Superiorly Based Short-Scar Mastopexy Augmentation: A 10-Year Review of 1217 Consecutive Cases.

BACKGROUND: Mastopexy augmentation is a challenging procedure, and a technique to create desirable, consistent, predictable results with a low rate of problems has not been well standardized. The inherent difficulty lies in competing surgical maneuvers. This study sought to evaluate the authors' experience and describe the key concepts and steps that allow safe, efficient, predictable results with low complication and long-term reoperation rates. METHODS: A 10-year retrospective review of all aesthetic breast operations between 2005 and 2015 was performed. Two senior surgeons (S.H.W. and H.C.W.) performed 1217 one-stage, superiorly based, short-scar mastopexy augmentation procedures. The data were evaluated in the context of other published series in the literature. RESULTS: The overall revision rate was 4.8%. Patients who had undergone prior breast surgery were statistically more likely to require a revision compared with patients who had virgin breast tissue (10.4% versus 3.8%; P = 0.0005). Average follow-up was 39 months. Twenty-eight percent of revisions were performed more than 2 years after the original surgery; 16% were performed more than 6 years later. All revisions were included, regardless of procedure scope or timing. Of the 58 revision cases, 86% were purely implant or implant-pocket related; 7% were purely tissue related. There was one case of partial nipple necrosis. There were no cases of emergent reoperation, implant loss, implant exposure, or major wound dehiscence. CONCLUSIONS: The authors' approach has been refined to maximize aesthetics, longevity, consistency, and surgical efficiency, and to minimize complications. This study demonstrates that safe and predictable results can be attained in one stage with low complication and reoperation rates. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Deep Subcutaneous Gluteal Fat Compartments: Anatomy and Clinical Implications.

BACKGROUND: Advances in gluteal fat grafting have resulted in diminished risks through improved understanding of regional anatomy and technical nuances. No anatomic studies identifying the presence or absence of buttock fat compartments have yet been reported. OBJECTIVES: The aim of this cadaveric study was to identify and characterize the deep subcutaneous gluteal fat compartments to further understand the nuanced differences between deep and superficial subcutaneous fat layers. METHODS: A cadaveric study was performed to identify the fat compartments. Latex injection into the iliac artery and vein was used to prepare 4 fresh (N = 8 hemibuttocks) hydrated cadavers for dissection. Preliminary work identified the likely position of deep gluteal fat compartments. The cannula was positioned under ultrasound guidance in between the superficial and deep gluteal layers. Cadaveric buttocks were infiltrated by the static technique with dyed human fat, dyed applesauce, and dyed saline in an attempt to identify the gluteal deep subcutaneous fat compartments. RESULTS: Dissection identified and characterized 7 discrete deep gluteal fat compartments. These comprise 3 medial fat compartments (superior, middle, and inferior); a central fat compartment; and 3 lateral (superior, middle, and inferior) deep fat compartments. CONCLUSIONS: Seven deep gluteal fat compartments have been identified that have distinct boundaries and maintain injected contents separate from each other above the gluteal muscle fascia. These compartments can be selectively expanded for buttock augmentation. Knowledge of these compartments enables surgeons to perform gluteal augmentation by static infiltration, injecting autologous fat under ultrasound guidance in the deep subcutaneous fat layer, while optimizing aesthetic considerations.

Simultaneous Separation and Tumescence: A New Paradigm for Liposuction Donor Site Preparation.

BACKGROUND: An ever-increasing demand for liposuction and fat transplantation procedures in the United States reflects their continued safety and clinical effectiveness. Technical breakthroughs, such as the utilization of tumescent infiltration and fat separation techniques, have been instrumental in optimizing outcomes but add time to the surgical procedure. Simultaneous separation and tumescence (SST) is a new technique combining these innovations to further improve safety and efficiency in liposuction. OBJECTIVES: The authors describe their technique for utilizing SST on more than 1200 patients spanning a 6-year period. A split abdomen study was designed to compare the vasoconstrictive effectiveness of SST with traditional Klein infiltration techniques. METHODS: A quantification perfusion analysis utilizing indocyanine green angiography was performed on 4 patients to illustrate the vasoconstrictive effectiveness of SST over traditional Klein infiltration techniques. A mean relative vasoconstriction score was calculated relative to the umbilicus for each technique. RESULTS: Compared with traditional Klein tumescence techniques, SST has a similar complication rate, utilizes similar infiltrative volumes, and increases vasoconstriction (mean 89.6% SST hemiabdomen vs 48.1% Klein hemiabdomen at 2 minutes, P < 0.0001). CONCLUSIONS: SST represents a novel, long-overdue departure from Klein tumescence, which has been a valuable mainstay for donor site preparation for over 3 decades. SST will pave the way for more efficient operative times and potentially higher volumes of fat being safely extracted.

