SPA face lift: SMAS plication-anchoring.

A variation of the superficial musculoaponeurotic system (SMAS) plication called SPA face lift is here described. An axial line and then two medial and lateral parallel lines are penciled on the skin from the lateral canthus to the earlobe to show the future plication area. The undermining zone is delimited 1 cm beyond the medial line. In face- and neck-lifting, such marks extend vertically to the neck. Once the skin is undermined up to the delimiting marks, the three lines are penciled again on the fat layer, and a running lock suture is used for plication, with big superficial bites between the two distal lines. In fatty faces, a strip of fat is removed along the axial line to avoid bulging that can be seen through the skin. Because the undermining is limited, minor swelling occurs, and the postoperative recovery is shorter and faster. The same three lines can be marked in the contralateral side or can differ in cases of asymmetry. This report describes 244 face-lifts without any facial nerve problems. The author managed five hematoma cases in which surgery to the neck was performed. Three patients had to be touched up for insufficient skin tension. The SPA technique is consistent and easy to learn.

Internal lateral nasal osteotomy: double-guarded osteotome and mucosa tearing.

For the internal lateral nasal osteotomy, a 4-mm double-guarded straight osteotome that separates the external periost and mucoperiosteum while the osteotomy is progressing is presented. Before the osteotomy, the external periost and the internal mucoperiosteum are infiltrated with local anesthesia and elevated by tunneling with an elevator. As the sharp part is behind the guards, it is not possible for the osteotome to slip away laterally or medially from the nasal bone. By tunneling just at the base of the nasal bones, arteries, veins, and lymphatics are preserved while the superior part of the external periosteum and the internal mucoperichondrium maintained the bones in a stable position with firm support to both sides. Forty consecutive rhinoplasties were studied with an endoscope. In 35 primary rhinoplasties the mucosa laceration rate was 1.5%, whereas in secondary rhinoplasties it was 80%. The approach to the piriform aperture was intranasal in the first 16 cases and intraoral in the last 24 cases. The intraoral mucosal elevation and osteotomy were easier to carry out than in the intranasal approach. In general, minor lower-lid edema and ecchymosis were observed, possibly related to the fact that the periosteum was elevated, thus preserving the supraperiosteal arteries, veins, and lymphatics. When the mucosa was elevated, the internal irrigation of the mucosa and the lymphatics was also preserved, thus avoiding intraoperative bleeding, intranasal packing, and postoperative bleeding.

Breast enlargement after two reduction mastoplasties: a case report.

In 1989, a bilateral breast reduction was performed for a large-breasted woman. She returned 1 year later with bilateral breast enlargement as severe as in the original case. The operation was repeated but in a more aggressive way. She became pregnant 2 years later, and both her small breasts began to grow again until they became gigantic. Hormonal tests showed results within the standard limits, and no medical treatment was effective. After the delivery, her breasts reduced in size spontaneously.

Transaxillary breast augmentation: two breast cancer patients with successful sentinel lymph node diagnosis.

In recent years, some surgeons have been warned of possible problems with sentinel lymph node diagnosis (SLND) for patients who have undergone transaxillary breast augmentation (TBA), although no scientific studies support this warning. The authors report two additional cases of breast cancer in which the SLND was successfully performed for patients with previous TBA. The surgical anatomy of the axilla, the groups of lymph nodes, and a personal way of performing TBA are described. Five other reports concerning the same issue are thoroughly discussed. Four of these are clinical in vivo reports, and one is a cadaver study. The four in vivo studies and what we are reporting now clearly demonstrate that what was said regarding possible problems in the SLND after TBA was not founded on clinical research and contradicts these five clinical findings.

Periareolar mastopexy and augmentation.

The author performs periareolar mastopexy only in cases requiring correction of moderate ptosis and skin redundancy. The size and shape of the implant to be used and the surgical plan are both decided at consultation. The author prefers high-textured cohesive silicone gel-filled implants placed in the subpectoral position. To facilitate the surgical procedure, the author administers profuse local anesthesia and leaves compresses in the dissected pocket. The use of a cinching running suture helps to obtain a good-quality periareolar scar with minimal wrinkling. These techniques can reduce the incidence of complications and minimize the need for surgical revision.

Open frontal lift: a conservative approach.

