus Triamcinolone in an Athymic Nude Mouse Model.

BACKGROUND: Keloid scarring is a serious condition that mostly affects patients of African or Asian descent. Often disfiguring, this condition can have devastating psychosocial consequences. To date, no treatment modality has been proven ideal. The authors' objectives were (1) to determine the efficacy of botulin toxin type A injection for the treatment of keloid scars compared to steroid injection and to control saline injection (this was achieved through a basic science animal model using athymic nude mice and implanted human keloid tissue); and (2) to analyze the histopathologic changes that occur in an organized keloid scar following botulinum toxin type A injection as compared to steroid and saline injections. METHODS: Keloid scars from four patients were excised and implanted subcutaneously into 28 mice. Three small keloid tissue samples were implanted in each of the 28 mice. One week after implantation, each implant received one of three injections: botulinum toxin type A (treatment drug), saline (control), or steroid injection (first-line gold standard). The keloid tissue was extracted 3 weeks after implantation. Weight analysis, immunohistochemistry, and standard hematoxylin and eosin pathologic analysis were performed on each extracted tissue sample. RESULTS: Paired t test analysis of pretreatment and posttreatment tissue weights revealed a statistically significant difference between the treatment and control groups (p < 0.05). Analysis by a blinded pathologist confirmed fewer collagen bundles in the treatment group. Immunohistochemistry with Ki-67, a marker of cell proliferation, revealed significantly less staining in the treatment groups. CONCLUSION: Botulinum toxin type A could be an effective treatment for keloid scars.

Universal Trichloroacetic Acid Peel Technique for Light and Dark Skin.

IMPORTANCE: Despite their great potential, medium and deep trichloroacetic acid peels are underused in light-skinned patients and are rarely used in darker-skinned patients because of the widespread fear of pigmentary complications and scarring. This concern has led many physicians to opt for the use of lighter types of peels (glycolic acid peel, Jessner peel, etc) and different lasers and intense light technologies. Trichloroacetic acid peels have been described in numerous publications. However, no study to date has described the precise technique and the practical pearls of a successful trichloroacetic acid peel approach in a clear, detailed, and reproducible manner. OBJECTIVES: To clarify a practical approach to a universal trichloroacetic acid peel and to offer novice and experienced facial plastic surgeons an organized, easy, and safe technique for medium and deep trichloroacetic acid peels. DESIGN, SETTING, AND PARTICIPANTS: This study was a case series of universal trichloroacetic acid peels in an academic setting. The study dates were January 1, 1996, to November 1, 2015. MAIN OUTCOMES AND METHODS: This article discusses the preoperative evaluation for a chemical peel, a previously published genetico-racial skin classification, and the trichloroacetic acid peel technique, which aims at standardizing and controlling the application of the acid to improve results and lessen complications. The "strip" technique is described, which increases the physician's control over the peel depth. RESULTS: A total of 923 trichloroacetic acid peels in 803 female patients (87.0%) and 120 male patients (13.0%) were reviewed (mean age, 41.59 years). The follow-up period ranged from 6 months to 13 years (mean, 13 months). This case series revealed a low incidence of complications, including 54 patients (5.9%) with persistent hyperpigmentation, 3 patients (0.3%) with mild telangiectasia, 2 patients (0.2%) with acute herpesvirus infection, 2 patients (0.2%) with bacterial Staphylococcus infection, and 1 patient (0.1%) with hypopigmentation. CONCLUSIONS AND RELEVANCE: When properly applied, trichloroacetic acid peels are efficient and safe for light and dark skin. The technique can be an easily implementable addition to a physician's cosmetic practice. LEVEL OF EVIDENCE: 4.

Dacron implants in rhinoplasty: a review of 136 cases of tip and dorsum implants.

The achievement of successful results in rhinoplasty may require the use of autografts, homografts, or alloplastic materials. Among the alloplasts, Dacron is an easily handled and manipulated synthetic material, readily applicable to nasal augmentation. The following represents the indications, surgical technique, outcome results, and analysis of our experience with Dacron mesh implants to the nasal tip, dorsum, and lateral walls in 136 patients.