Safety Comparison of Abdominoplasty and Brazilian Butt Lift: What the Literature Tells Us.

BACKGROUND: Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS: Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS: Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS: Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Subcutaneous Migration: A Dynamic Anatomical Study of Gluteal Fat Grafting.

BACKGROUND: Recent anatomical studies have demonstrated that fat placed subjacent to the fascia of the gluteus maximus muscle can migrate deep through the muscle into the submuscular space, possibly causing tears in the gluteal veins, leading to fat embolisms. The purpose of this study was to define and to study subcutaneous migration and to determine whether fat placed in the subcutaneous space under a variety of pressures and fascial integrity scenarios can indeed migrate into the deep submuscular space. METHODS: Four hemibuttocks from two cadavers were used. Proxy fat was inserted using syringes with various fascia scenarios (1: fascia intact; 2: cannula perforations; 3: 6mm fascia defects) or using expansion vibration lipofilling (4: fascia intact). Subcutaneous pressures were recorded. After injections, anatomical dissections were performed to evaluate the migration of the proxy fat for each of the scenarios. RESULTS: Scenario 1: pressure reached approximately 125 to 150 mmHg and then plateaued and all the proxy fat remained in the subcutaneous space. Scenario 2: pressure reached a 199-mmHg plateau and no proxy fat spread deeper into the muscle or beneath it. Scenario 3: pressure gradually rose to 50 mmHg then fell again and the submuscular space contained a significant amount of proxy fat. Scenario 4: pressure rose to a maximum of 30 mmHg and all of the proxy fat remained in the subcutaneous space. CONCLUSIONS: The gluteus maximus fascia is a stout wall that sets up the dangerous condition of deep intramuscular migration with subfascial injections and the protective condition of subcutaneous migration with suprafascial injections. These persuasive findings are profound enough to propose a new standard of care: no subfascial or intramuscular injection should be performed, and all injections should be performed exclusively into the subcutaneous tissue.

An Observational Study of the Safety and Efficacy of Tissue Stabilized-Guided Subcision.

BACKGROUND: Cellulite is a common female cosmetic concern for which there are few treatment options with long-term effectiveness data. The aim of this multisite prospective registry study was to collect observational data on the real-life clinical use of a tissue stabilized-guided subcision (TS-GS) system for long-term improvement of cellulite appearance. METHODS: Fifty-three subjects were enrolled and received a single treatment using the TS-GS system. Physicians treated the subjects according to their standard of care. Global Aesthetic Improvement Scale (GAIS) was completed by the patient and clinician assessing overall aesthetic improvement after 180 days. Treatment parameters, pain scores, quality of life data, and expected treatment effects and adverse events were also recorded throughout the study. RESULTS: The patient and physician GAIS scores at Day 180 revealed an overall improvement in 91% and 96% of patients, respectively. Quality of life and self-confidence scores also improved through 180 days. No serious adverse events were reported. Expected treatment effects were similar to those reported in the pivotal trial supporting FDA clearance. CONCLUSION: This study demonstrated significant improvement in the appearance of cellulite after a single treatment session in patients with moderate-to-severe cellulite. These results are consistent with the previously published the pivotal study data.

Expansion Vibration Lipofilling: A New Technique in Large-Volume Fat Transplantation.