This study aimed to demonstrate that during an open frontal lift, transection of the galea is not necessary. The forehead is elevated, and the ptotic brow is raised after a strip of skin or scalp is removed by folding of the galea. The marcation is penciled on the skin according to the amount of skin--scalp the surgeon estimates it is necessary to remove. Local anesthesia is profusely injected, separating all layers and facilitating surgery. The skin is stripped off the galea, and then through a small incision in the middle, a large dissector separates the galea from the periosteum of the forehead and temporal regions. This dissection can be completed from the temporal area or from the blepharoplasty incisions. With a long pair of scissors, the orbital borders are reached and opened perpendicularly to the bone, releasing the fascia and muscle attachments from the orbital rim without anything being cut. During the coronal approach, once the scalp and forehead are completely mobile, the galea is folded with a continuous running 3/0 Vicryl suture, which after five or six big bites is strongly pulled to fold the galea. The wound then is sutured without tension using staples. When the incision is precapillary, the folding is fixed with Vicryl 3/0 uncolored thread, and the skin is sutured with mononylon 6/0. Complementary corrugator transections are performed from the blepharoplasty incision or by use of the endoscope. With the coronal approach, the surgery requires about 20 min, whereas the precapillary approach requires about 40 min. When only the skin is removed, bleeding is scarce and frontal postoperative edema is minimal. The author has used these techniques in 22 precapillary cases and the intracapillary procedure in 28 cases, some of which had a 4-year follow-up period. With the precapillary approach, temporary paresthesia occurred in some cases, but in all cases, sensibility was recovered within the first 2 to 6 months. With this simple and brief technique, the galea is not transected, no branches of the sensitive nerves are sectioned, and temporal and frontal arteries and veins that supply the scalp are not interrupted. Thereafter, wound healing is fast, allowing a quick recovery without areas of permanent numbness. As a result of this technique, the position of the eyebrows is the same as when frontal lifts are performed with transection of the galea and eversion of the flap, but without the side effects.

Circumvertical reduction mastoplasty: new considerations.

The circumvertical technique is a mixture of the periareolar and the vertical techniques in which the skin resection is performed around the areola and is continued in an inverted cone that starts at the infraareolar area and ends 2-4 cm above the submammary crease. Some advantages of this technique are: The glands are removed from the inferior glandular quadrant and from the inferior borders of the lateral and medial quadrants. The areola is moved upward and attached to the gland, preserving the nursing function. There is a harmonious distribution of the pleats around the areola and at the vertical wound. The vertical suture never crosses the submammary crease. The postoperative result is acceptable. Local anesthesia with vasoconstrictor is used minimizing bleeding. Bupivacaine is also included, prolonging the anesthetic effect hours after surgery. This paper describes this simple and rapid surgery and discusses some new, previously unpublished considerations and tricks.

Face lift postoperative recovery.

The purpose of this paper is to describe what I have studied and experienced, mainly regarding the control and prediction of the postoperative edema; how to achieve an agreeable recovery and give positive support to the patient, who in turn will receive pleasant sensations that neutralize the negative consequences of the surgery.After the skin is lifted, the drainage flow to the flaps is reversed abruptly toward the medial part of the face, where the flap bases are located. The thickness and extension of the flap determines the magnitude of the post-op edema, which is also augmented by medial surgeries (blepharo, rhino) whose trauma obstruct their natural drainage, increasing the congestion and edema. To study the lymphatic drainage, the day before an extended face lift (FL) a woman was infiltrated in the cheek skin with lynfofast (solution of tecmesio) and the absorption was observed by gamma camera. Seven days after the FL she underwent the same study; we observed no absorption by the lymphatic, concluding that a week after surgery, the lymphatic network was still damaged. To study the venous return during surgery, a fine catheter was introduced into the external jugular vein up to the mandibular border to measure the peripheral pressure. Following platysma plication the pressure rose, and again after a simple bandage, but with an elastic bandage it increased even further, diminishing considerably when it was released. Hence, platysma plication and the elastic bandage on the neck augment the venous congestion of the face. There are diseases that produce and can prolong the surgical edema: cardiac, hepatic, and renal insufficiencies, hypothyroidism, malnutrition, etc. According to these factors, the post-op edema can be predicted, the surgeon can choose between a wide dissection or a medial surgery, depending on the social or employment compromises the patient has, or the patient must accept a prolonged recovery if a complex surgery is necessary. Operative measures which prevent extensive edemas are: avoiding transection of the temporal pedicle, or to realizing platysma plication too tight by using strong aspirative drainage instead of elastic bandages. In the post-op, the manual lymphatic drainage is initiated on the third or fifth day, but must be done by a trained professional, in a method contrary to that specified in the books for non-operated individuals. An aesthetician washes the hair and applies decongestive cold tea on the face the second day, and on the fifth, moisturizes the skin and cosmetically conceals any signs of bruising. The psychological support provided by the staff keeps the patient calm and relaxed. Five years experience with this protocol has enabled us to minimize post-op pain. The edema can be predicted with certain consistency (in which surgery there will be more or less edema) and the proper technique can be selected, permitting the patient to choose the best moment for a FL while the surgeon can avoid intra and postoperative measures that increase the edema. After surgery, the patient receives the daily assistance of the staff, which rapidly and efficiently improves this condition. We can predict and control the post-op recovery and the patient feels fine, unlike the past when recovery was abandoned to its natural evolution. If the patient perceived an intensive, positive support on behalf of the entire staff that kept him or her content, then we have succeeded in doing an excellent marketing. This may encourage others to undergo aesthetic surgery, especially those who are convinced that after surgery they might have to endure considerable suffering.

The fate of lidocaine infiltrate during abdominoplasty and a comparative study of absorption of local anesthetic in 3 different regions: experimental studies in a porcine model.