The new Genetico-Racial Skin Classification: How to maximize the safety of any peel or laser treatment on any Asian, Caucasian or Black patient.

The popular skin classifications, notably the 'Fitzpatrick' and 'Obaji' classifications, are primarily based on skin colour. Other criteria are occasionally considered, such as the degree of skin oiliness, thickness, sensibility, etc. Although these classifications are easy to understand and apply, their simplicity limits their precision, sophistication and applicability.The new genetico-racial skin classification proposed herein suggests that skin response to any peel or laser treatment is genetically programmed and is, therefore, linked to the genetic and racial origin of the patient. In other words, in addition to skin colour, the patient's facial features and ancestry should be taken into account when classifying any skin.The new genetico-racial skin classification enables the physician to determine with great precision, and before any peel or laser treatment, the level of the patient's suitability and the expected postoperative outcomes; therefore, reducing the likelihood of complications.

The new "genetico-racial" skin classification: maximizing the safety of skin treatments for Asians.

Racial genetics play a significant role in determining a patient's response to any skin treatment. Contrary to traditional skin classifications, the new genetico-racial classification takes into consideration the racial origins of patients, as manifested in both their skin color and their feature contour characteristics, rather than their skin color alone. According to this new classification, patients may belong to 1 of 6 categories, originating from the 3 ancient continents: Africa, Europe, and Asia. In this article the Asian category, as well as its subcategories, are approached in a radically different way. This new geneticoracial classification ushers in a "paradigm shift" in the way Asian patients are perceived before, during, and after skin treatments. The new geneticoracial classification advances that Asians are excellent candidates to most peels and laser treatments, as long as their genetic disposition and their anticipated responses to those treatments are understood and respected.

'Universal retraction suture' for the overprojecting nasal tip.

Achieving a proper nasal tip projection is a crucial element of a successful rhinoplasty. A large number of correction methods and manoeuvres have been proposed in the medical literature as solutions for the prominent nasal tip, thus complicating the surgeon's strife to choose the ideal plan of action. In the present article, a single straight-forward technique, christened the 'universal retraction suture', is suggested to tackle the overprojecting tip in a simplified, controlled and efficient fashion.

Nipple reduction - An adjunct to augmentation mammaplasty.

Nipple hypertrophy is an occasional deformity in Asians and a rare one in Caucasians. Lately, it has been showing up more often in plastic surgeons' offices across North America and elsewhere, owing to the influx of Asian immigration worldwide, as well as to the rising interest in esthetic surgery among Asian communities.A simplified technique for nipple reduction is described herein. It is very easy to execute, delivers accurate results and is extremely safe. It tackles both the excessive 'projection' and the less frequent excessive 'width' of the nipple. It may be used separately or incorporated as an adjunct to mammary augmentation or mastopexy. Excellent esthetic results are obtained, while both the nipple innervation and its lactiferous ducts are preserved. The patient's and surgeon's satisfaction is high.

Minimal inframammary incision for breast augmentation.

The inframammary approach in breast augmentation, still the most popular technique among plastic surgeons, has always been hampered by the undesirable appearance of its scar. The present paper describes a modified approach to inframammary augmentation with saline-filled prostheses. This approach uses a very short incision, thus resulting in a much less noticeable scar. The surgical technique is easy to learn, simple to execute, does not necessitate any special equipment and gives consistent results. Decreasing the scar length to an absolute minimum ensures higher patient and surgeon satisfaction.

Predicting the results of rhinoplasty before surgery: Easy noses versus difficult noses.

