Orlando 2006: plastic surgeons rate the "Hot Topics".

During the "Hot Topics" seminar at The Aesthetic Meeting 2006, authors polled participants to gain insight into how plastic surgeons evaluate current hot topics. Here are the results as well as the authors' notes on additional presentations.

Waste not, want not: the use of AlloDerm in secondary rhinoplasty.

BACKGROUND: This article describes the author's successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in secondary rhinoplasty. AlloDerm is a cadaver dermal filler graft, an off-the-shelf product that is readily available, pliable, and affordable. It is particularly suited for secondary rhinoplasty patients who are graft-depleted. The maximum dorsal augmentation is less than or equal to 3 mm; it is not a support graft. The major indication in this study was dorsal augmentation in the overresected secondary rhinoplasty patient to create a soft, smooth bridge and pleasing dorsal aesthetic lines. METHODS: Twenty-five secondary rhinoplasty patients underwent multiple nasal corrections and were followed for 2 to 8 years. RESULTS: Analysis demonstrated no contour changes between year 1 and year 2, showing the dermal grafts to be stable after 1 year. Long-term follow-up for 2 years or longer showed good results, although partial graft resorption (defined to be < or = 50 percent) occurred in 45 percent of patients. Resorption was most common over the bony dorsum, with approximately 20 to 30 percent of the graft absorbing; over the tip, approximately 10 to 15 percent of the graft absorbed. CONCLUSION: Absorption did not seem to relate to the number of layers used. AlloDerm does not shift. Overall, the experience for nasal augmentation in secondary rhinoplasty was encouraging. Partial absorption, especially over the bony dorsum in a thin-skinned patient, is a definite disadvantage. Complete absorption was not seen in this study. The author has discovered that it is imperative to overcorrect the defect intraoperatively. Regrafting is possible and sometimes necessary.

Visible scars from percutaneous osteotomies.

BACKGROUND: One of the criticisms of the percutaneous lateral nasal osteotomy technique is the potential for unfavorable, visible scarring. No clinical study has compared the external percutaneous approach with an internal approach to evaluate scarring in the same patient. This prospective, randomized, blinded study was designed to test the hypothesis that percutaneous perforating osteotomies cause perceptible scars when compared with the transnasal internal lateral osteotomy methods. METHODS: Fifty consecutive rhinoplasty patients requiring bilateral osteotomies (100 total lateral osteotomies) were prospectively randomized (institutional review board no. 1341-1M) so that each patient received an external skin puncture perforating osteotomy on one side and an internal lateral osteotomy on the control side. The percutaneous skin puncture was made with the flat edge of the sharpened 2-mm unguarded osteotome. The puncture site was approximated with Steri-Strips as part of the postoperative nasal splint. All patients were evaluated for scarring on the left versus the right side of the face at 1, 3, and 6 weeks; 6 months; 1 year; and when possible up to 2 years after the operation. The median follow-up in this series is over 1 year. RESULTS: The external percutaneous approach caused a visible scar in three patients (6 percent) as noted by three blinded examiners. One of these patients (2 percent) required a scar revision. Care must be taken to cleanse the chisel before percutaneous entry. This practice should avoid a traumatic tattoo. CONCLUSION: Percutaneous osteotomies generally produce an imperceptible scar (94 percent) but may cause a visible scar in a small percentage of patients.

Decision and management algorithms to address patient and food and drug administration concerns regarding breast augmentation and implants.

During the U.S. Food and Drug Administration's advisory panel hearings to evaluate the premarket approval for conventional silicone gel implants on October 14 and 15, 2003, panel members and patient advocate representatives focused on four specific areas of concern: reoperation rates in primary breast augmentation; levels, depth, and methods of patient education and informed consent; modes, frequency, and management of silicone gel implant device failures, including management of "silent" ruptures; and methods of monitoring and managing symptoms or symptom complexes that may or may not be associated with connective tissue disease or other undefined symptom complexes. These concerns, with a reported 20 percent reoperation rate for primary augmentation within just 3 years, and a lack of concise, definitive management protocols addressing these areas of concern may have contributed to the Food and Drug Administration's rejection of the premarket approval, despite the panel's recommendation for approval. This article presents decision and management algorithms that have been used successfully for 7 years in a busy breast augmentation practice (Tebbetts and Tebbetts). The algorithms have been further expanded and refined by a group of surgeons with diverse experiences and expertise to address the following clinical situations that coincide with concerns expressed by patients and the Food and Drug Administration: implant size exchange, grade III to IV capsular contracture, infection, stretch deformities (implant bottoming or displacement), silent rupture of gel implants, and undefined symptom complexes (connective tissue disease or other). In one practice (Tebbetts and Tebbetts) that uses the TEPID system (tissue characteristics of the envelope, parenchyma, and implant and the dimensions and fill distribution dynamics of the implant), implant selection is based on quantified patient tissue characteristics, pocket selection is based on quantified soft-tissue coverage, and anatomic saline implants have fill volumes that are designed to minimize shell collapse and fold fatigue; in this practice, the algorithms contributed to a 3 percent overall reoperation rate in 1662 reported cases with up to 7 years of follow-up, compared with a 20 percent reoperation rate at 3 years in the 2003 premarket approval study.

Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique.

