Split Pectoralis Muscle Patch: A Surgical Adjunct During Prepectoral Breast Reconstruction Salvage.

ABSTRACT: Prepectoral implant-based breast reconstruction after mastectomy is a safe and reliable surgical option to restore aesthetic contour. Perioperative radiation therapy lends a morbidity to the integrity of the thin-walled mastectomy construct. Wound complications may result in implant exposure, which is potentially devastating to the reconstructed breast. Salvage often leads to implant explantation with the subsequent need for autogenous tissue grafts. Such rotational and free flap procedures result in prolonged operative times and inpatient length of stay, as well as donor site morbidity. Here we present a technique that utilizes a pedicled split pectoralis muscle flap as an internally rotated breast envelope patch to buttress a mastectomy flap repair during salvage of the prepectoral breast envelope when full-thickness tissue defect is present.

Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty.

BACKGROUND: The tear trough deformity is challenging in lower eyelid rejuvenation. Surgical treatment has evolved, with more modern techniques preserving orbital fat and using autologous fat transposition. The senior author (M.A.C.) reviewed his own experience in targeting the tear trough in lower lid blepharoplasty and presents a new technique that incorporates the addition of micro free fat grafts that adds direct volume to the underlying anatomical depression using a transcutaneous skin-muscle approach. METHODS: Medical records of lower lid blepharoplasty patients performed from February of 2011 to February of 2016 were reviewed. Patients who had tear trough deformities with the addition of micro free fat grafts were included. Standard patient characteristics were collected, complications were identified, and assessment of postoperative results was performed. RESULTS: There were 32 patients included in the study, with a median follow-up of 392 days (range, 45 to 1709 days). Scleral show requiring operative correction occurred in one patient (3 percent). Additional complications included chemosis in four patients (13 percent), which resolved in all patients. No patients had infections, ectropion, lid retraction, or palpable or visible grafts. CONCLUSION: The use of micro free orbital fat grafts is an effective and safe technique to treat the tear trough deformity without increased complication rates and good patient and surgeon satisfaction and should be considered a surgical adjunct during an open blepharoplasty technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evidence-Based Medicine: Face Lift.

LEARNING OBJECTIVES: After studying this article, the participants should be able to: 1. Describe pertinent surgical anatomy relevant to safe and effective face-lifting techniques. 2. Identify key aspects of facial aging. 3. Incorporate risk-reduction strategies during preoperative assessment. 4. Tailor their approach to face lifting based on patient anatomy. 5. Identify and treat complications after face-lift surgery. 6. Incorporate use of valid patient outcomes assessment tools in their practice to facilitate standardized outcomes reporting in the face-lift literature. SUMMARY: Treating the aged face requires an understanding of bone and soft-tissue anatomy, including the analogous lamellar layers of the face and neck, and the techniques designed to restore youthful skin tone and facial contours. Although volume restoration with fillers is effective for restoring youthful facial contours, the power of face lifting is unmatched in its ability to rejuvenate a sagging facial shape. Standard face-lifting techniques are described, along with the authors' preferred approach, supplemented by video demonstration of the high-superficial musculoaponeurotic system technique. Complications, along with their prevention and treatment, are reviewed. Currently available comparative studies of face-lifting outcomes consider surgeon opinion and postoperative complications rates. A valid, standardized, patient-reported outcome tool, the FACE-Q, has been available since 2010, and should be a component of any comparative discussion of face-lifting techniques in the future.

Embrace the Change: Incorporating Single-Stage Implant Breast Reconstruction into Your Practice.