A major problem for many rhinoplastic surgeons is the ability to predict, before surgery, the difficulty of the procedure (whether the rhinoplasties will be technically easy or technically difficult to perform) and the success rate of the result (whether the rhinoplasty will likely give good results or poor ones).The present paper outlines a systematic approach to nasal analysis, allowing the surgeon to consistently estimate, before surgery, the degree of technical difficulty of each rhinoplasty, as well as predicting its future result in terms of patient satisfaction. This preoperative evaluation is based on the analysis of the skin texture and the osteocartilagenous framework on lateral and frontal views. It allows for the nose to be classified as green (easy), yellow (moderate) or red (difficult), depending on two factors: the degree of surgical difficulty and the expected patient's satisfaction with the result.The essence of the present paper is to introduce a simple, systematic approach to assist the novice rhinoplastic surgeon to assess the complexity, the risks and the expected outcome of a rhinoplasty in the preoperative period, rather than postoperatively.

The 'bikini lip reduction': A detailed approach to hypertrophic lips.

Excessively large lips represent an occasional but significant challenge in aesthetic surgery. Previously described techniques focus largely on the simple excision of a strip of tissue to reduce the lips, without specific attention to the resultant lip contour or to the volume relationship between the lips. The present paper describes a new technique for lip reduction, called the 'bikini lip reduction'. This technique not only reduces the volume of the lips, but also restores an attractive labial contour, as well as an ideal volume relationship between the upper and lower lips. Because it is based on aesthetic analysis, this technique consistently yields both smaller and more aesthetically appealing lips. Simply stated, the bikini lip reduction consists of excision of a 'bikini top' (two cups and a middle strap) from the upper lip and a 'bikini bottom' (a triangle) from the lower lip. The aesthetic results and the patient satisfaction achieved through the bikini lip reduction technique have been very satisfactory.

'Optimum mobility' facelift. Part 1 - the theory.

Traditional rhytidectomy techniques, such as the cutaneous lift, the superficial musculoaponeurotic system lift, the deep plane lift and the subperiosteal lift, are mostly differentiated by their different planes of dissection. As well, many of these techniques consider the complete mobilization of tissues a prerequisite for obtaining a satisfactory result.However, is it true that the result of a rhytidectomy is linked to the choice of the dissection plane? Also, is it true that the adequacy of the surgical mobilization of tissues is vital to the outcome? The present paper discusses the above questions and introduces a factor that is believed to be crucial to the planning and success of a rhytidectomy: facial tissue mobility. The analysis of this mobility is presented and leads to the development of three theories: 'intrinsic mobility', 'surgically induced mobility' and 'optimum mobility points'. These theories form the foundation of a rhytidectomy technique termed 'optimum mobility' facelift.

'Optimum mobility' facelift. Part 2 - the technique.

In the first of this two-part article on the 'optimum mobility' facelift, facial tissue mobility was analyzed, and three theories or mechanisms emerged: 'intrinsic mobility', 'surgically induced mobility' and 'optimum mobility points'.In this second part, these three theories are applied to a rhytidectomy procedure termed 'optimum mobility' facelift. Before surgery, 'optimum mobility points' are marked on the skin. During surgery, the subcutaneous dissection is kept to a minimum by carrying it out precisely to these 'optimum mobility points'. The facial tissues, with their skin and superficial musculoaponeurotic system attachments intact, are then mobilized laterally using the 'intrinsic mobility' phenomenon, and this mobilization fixed in place using mattress sutures.The 'optimum mobility' facelift is an efficient rhytidectomy technique that has a thoughtful, precise plan, a low complication rate, a fast recovery and very satisfactory results.

Narrowing of the wide nasal dorsum in the 'minimal-hump' nose: A simplified universal approach.

The operative procedure frequently used to narrow the nasal pyramid in the context of a regular rhinoplasty is well known to all rhinoplastic surgeons. It consists of hump removal, followed by lateral osteotomies and medialization of the nasal bones. However, narrowing of a wide nasal pyramid, in the absence of an appreciable dorsal hump, as in the case of an ideal dorsal height or a mild hump, presents a different challenge. The present article describes a simplified approach to the 'nasal plateau resection', a technique that allows the creation of an open nasal roof, without hump removal and without compromising dorsal projection. This permits the medialization of the lateral nasal bones and the subsequent narrowing of the wide pyramid, while preserving the height of the nasal dorsum as viewed in profile.