BACKGROUND: Despite rapid growth, gluteal fat transplantation is an operation in search of science and a teachable technique. Long operating times, tedious syringe transfers, inability to shape the recipient site, and the risk of fat embolism all headline as impediments to clinical adoption of the procedure. Expansion vibration lipofilling is a syringe-free surgical strategy that is a logical extension of Separation, Aspiration, and Fat Equalization (SAFELipo). In expansion vibration lipofilling, there is simultaneous disruption of recipient-site connective tissue, internal expansion using exploded-tip cannulas, and backfilling of these spaces with roller pump-propelled fat. METHODS: Two thousand four hundred nineteen consecutive cases of expansion vibration lipofilling fat transplantation to the buttocks were reviewed. Average follow-up was 12 months. The technique of expansion vibration lipofilling is dependent on the use of larger caliber cannulas attached to a roller pump and to an oscillatory power-assisted liposuction device, which is less labor-intensive, potentially allowing for better knowledge of cannula-tip location at all times during the procedure. RESULTS: Operating times averaged 1 hour 40 minutes. The average volume of fat inserted was 1003 cc. Complications included donor-site seroma, infection, and one pulmonary embolism treated with anticoagulation. There were no cases of fat embolism or death. CONCLUSIONS: Expansion vibration lipofilling is a new method for large-volume fat transplantation. Avoidance of fatal fat emboli demands a surgeon's complete knowledge of cannula tip location at all times during the procedure. Syringe-free, larger caliber, and less flexible cannulas, combined with techniques requiring less operator upper extremity effort resulting in less fatigue, may contribute to avoidance of this dreadful complication. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Separation, Aspiration, and Fat Equalization: SAFE Liposuction Concepts for Comprehensive Body Contouring.

BACKGROUND: Separation, aspiration, and fatty equilibration (SAFE) liposuction uses a process approach to body contouring and minimizes injury to surrounding structures. The multistep process allows for (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The purpose of this study was to review both outcomes and complications of primary SAFE liposuction. METHODS: Retrospective chart review was completed of patients undergoing SAFE liposuction from January of 2006 to January of 2011. Patient selection was limited to those undergoing liposuction alone with no adjuvant excisional procedures. Data were collected regarding demographics, body mass index, operative details, and outcomes. RESULTS: Seven hundred thirty-four patients were identified as having undergone SAFE liposuction. One hundred twenty-nine patients were found to have been treated with liposuction alone. Patient age ranged from 18 to 42 years and body mass index ranged from 18 to 42 kg/m (mean, 26.3 kg/m). Seven patients (5.4 percent) underwent treatment of the face and neck, six patients (4.7 percent) underwent treatment of upper extremities, 13 patients (10.1 percent) underwent treatment of the chest, 20 patients (15.5 percent) underwent treatment of lower extremities, 32 patients (24.8 percent) underwent treatment of the circumferential trunk, and 51 patients (39.5 percent) underwent treatment of circumferential trunk and additional area(s). No major complications occurred. Five of the 129 patients (3.87 percent) developed the minor complication of seroma formation. CONCLUSIONS: SAFE liposuction is a multistep process approach to body contouring consisting of (1) fat separation, (2) lipoaspiration, and (3) fat equalization. The results of this study show such technique to be safe and effective. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Determining the Safety and Efficacy of Gluteal Augmentation: A Systematic Review of Outcomes and Complications.

BACKGROUND: Augmentation gluteoplasty has been performed more frequently in the past decade, with over 21,000 procedures performed in the past year alone. The most popular methods for buttock augmentation involve silicone prostheses and autologous fat grafting. A comparison of complications of these two techniques does not exist in our literature. METHODS: The PubMed, MEDLINE, and Cochrane databases were searched through April of 2015 for studies that achieved buttock augmentation through the use of silicone implant placement or autologous lipoinjection. Complication outcomes of interest included wound dehiscence, infection, seroma, hematoma, asymmetry, and capsular contracture. RESULTS: Forty-four articles met inclusion criteria. The most commonly reported complications in 2375 patients receiving silicone implants were wound dehiscence (9.6 percent), seroma (4.6 percent), infection (1.9 percent), and transient sciatic paresthesias (1.0 percent), with an overall complication rate of 21.6 percent (n = 512). The most commonly reported complications in 3567 patients receiving autologous fat injection were seroma (3.5 percent), undercorrection (2.2 percent), infection (2.0 percent), and pain or sciatalgia (1.7 percent), with an overall complication rate of 9.9 percent (n = 353). Patient satisfaction after surgery was assessed differently among studies and could not be compared quantitatively. CONCLUSIONS: Although gluteal augmentation was once reported to have complication rates as high as 38.1 percent, a systematic review of the two most popular techniques demonstrated substantially lower overall complication rates. The overall complication rate with autologous fat grafting (9.9 percent) is lower than that with silicone buttock implants (21.6 percent). A standardized method of measuring patient satisfaction is necessary to fully understand outcomes of these increasingly popular procedures.

