Clinical Evaluation of Shaped Gel Breast Implant Rotation Using High-Resolution Ultrasound.

Background: Clinical trials have demonstrated through core and independent studies that anatomical devices are safe and effective with low complication rates. The rotation rate of shaped breast implants in the literature is 0 to 8.2%. Currently there are no studies evaluating the efficacy of in office ultrasound or clinical rotation vs actual rotation rates seen on high-resolution ultrasound (HRUS). Objectives: The purpose of the study is to demonstrate the ease and reliability of HRUS for evaluating the rotation rate of 2 different brands of anatomic implants and to correlate this with the presumed clinical rate, as well as independent evaluators assessments. Methods: A total of 69 patients were followed up at routine intervals and were evaluated for rotation. Any implant rotated past >30° off of midline (outside 5-7 o'clock) was considered to be rotated. To determine if radiographic rotation was clinically evident, 20 composite patient photos were blindly evaluated. Results: A random total of 69 patients underwent bilateral augmentation mammoplasty with form stable anatimic gel implants using 138 implants. Twenty-nine of the 69 (42%) patients and 37 of the 138 (27%) implants were found to be rotated-using HRUS. Eight of the 69 (12%) patients had bilateral rotations. Independent evaluators were able to identify two of 12 (17%) possible rotations, or 2 rotations in 40 (5%) total implants. Conclusions: Anatomic form stable gel implants are actually rotated up to 25 times more frequently than previously thought, but these rotations do not translate into clinically significant sequela. High-resolution ultrasound is a simple alternative for breast implant surveillance and is better accepted by patients than magnetic resonance imaging (MRI). The clinical value of HRUS is also discussed and recommendations for FDA implant labeling changes are provided in this article. Level of Evidence: 4

Skin Excursion with Cannula Lipodissection and the Anatomical Implications of Superficial Musculoaponeurotic System Movement in the Tumescent Face Lift.

BACKGROUND: The tumescent face lift uses the concept of subcutaneous cannula lipodissection of the neck, as opposed to wide skin undermining. Lipodissection mobilizes soft tissue while preserving perforating neurovascular branches. The purpose of this study is two-fold: (1) to compare the skin recruitment with subcutaneous lipodissection of the neck alone versus wide undermining and (2) to examine the effect of superiorly oriented superficial musculoaponeurotic system (SMAS) movement on jowl excursion in the tumescent face lift. METHODS: A cadaveric study was performed on five fresh tissue cadavers. Postauricular skin excursion was measured following subcutaneous lipodissection and then measured again after traditional, wide undermining of the neck skin. Jowl excursion (in reference to the mandibular border) was measured following superiorly oriented SMAS excursion. An electronic force gauge was used to measure force application during measurements. RESULTS: Cannula lipodissection resulted in a mean skin excursion of 41.9 mm. There was no significant difference in skin excursion compared to wide undermining (41.9 mm versus 42.1 mm; p = 0.785). Jowl position, in reference to the mandibular border, moved superiorly by a mean distance of 18.3 mm with vertical SMAS excursion. CONCLUSIONS: Subcutaneous cannula lipodissection results in equivalent skin recruitment in comparison to wide undermining of the neck. A superior vector of pull on the SMAS results in vertical excursion of the jowl in reference to the mandibular border.

Utilizing large volume fat grafting in breast reconstruction after nipple sparing mastectomies.

Nipple sparing mastectomy (NSM) has gained popularity especially in prophylactic mastectomies allowing improved cosmetics. Traditionally reconstruction has utilized implants or autologous tissue. With the development of large volume fat grafting additional reconstructive techniques can be utilized in NSM reconstruction. This can either complement a technique or be a standalone form of reconstruction. This paper is intended to serve as a broad overview of fat grafting and its potential role in reconstructing the breast following nipple sparing mastectomies.

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile.

BACKGROUND: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. METHODS: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. RESULTS: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. CONCLUSION: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.

The Importance of the Upper Lateral Cartilage in Rhinoplasty.

The upper lateral cartilages are instrumental in obtaining optimal outcomes in aesthetic and functional rhinoplasty. Knowledgeable manipulation of the upper lateral cartilages can take advantage of the crucial malleable parameters of projection, width, nasal dorsal shape, and tip rotation. A lucid understanding of the anatomical intricacies in this portion of the cartilaginous framework permits the surgeon to use their unique characteristics to consistently achieve the desired results.

Role of the Cephalic Trim in Modern Rhinoplasty.

There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.

Role of Autologous Fat Transfer to the Superficial Fat Compartments for Perioral Rejuvenation.

BACKGROUND: Autologous fat transfer to the deep compartments of the face has proven to be a powerful adjunct to volume restoration during rhytidectomy. However, to treat all components of volume deflation in facial aging, the perioral superficial compartments must be addressed. Various fillers have been used to augment these compartments; however, few studies have assessed the efficacy of autologous fat transfer to these areas. This study is the largest series to date to assess the utility of autologous fat transfer to the perioral superficial compartments. METHODS: A retrospective chart review was conducted on an individualized component rhytidectomy database. Patients who underwent autologous fat transfer to the perioral superficial fat compartments were identified; patients who did not undergo autologous fat transfer served as controls. All patients had follow-up images that had been obtained a minimum of 1 year postoperatively. Three independent observers reviewed preoperative and postoperative images using the Modified Fitzpatrick Wrinkle Scale. RESULTS: Sixty-five consecutive patients underwent rhytidectomy without perioral rejuvenation (group A), and 65 patients underwent rhytidectomy with autologous fat transfer to the perioral superficial compartments (group B). Group B had a two times more significant improvement in perioral aesthetics than group A. CONCLUSIONS: This study is the largest review to date demonstrating safety, longevity, and success of autologous fat as an ideal filler of the perioral superficial compartments. In light of the aesthetic improvements with autologous fat transfer to the perioral region, this surgical adjunct should be a fundamental component to achieve global facial rejuvenation during rhytidectomy.