L'intervention chirurgicale souvent utilisée pour réduire la largeur de l'arête du nez dans le contexte d'une rhinoplastie standard est bien connue de tous les rhinoplasticiens. Elle consiste à éliminer la bosse, puis à pratiquer des ostéotomies latérales et une médialisation des os du nez. Par contre, diminuer la largeur de l'arête du nez en l'absence de bosse appréciable, comme dans le cas d'une hauteur de nez idéale ou d'une bosse minime, représente un défi considérable.Le présent article décrit une approche simplifiée à la « résection du plateau nasal ¼, une technique qui permet de créer une voûte nasale ouverte, sans ablation de bosse et sans altération de la projection dorsale. Cette approche permet la médialisation des os latéraux du nez et la diminution subséquente d'une pyramide large, tout en préservant la hauteur de l'arête du nez vue de profil.

A new patient classification for laser resurfacing and peels: predicting responses, risks, and results.

Traditional classifications for skin treatment modalities are based on skin characteristics, the most important being skin color. Other factors are considered as well, such as oiliness, thickness, pathology, and sensitivity. While useful, these classifications are occasionally inadequate in predicting and explaining the outcome of some peels, dermabrasions, or laser resurfacing procedures. Why, for example, would a Korean patient with a light white skin inadvertently develop more hyperpigmentation than his darker skinned French counterpart? The new classification introduced here is based on the racial and genetic origins of patients. It suggests that racial genetic predisposition is the determining factor in human response to skin injury, including skin treatments. This classification takes into account both skin and features, rather than skin alone. It offers a new approach in evaluating patients scheduled for skin peels or laser resurfacing, in the hope of helping physicians to better predict reactions, select the appropriate type and intensity of the skin treatment and, ultimately, better control the outcome. Six categories (sub-races) are described: Nordics, Europeans, Mediterraneans, Indo-Pakistanis, Africans, and Asians. The reaction of each sub-race to peels, laser resurfacing, or dermabrasion is analyzed. The risks associated with each group are noted. This new classification provides physicians with a practical way to evaluate patients prior to treatment, with a view to determining each patient's suitability, postoperative reaction, the likelihood of complications, and likely result.

Estimating implant size in chin augmentation: A simplified approach.

A receding chin, colloquially known as a weak chin, is a significant aesthetic impediment to a pleasing face. Multiple techniques exist to evaluate the poorly projecting chin, but most are imprecise when it comes to choosing the proper implant size. This choice is further complicated by the impracticality of commercially available chin implants. Most implant manufacturers offer only three to four categories of implants (small, medium, large, etc) that differ in size from one company to another, making the choice of the proper implant size a real challenge. The present paper discusses a new approach to precise sizing of the chin implant, based primarily on the degree of chin convexity (curvature of the chin pad) in the profile view. Examples of mentoplasties performed using the chin convexity principle are presented.

Un menton fuyant est un obstacle esthétique important à un visage agréable. Il existe de multiples techniques pour évaluer cette mauvaise projection du menton, mais la plupart sont imprécises lorsqu'il s'agit de choisir un implant de bonne dimension. Ce choix est compliqué par le caractère peu pratique des implants de menton mis en marché. En effet, la plupart des fabricants n'offrent que trois ou quatre catégories d'implants (petit, moyen, grand, etc.), dont la dimension varie d'un fabricant à l'autre, ce qui transforme lp=e choix du bon implant en véritable défi. Le présent article présente une nouvelle démarche pour établir la dimension exacte de l'implant du menton, fondée principalement sur le degré de convexité du menton (la courbe du coussinet du menton) selon une vue de profil. Des exemples de mentoplasties exécutées selon le principe de convexité du menton sont présentés.