The silicone gel-filled breast implant controversy: an update.

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be familiar with the medical uses of silicone. 2. Have a working knowledge of the most important epidemiologic studies regarding silicone gel-filled breast implants. 3. Be aware of the issues about which patients desiring breast augmentation or reconstruction with implants must be counseled.

Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique.

The lateral nasal osteotomy is an integral element in rhinoplasty. A reproducible and predictable technique for the lateral nasal osteotomy (when indicated) is a significant contributor to operative success. A variety of methods and instrumentation are used to produce lateral osteotomies; currently, the two different modes used most frequently are the internal continuous and external perforated techniques. A previously published study by the senior author detailed the benefits of the external perforated osteotomy after comparing the two different methods. This article describes the role of the external perforated osteotomy technique in reproducing consistent results in rhinoplasty with minimal postoperative complications.

Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair.

The purpose of this study was to determine the incidence of cleft palatal fistula in a series of nonsyndromic children treated at the authors' institution. This retrospective analysis of 103 patients with cleft palate treated by five surgeons between 1982 and 1995 includes 60 boys and 33 girls, whose median age was 18.4 months at the time of surgery. The median length of follow-up was 4.9 years after primary palatoplasty. Cleft palatal fistula was defined as a failure of healing or a breakdown in the primary surgical repair of the palate. Intentionally unrepaired fistulas of the primary and secondary palate were excluded. Extent of clefting was described according to the Veau classification. Statistical examination of multiple variables was performed using contingency table analysis, multivariate logistic regression, and the Wilcoxon rank sum test. The incidence of cleft palatal fistula in this series was 8.7 percent. All of these fistulas were clinically significant. The rate of fistula recurrence was 33 percent. The incidence of cleft palatal fistula when compared by Veau classification was statistically significant, with nine fistulas occurring in patients with Veau 3 and 4 clefts and no fistulas occurring in patients with Veau 1 and 2 clefts (p = 0.0441). No significant differences between patients with and without fistulas were identified with respect to operating surgeon, patient sex, patient age at palatoplasty, type of palatoplasty, and use of presurgical orthopedics or palatal expansion. All three recurrent fistulas occurred in the anterior palate, two in patients with Veau class 3 clefts and one in a patient with a Veau class 4 cleft. The low rate of clinically significant fistula was attributed to early delayed primary closure, with smaller secondary clefts allowing repair with a minimum of dissection and disruption of vascularity.

The superiorly based nasolabial flap for simultaneous alar and cheek reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the epidemiology of skin cancer in a patient with preexisting skin cancer. 2. Understand the indications for the use of a nasolabial flap and nonanatomic alar strut graft. 3. Describe the blood supply to the nasolabial flap. The goals of reconstructing deformities of the face acquired secondary to skin tumors include optimizing donor-site aesthetics and reconstructing the area with similar types of tissue when possible. Multiple skin-cancer defects are often seen by the plastic surgeon and complicate the reconstruction, requiring more than one flap or skin graft. A case analysis of an innovative application of the nasolabial flap for reconstruction of a simultaneous medial cheek and alar-base nasal defect is presented. Concepts in nasal reconstruction are reviewed, and the authors' approach to alar reconstruction is presented.

Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery.

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution.

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures. The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.

The boxy nasal tip: classification and management based on alar cartilage suturing techniques.

The boxy nasal tip is characterized by a broad, rectangular appearance of the tip lobule on basal view. This manifests anatomically as one of three types: type I, which features an increased intercrural angle of divergence (greater than 30 degrees) and normal domal arc (4 mm or less) manifesting as the tip-defining points; type II, which features an increased angulation of the domes of the lower lateral segments of cartilage, creating a widened domal arc (greater than 4 mm) and normal angle of divergence (30 degrees or less); and type III, which features a combination of increased angle of divergence (greater than 30 degrees) and widened crural domal arc (4 mm or greater). In this article, the available techniques for correction of the boxy tip are reviewed and an algorithmic approach for the management of this problem is demonstrated using the open approach to rhinoplasty. Using an individualized algorithmic approach with intraoperative nasal tip analysis and three nasal tip suture reshaping techniques, consistent aesthetic results can be obtained in the correction of the boxy nasal tip.

The zones of adherence: role in minimizing and preventing contour deformities in liposuction.

True body sculpting demands a three-dimensional artistic understanding of the anatomic and surgical adipose layers of the central trunk when performing circumferential liposuction. This is essential in preventing complications from both ultrasound-assisted and suction-assisted lipoplasty. The authors describe five zones of adherence that should be avoided to prevent contour deformities in the central trunk area when performing circumferential liposuction. The anatomy of the subcutaneous tissue of these five anatomic zones is reviewed and correlated radiographically with magnetic resonance imaging studies. Aesthetic and technical considerations required to properly liposculpt the central trunk are demonstrated by case analysis of primary and secon-dary liposuction patients. These cases also delineate how to prevent and/or minimize deformities after liposuction.