BACKGROUND: Multiple studies have reported on the safety of nipple-sparing mastectomy and low complication rates associated with single-stage implant breast reconstruction. Yet many plastic surgeons continue to be resistant to change. This article presents the senior author's (M.A.C.) experience during his transition period from the latissimus dorsi flap with adjustable implants to a "one-and-done" approach using shaped implants and fetal bovine acellular dermal matrix. METHODS: A literature review was performed selecting articles discussing single-stage implant reconstruction, indications, outcomes, technique, and complications. Additional articles were selected after review of the references of identified articles. Clinical pearls discussed include patient selection, implant selection, and mastectomy incision choices, with a detailed description of the senior author's operative technique. RESULTS: Twenty-seven single-stage implant reconstructions were performed. Average mastectomy weight was 343.82 g. The average implant volume was 367 cc. Shaped implants were most commonly used. Acellular dermal matrix was used in all breasts. Complications included erythema requiring intravenous antibiotics (three patients), skin ischemia caused by methylene blue (one patient), seroma (one patient), unilateral partial nipple necrosis (one patient), mastectomy skin necrosis (one patient), and exposed/infected implants that were salvaged using a sequential irrigation protocol described by Sforza et al. in 2014 (two patients). CONCLUSIONS: Breast reconstruction after mastectomy has evolved toward less invasive, single-stage procedures. Aesthetic refinements include nipple-sparing mastectomy, use of acellular dermal matrix, shaped implants, and fat grafting. Selected patients will benefit from a one-and-done breast implant reconstruction with no additional oncologic risk. Surgeons must embrace the change and provide their patients with a procedure that will offer the best aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Textured silicone breast implant use in primary augmentation: core data update and review.

Evolution of silicone breast implant design has focused primarily on advances in implant fill, surface texture, and shape. Fifth-generation, shaped, form-stable, silicone breast implants from all three major implant manufacturers are now approved for use by the U.S. Food and Drug Administration in the United States. As part of this approval, the U.S. Food and Drug Administration mandated Core Study follow-up of silicone implants for 10 years after premarket approval. An updated and comprehensive collection of Core data from all three manufacturers is presented in this review. In addition, cause and rates of capsular contracture, seroma, rippling, and malposition are discussed. New concepts such as tissue friction coefficient are discussed that may influence outcome after primary breast augmentation. The theoretical advantages and disadvantages of the various textured surfaces ranging from microtexturing to macrotexturing are presented in relation to breast tissue incorporation.

Functional considerations in aesthetic eyelid surgery.

BACKGROUND: Aesthetic eyelid surgery involves intricate techniques to improve the appearance of the periorbital region. In the presence of preoperative ptosis, lower lid laxity or malposition, prominent eyes, and xerophthalmia (dry eyes), patients are at an increased risk of developing postoperative complications such as scleral show, ectropion, corneal injury, and persistent ptosis. METHODS: The authors identify patients at increased risk for functional problems after blepharoplasty and describe detailed preoperative evaluation to identify patients who may be at increased risk prior to surgery. RESULTS: In order to minimize the complications rates associated with blepharoplasty, it is of paramount importance to appreciate and address these functional concerns in the approach to blepharoplasty surgery. CONCLUSION: After reading this article, the participant should be able to demonstrate a systematic approach to identify high-risk blepharoplasty patients and manage functional issues in both upper and lower blepharoplasty.

Eyelid reconstruction.

Reconstruction of the eyelids after excision of skin cancer can be challenging. Knowledge of surgical eyelid anatomy and appropriate preoperative planning are critical in order to perform eyelid reconstruction and minimize complications and the need for reoperation. The fundamental principle for full-thickness eyelid reconstruction is based on reconstructing the subunits of the eyelid, including the anterior and posterior lamellae as well as the tarsoligamentous sling.

Retaining ligaments of the face: review of anatomy and clinical applications.

The retaining ligaments of the face are important in understanding concepts of facial aging and rejuvenation. They are located in constant anatomic locations where they separate facial spaces and compartments. Their superficial extensions form subcutaneous septa that separate facial fat compartments. Their main significance relates to their surgical release in order to achieve the desired aesthetic outcome. Furthermore, they have a sentinel role in their anatomic relationship to facial nerve branches. When performing facial aesthetic surgery, plastic surgeons should select a plane of dissection, release the appropriate ligaments depending on the desired aesthetic goals, and avoid nerve injury by using the ligaments as anatomic landmarks. Descriptions of the retaining ligaments are variable in the literature; due to different interpretations of anatomy, several classifications, locations, and nomenclature systems have been proposed. This article will review and clarify the anatomy of the retaining ligaments of the face, including the cheek, mandible, temporal, and periorbital areas.

Risk of breast implant bacterial contamination from endogenous breast flora, prevention with nipple shields, and implications for biofilm formation.

