Aesthetic aspects of neurofibromatosis reconstruction with the vacuum-assisted closure system.

Everyone agrees that any reconstructive procedure should carry with it the maximum of aesthetic considerations in order that the reconstructive procedure presents the minimal deformities. Vacuum-assisted closure-(VAC) has allowed surgeons to achieve this goal by creating the most optimal conditions for proper wound healing and thus the best aesthetic results. We present a tragic case whereby a 28-year-old Hispanic male patient with neurofibromatosis was treated for a soccer ball-sized tumor located on his upper left leg. The treatment plan consisted of partial excision with local flap coverage of the wound; however, due to persistent bleeding and tumor growth within the flap, the flap did not survive and we were left with an open wound measuring 20 x 40 cm extending from the patient's upper knee to his iliac crest. Had we attempted an autograft procedure at this time, there would scarcely have been enough donor skin areas to cover the wound. VAC was implemented in an attempt to control the bleeding and to possibly decrease the size of the wound. With the application of this procedure, the previously uncontrollable bleeding (12 units) stopped immediately, and the wound size shrank to 1/2 of its original dimensions. As a result, the area for skin grafting was decreased and was completed with 100% take. The VAC system turned out to be advantageous in achieving the most optimal conditions for our patient's wound to close and heal properly, allowing for enhancement of the aesthetic considerations for the patient.

The minimal facelift: liposuction of the neck and jowls.

We have used blunt liposuction for removing excess fat from the neck and jowls since 1983 with generally good results and few complications. Under local anesthesia with Valium and ketamine sedation and the use of the super-wet technique, and by using special precautions to avoid the complications of prominent platysmal bands, wrinkling of the neck, and salivary gland prominence, carefully performed liposuction to the neck and jowls has been shown to be a safe and dependable procedure with good results, and may delay or obviate the need for a facelift.

Simultaneous breast augmentation and lift.

Often, both augmentation and mastopexy are necessary to solve the problems of breast ptosis with hypoplasia. These two procedures can be done simultaneously with no increased risks. Patients who have any degree of ptosis may benefit from some lifting of the nipple areola complex if the nipple is not in the central portion of the general contour of the breast mound when seen in the upright position. A simple crescent or eccentric excision in the upper quadrant may be sufficient to lift the nipple-areola complex 1-2 cm. If the nipple needs to be moved more than a couple of centimeters, or if the distance between the nipple and the inframammary crease is already excessive, an inframammary skin excision and redraping will be necessary. We have been using these combined techniques for 20 years with universal patient satisfaction.

Noninvasive mechanical body contouring: (Endermologie) a one-year clinical outcome study update.

LPG Endermologie is a machine-assisted massage system that allows positive pressure rolling, in conjunction with applied negative pressure to the skin and subcutaneous tissues (LPG Endermologie U.S. A. (800-222-3911). Endermologie was originally developed in the late 1970s in France to soften scars and standardize physical therapy; however, patients treated with the LPG machine also showed improvement in body contour and skin texture. Since then, Endermologie machines have been used in France, the United States, and many other nations as an alternative method to altering fat distribution in the subcutaneous plane. The authors have continued their study of determining the safety and efficacy of this machine. Since our last report in March 1997 (Ersek RA et al., Aesth. Plast. Surg. 21(2):61-67, 1997), we have compiled records of 85 additional patients. With this larger patient pool, we can expect more statistically accurate results. This study is composed of 85 women between the ages of 21 to 61. The study group exhibited a wide range of body habitus, initial weights, and final results. Out of 85 patients, 46 patients completed seven sessions of treatment and showed a mean index reduction in body circumference of 1.34 cm, while 39 patients who completed 14 sessions of treatments showed a mean index reduction in body circumference of 1.83 cm. A decrease in mean body circumference index was seen regardless of loss or gain in patients' weight in most cases.

Lipo layering of autologous fat: an improved technique with promising results.

When using free fat autologous grafts as a filling material was first proposed in 1893 by Neuber, the idea rapidly gained enthusiasm and endorsements. Our early experience with autologous fat transplantation was disappointing, but even then it was clear that fat could be transferred with partial success. Since then, further clinical works by Guerrerosantos, Coleman, and others have shown that it is possible, by careful handling of transplanted fat, to improve the survival of this tissue. We have reviewed our recent experiences and have found several patients with whom autologous fat transplant has been successful with up to an 8-year postoperative follow-up.

Textured surface, nonsilicone gel breast implants: four years' clinical outcome.

Since the development of smooth silicone breast implants in 1962, more than 1 million women throughout the world have opted for breast augmentation surgery. Although initially successful, smooth implants are prone to develop surrounding scar capsules that may harden and contract, resulting in discomfort, weakening of the shell with rupture, asymmetry, and patient dissatisfaction. This phenomenon has been shown to occur in as many as 70 percent of implanted patients over time. We have reviewed all of our patients and the Medical Device Reporting System for Bioplasty, Inc. (Minneapolis, Minn.) for the history of this device. At 18 months, more textured implants remain soft than the smooth group. After an additional 30 months of follow-up, for a total of 48 months maximum and 18 months minimum, most textured implants still remain soft. Since 1990 we have used AU24K, bio-oncotic hydrogel filling material in molecular impact surface textured implants (MISTI) that is similar to breast tissue in color, radiodensity, and viscosity. Complications have been late leaks, infection, and capsular contracture. Several asymptomatic implants were removed because of anxiety over the FDA controversy. Our experience so far indicates that such a breast implant is a reasonable alternative to the prior art. The longer-term performance of these implants must await the availability of further clinical outcome data.

Bioplastique at 6 years: clinical outcome studies.

