Staged Mastopexy Before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Implant-Based and Autologous Breast Reconstruction.

BACKGROUND: Breast reconstruction following nipple sparing mastectomy in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS: A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before nipple sparing mastectomy and reconstruction in our institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS: In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3 percent) were reconstructed with free abdominal flaps, 6 (7.1 percent) with tissue expanders and 66 (78.6 percent) with permanent subpectoral implants and acellular dermal matrix. There was one postoperative superficial nipple areolar complex epidermolysis (1.2 percent), and two partial mastectomy skin flap necrosis (2.4 percent). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION: Mastopexy or breast reduction before nipple sparing mastectomy and reconstruction is a safe procedure with a low risk of ischemic complications.

A New Technique for Breast Pocket Adjustment: Argon Beam Thermal Capsulorrhaphy.

Implant malposition remains one of the main complications of aesthetic breast augmentation and alloplastic breast reconstruction with expanders and implants. Many capsulorrhaphy techniques have been described to adjust the breast pocket and correct the malposition. In this study, we tested the efficacy of the argon beam coagulator (ABC) for lateral capsulorrhaphy on breast reconstruction patients at the time of expander replacement with a permanent implant. We also experimentally compared the effects of the ABC and the standard electrocautery on fragments of healthy breast capsule. We noted a 69.5% capsule shrinkage with the ABC versus 46.8% with the standard electrocautery. We concluded that breast capsulorrhaphy using the ABC is a safe and efficient technique for the correction of breast implant malposition in both reconstructive and aesthetic breast surgery.

Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study.

BACKGROUND: Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty. METHODS: Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups. RESULTS: Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg; p = 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p < 0.0001). CONCLUSIONS: Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Impact of Upper Face Botulinum Toxin Injections on Eyebrow Height and Forehead Lines: A Randomized Controlled Trial and an Algorithmic Approach to Forehead Injection.

No previous study has objectively evaluated the effect of different forehead injection patterns on the eyebrow height and forehead lines. The patients were divided into three groups. Botulinum toxin was injected into both the lateral and medial eyebrow depressors in all groups. The frontalis was injected using either a V-pattern (group 1), a middle horizontal pattern (group 2), or a high horizontal pattern (group 3). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Validated photonumeric scales were used to assess the forehead lines. Fifteen patients (30 eyebrows) were included in each group. In all of the groups, 2 weeks after injection, the brow was lower at all the measured positions, with the exception of the lateral brow edge, which was higher in the three injection patterns. No difference was found when comparing group 1 to groups 2 and 3. The middle forehead injection pattern lowered the eyebrow more than the upper forehead injection pattern. The three techniques improved the forehead lines at rest and with contraction. The forehead lines with contraction were more improved in group 1 compared with both groups 2 and 3. Each forehead injection pattern yielded different results on forehead lines and eyebrow position. Upper forehead injections were less effective on forehead lines but prevented eyebrow ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, II.

Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and Neck Rejuvenation and a Crossover Clinical Trial.

BACKGROUND: Microbotox consists of the injection of microdroplets of botulinum toxin into the dermis to improve the different lower face and neck aging components. No clinical trial has evaluated its effect on the different face and neck components and no study has compared it to the "Nefertiti lift" procedure. METHODS: In this crossover study, patients previously treated with the Nefertiti lift were injected using the microbotox technique. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. RESULTS: Twenty-five of the 30 patients previously treated with the Nefertiti technique were injected with a mean dose of 154 U using the microbotox technique. Platysmal bands with contraction, jowls, and neck volume reached a statistically significant improvement. The microbotox technique improved the jowls and the neck volume more than the Nefertiti technique, whereas the platysmal bands at rest and with contraction were more improved by the Nefertiti technique. One hundred percent of patients were satisfied with both techniques and rated themselves as improved. CONCLUSIONS: The microbotox technique is a useful, simple, and safe procedure for lower face and neck rejuvenation. It is mainly effective in treating neck and lower face soft-tissue ptosis, in contrast to the Nefertiti technique, which is more effective on platysmal bands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Impact of Botulinum Toxin on Brow Height and Morphology: A Randomized Controlled Trial.

BACKGROUND: Previous reports have objectively demonstrated the efficacy of botulinum toxin for brow elevation. No clinical trial has compared the variation of the eyebrow shape and height when the lateral eyebrow depressors are injected alone or in combination with the medial eyebrow depressors. METHODS: A prospective, randomized, controlled study was designed to evaluate and compare the effect of two different botulinum toxin injection techniques on brow shape and position. Patients were divided into two groups. AbobotulinumtoxinA was injected in the lateral eyebrow depressors alone (group 1) or in both the lateral and medial eyebrow depressors (group 2). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Patient satisfaction was also evaluated. RESULTS: Fifteen patients (30 eyebrows) were included in each group. The brow elevated by 0.6 to 2.1 mm at all positions in group 1. In group 2, the brow elevated from the medial limbus to the lateral edge of the brow (1 to 1.7 mm), with no changes at the level of the medial brow and canthus. When comparing the two injection techniques, the authors found a statistically significant difference in the change of eyebrow height at the level of the medial brow, medial canthus, and lateral brow edge. Ninety-seven percent of patients were satisfied with their results. CONCLUSION: Different eyebrow injection techniques yield different elevation patterns. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection.

BACKGROUND: The "Nefertiti lift" consists of injecting the platysmal bands and the inferior border of the mandible with botulinum toxin. No clinical trial has evaluated its effect on the different lower face and neck aging components, and little is known about the clinical characteristics that predict treatment success. METHODS: Patients were injected with abobotulinumtoxinA along the inferior border of the mandible and into the platysmal bands. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. RESULTS: Thirty patients were injected with a mean dose of 124.9 U of abobotulinumtoxinA per patient. Platysmal bands at rest and with maximal tension reached a statistically significant improvement. The other components showed a tendency for improvement but did not reach statistical significance; 93.3 percent of investigators and patients rated the overall results as improved, and 96.6 percent of patients were satisfied with their results. When comparing the patients who improved the most to all the other patients, they had lower preinjection region-specific scores. CONCLUSIONS: The Nefertiti lift can be used on its own or in conjunction with other rejuvenating procedures. It is particularly helpful in younger patients with platysma muscle hyperactivity and retained skin elasticity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.