BACKGROUND: Capsular contracture (CC) is a common complication of breast augmentation that is thought to arise from bacterial contamination and subsequent biofilm formation on the implant. Endogenous breast flora expressed through the nipple may contaminate the sterile field during breast augmentation, acting as a possible source for initiation of biofilm formation. OBJECTIVES: The authors investigate the incidence of nipple bacterial contamination with endogenous breast flora after standard chest wall sterilization during breast augmentation. METHODS: Bacterial contamination of nipples and nipple shields was assessed in a series of 32 consecutive patients presenting for breast augmentation (63 breasts: 31 bilateral procedures and 1 unilateral procedure). After standard sterilization of the chest wall, occlusive nipple shields were applied and breast augmentation was performed. At the conclusion of breast augmentation, the nipple shields were removed and, using the same swab, both the nipple/areolar area and occlusive dressings were cultured. RESULTS: Data from 63 cultured nipples and nipple shields revealed that 22 nipples/nipple shields (34.9%) were positive for bacterial contamination. Three patients, all of whom had negative cultures, developed CC after augmentation. CONCLUSIONS: The exposed nipple is a potential source of implant contamination during breast augmentation. An improved understanding of biofilms and related risk factors for CC can provide surgeons with insights for addressing this common complication. Meticulous hemostasis, use of nipple shields, and submuscular device placement may contribute to a lower incidence of CC.

Tear trough deformity: review of anatomy and treatment options.

The lower eyelid can be a challenging area in facial rejuvenation. While lower eyelid bags are commonly the reason that patients present for lower eyelid rejuvenation, a separate entity known as a tear trough deformity may occur in conjunction with lower eyelid bags or alone. In this article, the authors outline the current understanding of the tear trough anatomy; describe multiple classification systems, which provide an objective means of evaluating the deformity and aid the surgeon in choosing appropriate treatment options; and review surgical and nonsurgical techniques for correcting the tear trough deformity. Treatment options include hyaluronic acid filler, fat grafting, skeletal implants, and fat transposition. Each procedure is associated with advantages and disadvantages, and each should be considered more complex than traditional lower blepharoplasty alone. While lower blepharoplasty removes excess fat and may tighten the anterior lamella, tear trough procedures require the addition of volume to the underlying depression. These procedures requiring release of the ligamentous structures and orbicularis (of which the tear trough is composed), as well as fat transposition or fat grafting, are associated with additional complications, which are also reviewed.

A 15-year experience with primary breast augmentation.

BACKGROUND: This study evaluated patients who underwent primary breast surgery within a single group practice from 1994 to 2009. Reoperations were divided by reoperation reason into total reoperations and implant-specific reoperations. The authors hypothesized that the implant-specific reoperation rate will provide the most accurate measurement of complications caused by the breast implant device. METHODS: A total of 812 patients received the same brand of breast implant for primary breast augmentation or augmentation/mastopexy. Safety and efficacy data were recorded and complication rates were calculated. Statistics were applied using Kaplan-Meier estimated cumulative incidence calculations. RESULTS: This study included 482 patients with saline and 330 patients with silicone implants. The most common complications included capsular contracture, rippling, rupture, infection, and hematoma. A total of 8.2 percent of patients developed Baker grade III/IV capsular contracture by 6 years. The raw incidence of rippling was 7.1 percent, and the rate was significantly increased in underweight patients with subglandular saline implants (p = 0.045). The rate of total reoperation at 1 year was 14.2 percent. While a significantly increased rate of total reoperation was seen for silicone compared with saline implants (p < 0.01), no difference was seen in the rate of implant-specific reoperation for saline compared to silicone implants (p = 0.582). CONCLUSIONS: The use of total reoperation rates as an indication of complications of breast implants can lead to both an overestimation of implant-related complications and the inaccurate conclusion that silicone implants result in higher complication rates than saline implants. The implant-specific reoperation rate may provide a more accurate incidence of implant complications than the total reoperation rate, which includes reoperations for factors unrelated to the implant.

Silent sinus syndrome: a rare presentation after botulinum toxin injection.