Bioplastique is a biphasic polymer for the permanent augmentation of some soft tissues. It was developed in 1987, and clinical studies at this institution were begun in 1990. The combination of low molecular weight polyvinylpyrrolidone and solid polymer particles allows the implantation of permanent polymer spheres through a small needle under local anesthesia. In this study 127 cases are reviewed of consecutive patients who have received Bioplastique for scar revision, wrinkles, and augmentation for soft-tissue defects at 6 years after application. All patients who had not been in for follow-up recently were contacted by mail and questioned on the permanence of augmentation and migration of particles. About 30 percent of the patients were unreachable and had their charts reviewed for permanence and migration of particles. In eight of these cases, Bioplastique was removed because of overcorrection, two of them may have had infection. Bioplastique has gained wide use throughout the world and although some complications have been reported, in general, it functions quite well when used in selected cases.

Abdominal etching.

The development of blunt liposuction by Illouz [1] in 1978 ushered in a new era in body sculpting. For the first time it had become possible to dependably remove large amounts of subcutaneous fat and decrease saddlebags and bulges to provide a smoother contour. Refinements in liposuction techniques have made it possible to dramatically resculpt the subsurface plane and improve body contour virtually from head to toe -2-4-. Mark Gilliland first performed abdominal etching by removing specific grooves of subcutaneous fat to accentuate the appearance of the abdominal musculature [5-8]. We have developed a new cannula for precision etching. This technique has been used in 25 patients with good results and has resulted in only one complication, which was the result of placing one of the horizontal etching lines at the level of the umbilicus. This created an unseemly fold that is best avoided.

Noninvasive mechanical body contouring: a preliminary clinical outcome study.

L.P.G.'s Endermologie is a massage method consisting of positive pressure rolling, in conjunction with applied negative pressure to both the, skin and subcutaneous tissues (L.P.G. Endermologie U.S.A., 3101 North Federal Highway, Suite 301 Fort Lauderdale, Florida 33306, U.S.A., (800) 222-3911). Devised in France during the 1970s, L.P.G.'s original purpose was to soften scars and standardize physical therapy; however, patients treated with the L.P.G. machine also showed an improvement in body contour and skin texture. Since then, several thousand machines have been in use in France as an alternative method for altering fat distribution in the subcutaneous plane. The authors began a study to determine the safety and efficacy of this machine. This study is composed of 22 women between the ages of 24 and 48. All 22 women completed at least seven sessions of treatments. Six of these 22 women completed all 14 sessions of the prescribed treatments. The study group exhibited a wide range of body habitus, initial weights, and final results. Of the 22 women who completed seven sessions of treatment, three had an increase in body weight and a mean index (see Materials and Methods) reduction in body diameter of 1.38 cm (0.5 in). Three of the six patients who completed all 14 treatment sessions had an increase in body weight and a mean index reduction in body diameter of 2.85 cm (1.12 in). All but one of the patients had a decrease in their mean body diameter index, regardless of their loss or gain in weight.

Biodegradable positive fixation for the endoscopic brow lift.

Development of endoscopic techniques allows the separation and repositioning of the periosteum of the orbital rims and zygomaxilla for a brow lift without skin excision. Questions have been raised about the permanence of this repositioning without fixation. We have developed a technique using biodegradable polylactide pericranial pins that serve as fixation points to allow specific suspension of the periosteum with positive positioning until the third phase of wound healing is complete. Through two inconspicuous incisions near the midportion of the scalp, subperiosteal dissection is carried to the orbital rims and the zygomatic arch anteriorly and all the way to the base of the occiput posteriorly. This allows for contracture of the occipitalis muscle to contribute to the repositioning and lifting of the brow. Up to seven sutures are then placed through and through the pericranium of the periosteum and frontalis along the superior and lateral border of the orbital rim. These stitches of long-acting polylactide acid are secured to two pins placed in the outer table of the cranium to maintain positive fixation for more than 6 weeks. In this way precise, positive positioning is maintained until wound healing and reattachment of the structures are complete. We began these procedures in 1993; our results at 24 months are promising.

The saddle lift for tight thighs.

Efforts to tighten the lateral thigh skin and subcutaneous tissue after liposuction may result in conspicuous scars on the hips, groin crease, or medial thighs. We have developed a technique that enables the excision of skin and subcutaneous tissue, measuring about 20 x 10 cm2, from the inner thigh and central buttocks crease where the scar can be completely hidden. We present a patient who, after appropriate liposuction, had a nearly perfect silhouette but who continually complained about the looseness of the skin on her lateral and posterior hips. The patient suggested that we remove the skin and subcutaneous tissue from the middle portion. We did so and the results were surprisingly good. We recommend this procedure for those patients in whom no external scar is acceptable and who require tightening of the skin of the upper thighs and buttocks.

Chin augmentation using minimally invasive technique and bioplastique.

The plethora of problematic techniques for improving minor chin recessions has left the plastic surgeon inevitably uncertain of the most effective remedy. Research we began in 1968 has led us to the development of a new biphasic polymer and minimally invasive implantation techniques aimed at solving the soft-tissue deficiency dilemma. Bioplastique consists of inert, textured particles of critical dimension dispersed within a bioexcretable gel vehicle. Previous experimentation in rabbit ears has shown that the gel component is rapidly phagocytosed, excreted, and replaced by a fibrin matrix within 3 days. The matrix is then replaced by host collagen, gradually forming a stable encasement around each microparticle. Further evaluation has revealed that the implant resists migration and absorption. Based on these encouraging results, a clinical phase was initiated. Thirteen patients lacking chin prominence have subsequently been improved with Bioplastique implants. The infection rate was 0 percent, and other complications were minor. At 26 months, no evidence of migration or absorption has been observed, and the aesthetic results remain.