Do perforating lateral osteotomies cause less ecchymosis and edema compared with the popular continuous method? Many studies have demonstrated that perforated osteotomies cause less trauma and periosteal disruption. Numerous investigators have subjectively perceived less postoperative ecchymosis and edema, but no clinical study has compared the perforated methods versus the continuous technique in the same patient. This prospective, randomized, partially blinded study was designed to test the hypothesis that the perforating method causes less postoperative ecchymosis and edema compared with the continuous lateral osteotomy technique. The questions remain: does the type of perforating osteotomy affect the results? Does a percutaneous approach cause more ecchymosis and edema by the access maneuver of piercing the skin? The two perforating lateral nasal osteotomy techniques require the same 2-mm straight osteotome, so any genuine difference in postoperative ecchymosis or edema could only be attributed to the differing surgical approaches. Accordingly, this study also tests whether the external percutaneous perforating osteotomy causes more ecchymosis and edema than the internal transnasal perforating method. Twenty-five consecutive rhinoplasty patients (group A) requiring bilateral osteotomies (50 total lateral osteotomies) were randomized so that each patient received an internal/transnasal perforating lateral osteotomy (2-mm straight chisel) on one side and an internal/transnasal continuous osteotomy (4-mm curved, guarded osteotome) on the other. The next 25 patients studied (group B) received an external/percutaneous perforating lateral osteotomy (same 2-mm straight chisel as used in group A) on one side and the same internal/transnasal continuous osteotomy on the other. The final 25 consecutive rhinoplasty patients (group C) received an external percutaneous perforating lateral osteotomy on one side and an internal transnasal perforating lateral osteotomy on the other. The entry sites for the perforating osteotomies were either external (groups B and C) with a percutaneous skin puncture or intranasal (groups A and C) at the pyriform aperture. All 75 patients (150 total lateral osteotomies) initialed the surgical plan on the Gunter rhinoplasty worksheet, which has been approved by the Institutional Review Board of Abbott-Northwestern Hospital, Minneapolis, Minnesota (study no. 1341-1 M). All patients were evaluated for ecchymosis and edema on the left versus the right side of the face at 2 to 3, 7, and 21 days after the operation. The clinical evaluation was performed by two blinded examiners (clinic registered nurse and the patient with his or her family) and a partially blinded examiner (the surgeon, who did not refresh his memory about the randomization). To compare the two methods in each study (groups A, B, and C) for the six outcomes (edema and ecchymosis at 2 to 3, 7, and 21 days), the authors used an exact binomial test of the null hypothesis that the treatments do not differ. To compare the two methods in each study (groups A, B, and C) using all six outcomes simultaneously, the authors used a permutation test. By both testing methods, the perforating internal method was superior to the continuous technique (group A; p < 0.01 in both tests). Although the perforating external method gave better results than the continuous technique (group B) and the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method. A lateral osteotomy technique should be precise, reproducible, and safe, and it should minimize ecchymosis and edema. Since edema and ecchymosis are comparable regardless of osteotome size, this prospective randomized study confirms the subjective clinical impression that perforating lateral osteotomies with a 2-mm straight osteotome reduce postoperative ecchymosis and edema in rhinoplasty patients compared with the continuous osteotomy (4-mm curved, guarded osteotome). These findings should encourage te the use of perforating osteotomies rather than continuous osteotomies.

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates.

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.

Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns.

At The Aesthetic Meeting 2002 of the American Society for Aesthetic Plastic Surgery, the Aesthetic Surgery Education and Research Foundation/Plastic Surgery Educational Foundation (ASERF/PSEF) Emerging Trends Task Force and Innovative Procedures Committee requested an update on zafirlukast (Accolate; AstraZeneca Pharmaceuticals, Wilmington, DE) and montelukast (Singulair; Merck & Co, West Point, PA) - what they are and how they work. These two asthma medications were reported to possibly treat and prevent capsular contracture after breast augmentation. On further analysis of postmarketing complications associated with zafirlukast based on information obtained through the Freedom of Information Act, it was discovered that between November 1, 1997, and October 31, 2002, 66 cases of hepatitis or liver failure in asthma patients occurred after a normal dose (13 of these 66 patients were taking no other medication). Two patients required liver transplants. Twenty-three deaths were reported (8 of these 23 patients were taking no other medication); 12 of these deaths followed liver failure. It should be noted that the Adverse Event Reporting System contains a disclaimer saying, "The reports have not been scientifically or otherwise verified as to a cause-and-effect relationship and cannot be used to estimate the incidence of adverse drug reactions." Many physicians entered the specific code to indicate zafirlukast as the "primary suspect" in the adverse event. Merck & Co reported no postmarketing cases of hepatitis or liver failure associated with montelukast. This article summarizes the proposed logic behind using these two asthma medications for the prevention and treatment of breast implant capsular contracture. (Aesthetic Surg J 2003;23:98-102.).

"Zigzag" wavy-line periareolar incision.

There is almost no mention of improvement in the aesthetics of areolar incisions in the plastic and reconstructive surgery literature. The most visible area of the breast is the central mound; therefore, it behooves surgeons to make an areolar incision as inconspicuous as possible. Minimal incision breast operations and short-scar operations, such as mastopexy and vertical reduction mammaplasty, use a circumareolar incision. This circumareolar technique, which specifically avoids a purse-string support suture, is useful in all periareolar incisions. This method creates a scar that mimics the elusive, natural irregularity between the areola and periareolar skin. The goal is to have an irregular, random, wavy line that appears more natural. Between August of 1998 and August of 1999, 104 "zigzag" wavy-line procedures were performed. The complications seen in this series included delayed healing in four patients and hypertrophic scar in two patients. No scars were surgically revised. The results demonstrated a definite difference compared to a circular scar. The zigzag wavy-line technique complements the innovative methods that shorten scars while they create a more natural, lasting breast mound. For areolar incisions, good results are deceptively subtle, but unnatural results can be painfully obvious. The zigzag wavy-line incision subtly eludes the eye in diminishing the signs the patient has undergone an operation.

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection.

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.