Silent sinus syndrome is a unique diagnosis characterized by spontaneous enophthalmos and hypoglobus resulting from collapse of the orbital floor secondary to chronic subclinical sinusitis. Although reported in the ophthalmology and otolaryngology literature, there is no mention of silent sinus syndrome in the plastic surgery literature. The authors present a case report, along with a brief overview of silent sinus syndrome, so that knowledge of this rare but potentially devastating clinical entity may supplement plastic surgeons' differential to ensure proper diagnosis and treatment.

Aesthetic and technical refinements in latissimus dorsi implant breast reconstruction: a 15-year experience.

BACKGROUND: The latissimus dorsi myocutaneous flap and implant breast reconstruction procedure has undergone many refinements over its lifetime. In fact, the authors have made many aesthetic and technical refinements to their own approach to breast reconstruction. OBJECTIVES: The authors review the historical progression of latissimus flap and breast reconstruction techniques and compare these to their own 15-year experience. METHODS: A retrospective chart review was conducted for all latissimus and implant breast reconstructions performed by the senior author (MAC) from July 1994 to June 2009, for a total of 52 procedures in 31 patients. Surgical and oncological data, complications, and outcomes data were recorded. RESULTS: The mean age of the patients at time of surgery was 47.6 years. Average mastectomy weight was 283 grams and average final implant volume was 364 cc. Average follow-up was three years, four months. Of the 52 total procedures, 34.6% were immediate breast reconstructions utilizing skin-sparing mastectomy (SSM); 13.5% of the reconstructed breasts also had preservation of the areola (areolar-sparing mastectomy [ASM]). The most common complication was donor site seroma (40.4%). Aesthetic and surgical refinements identified over the time period included the adoption of SSM and ASM techniques, immediate nipple reconstruction, the placement of an adjustable saline implant to allow for postoperative size adjustment, and implant placement in the prepectoral position. The overall latissimus dorsi implant reconstruction success rate was 94.2% (49/52). CONCLUSIONS: The data demonstrated a successful outcome for latissimus dorsi and implant breast reconstruction for patients with a low or normal body mass index and a small (A to C cup) breast size. The aesthetic outcome of latissimus dorsi breast reconstruction has been improved over the past 15 years by the adoption of SSM and ASM techniques. Immediate nipple reconstruction and the placement of an adjustable saline implant potentially render this procedure a true single-stage reconstruction. Prepectoral implant position provides good aesthetics while preserving the subpectoral space for future management of capsular contracture if required.

Upper and lower eyelid reconstruction.

Reconstruction of the eyelids can range from simple repair to the integration of multiple complex procedures. Knowledge of eyelid anatomy, adequate preoperative planning, and meticulous surgical technique will optimize the anatomical and functional result. The purpose of this article is to review the relevant anatomy for eyelid reconstruction, to simplify defect analysis and preoperative planning, and to provide options for reconstruction of this complex area.

Blepharoplasty and brow lift.

Brow lift and blepharoplasty are among the most commonly requested procedures in facial aesthetic surgery. The purpose of this article is to provide an overview of current concepts, including goals, surgical options, and outcomes for aesthetic improvement of the forehead and periorbital region. Preoperative patient assessment, anatomical and surgical concepts, advantages and disadvantages, and prevention and management of complications and expected results are discussed. Surgical results of endoscopic and lateral brow lift, upper lid blepharoplasty with supratarsal fixation, and lower lid blepharoplasty with correction of the tear trough are presented. Details of the perioperative techniques are presented in accompanying video format. A critical understanding of patient expectation, surgical anatomy, and operative technique is important for avoiding complications and achieving aesthetic results in brow and eyelid rejuvenation.

Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show.

SUMMARY: Blepharoplasty remains one of the most popular operations in facial aesthetic surgery. Serious complications, which include blindness, retrobulbar hematoma, and ectropion, although relatively rare, are well reported in the literature. As techniques evolve in aesthetic eyelid surgery, minor complications continue to be very common. Nonetheless, management of these complications can be challenging and may require extended management or surgical revision. The authors discuss several of the most common minor complications, including hematoma, dry-eye syndrome, infections, atypical lesions, lid malposition, and scarring. In addition, preoperative assessment of risk factors, treatment, and management of these minor complications are presented.