BACKGROUND: Plasma lidocaine levels obtained during face lifts, breast surgery, and abdominoplasties showed an unexpectedly low absorption of anesthetics despite the use of doses exceeding the manufacturer's recommended maximum limit. OBJECTIVE: With the use of an animal model, we sought to determine the amount of anesthetic lost during an abdominoplasty and the levels of anesthetic absorption in different areas of the body. METHODS: In the first part of our study, 10 Duroc-Jersey pigs were infiltrated by using the same technique as for an abdominoplasty-specifically, with 14 mg/kg lidocaine (twice the manufacturer's recommended dose). Plasma lidocaine levels were determined at seven 15-minute intervals after surgery. After 2 days, abdomens of the same animals were infiltrated as before. An abdominoplasty was performed, and plasma lidocaine levels were obtained at 15-minute intervals during surgery. In a second study, we selected 10 pigs to analyze the absorption of anesthetics in different regions and tissues of the body. The axillary and pectoral regions, the face and neck area, and abdominal fat were each infiltrated with a solution containing 14 mg/kg lidocaine, with 2-day intervals between the infiltration of each region. For each region, samples were obtained at 15-minute intervals to determine plasma lidocaine levels. RESULTS: In the first study, plasma lidocaine levels in the animals that underwent abdominoplasty were 32% less at 15 minutes after infiltration and approximately 50% less at the later time intervals than those in the nonoperated animals. In the second study (without surgery), the rate of total absorption of lidocaine was 5.6 mug in the thorax (under the pectoralis major and in the axilla), 3.5 mug in the face, 3.5 mug in the neck, and 2.8 mug in the abdominal fat tissue. CONCLUSIONS: In a porcine model, approximately half the injected lidocaine anesthetic is lost during an abdominoplasty. Without performance of surgery, The abdomen has the lowest rate of absorption of anesthetics, the pectoral region the highest, and the subcutaneous tissues of the face and neck an intermediate rate, all of which were within the safe limits recommended by the manufacturer. (Aesthetic Surg J 2001;21:418-422.).

Local infiltrative anesthesia for transaxillary subpectoral breast implants.

Breast augmentations using a transaxillary subpectoral approach are usually performed under general anesthesia. This article describes a technique that uses local infiltrative anesthesia in breast augmentation, adenomastectomies with immediate breast reconstruction, and when placing breast expansors. Large anesthetic solutions with vasoconstrictor and long-acting effects are prepared. The axila, the subpectoral space, and a surrounding area of 3 cm outside the demarcation limits are infiltrated. Minimal bleeding, long-lasting effects, and a considerable postoperative analgesic effect are some of the advantages of this procedure.

Gigantomastía en embarazo / Gigantomastia in pregnancy

De etiología y por mecanismos fisiopatológicos desconocidos, durante el embarazo algunas mujeres desarrollan sus mamas en forma patológica. Las mamas crecen exageradamente de tamaño, adquieren un peso excesivo, presentándose de color rojo, totalmente inflamadas y edematizadas. Sus areoloas están distendidas y aumentadas de tamaño. Grandes venas congestivas cruzan la glándula, y la prolongación axilar dolorosa impide tener los brazos próximos al tórax. La clínica suele ser parecida al carcinoma inflamatorio, por lo que se debe realizar un buen diagnóstico diferencial. Los estudios hormonales generalmente son normales. Este cuadro evoluciona progresivamente hasta el parto y luego involuciona. Los tratamientos médicos y hormonales se han mostrado como inefectivos. Cuando se ha intentado su operación, la cirugía ha sido muy cruenta y riegosa. Esta patología puede aparecer en cualquier embarazo y suele tener como antecedentes anteriores, mastoplastías reductivas. Como análisis de 5 casos tratados, se sugiere realizar tratamiento médico mientras cursa el proceso y adenomastectomía con reconstrucción mamaria luego del parto.

Gigantomastía en embarazo / Gigantomastia in pregnancy

De etiología y por mecanismos fisiopatológicos desconocidos, durante el embarazo algunas mujeres desarrollan sus mamas en forma patológica. Las mamas crecen exageradamente de tamaño, adquieren un peso excesivo, presentándose de color rojo, totalmente inflamadas y edematizadas. Sus areoloas están distendidas y aumentadas de tamaño. Grandes venas congestivas cruzan la glándula, y la prolongación axilar dolorosa impide tener los brazos próximos al tórax. La clínica suele ser parecida al carcinoma inflamatorio, por lo que se debe realizar un buen diagnóstico diferencial. Los estudios hormonales generalmente son normales. Este cuadro evoluciona progresivamente hasta el parto y luego involuciona. Los tratamientos médicos y hormonales se han mostrado como inefectivos. Cuando se ha intentado su operación, la cirugía ha sido muy cruenta y riegosa. Esta patología puede aparecer en cualquier embarazo y suele tener como antecedentes anteriores, mastoplastías reductivas. Como análisis de 5 casos tratados, se sugiere realizar tratamiento médico mientras cursa el proceso y adenomastectomía con reconstrucción mamaria luego del parto.