Impact of liposome bupivacaine on the adequacy of pain management and patient experiences following aesthetic surgery: Results from an observational study.

BACKGROUND: Despite the efficacy of opioid analgesics for postsurgical pain, they are associated with side effects that may complicate recovery. Liposome bupivacaine is a prolonged-release formulation of bupivacaine approved for intraoperative administration at the surgical site for postsurgical analgesia. OBJECTIVES: To evaluate the effect of a single intraoperative administration of liposome bupivacaine on postsurgical pain, opioid use and opioid-related side effects in subjects undergoing breast surgery and/or abdominoplasty. METHODS: In the present phase IV, multicentre, prospective observational study, subjects received a single intraoperative administration (266 mg) of liposome bupivacaine. Rescue analgesia was available to all subjects as needed. Outcome measures, assessed through postoperative day 3, included postsurgical pain intensity (11-point numerical rating scale), opioid consumption and overall benefit of analgesic score. Results were evaluated comparing investigators' previous experience with similar surgeries. RESULTS: Forty-nine subjects entered the study: 34 underwent breast surgery only and 15 underwent abdominoplasty with or without breast surgery (six underwent breast surgery in addition to abdominoplasty). Mean numerical rating scale pain scores remained ≤4.3 from discharge through postoperative day 3. Median daily oral opioid consumption was approximately 1.0 tablet postoperatively on the day of surgery and was approximately 2.0 tablets by postoperative day 3. Mean overall benefit of analgesic score ranged between 2.8 and 4.9 throughout the study. CONCLUSION: In this particular subject population, liposome bupivacaine was associated with low pain intensity scores and reduced opioid consumption compared with the investigators' previous experiences. Subjects' satisfaction with postsurgical analgesia was high, with a low burden of opioid-related side effects.

HISTORIQUE: Malgré l'efficacité des opioïdes pour soulager la douleur postchirurgicale, des effets secondaires peuvent compliquer le rétablissement. La bupivacaïne liposomique est une formulation à libération prolongée approuvée pour l'administration peropératoire d'une analgésie postchirurgicale au site opératoire. OBJECTIFS: Évaluer l'effet de l'administration peropératoire d'une seule dose de bupivacaïne liposomique sur la douleur postchirurgicale, ainsi que sur l'utilisation d'opioïdes et leurs effets secondaires chez des sujets subissant une chirurgie mammaire, une abdominoplastie ou les deux interventions. MÉTHODOLOGIE: Dans le cadre de la présente étude d'observation prospective et multicentrique de phase IV, les sujets se sont fait administrer une seule dose peropératoire de bupivacaïne liposomique (266 mg). Tous les sujets pouvaient recevoir une analgésie de secours, au besoin. Les mesures des résultats, évaluées jusqu'au troisième jour postopératoire, incluaient l'intensité de la douleur postchirurgicale (sur une échelle numérique de onze points), la consommation d'opioïdes et les bienfaits globaux du score analgésique. Les chercheurs ont évalué les résultats en les comparant à leur expérience de chirurgies similaires. RÉSULTATS: Quarante-neuf sujets ont participé à l'étude : 34 ont subi seulement une chirurgie mammaire et 15, une abdominoplastie accompagnée ou non d'une chirurgie mammaire (six ont subi une chirurgie mammaire en plus de l'abdominoplastie). Les scores de douleur moyens sur l'échelle numérique ne dépassaient pas 4,3 entre le congé et le troisième jour postopératoire. La consommation quotidienne médiane d'opioïdes par voie orale après l'opération était d'environ 1,0 comprimé le jour de la chirurgie et d'environ 2,0 comprimés le troisième jour postopératoire. Les avantages globaux moyens du score analgésique se situaient entre 2,8 et 4,9 tout au long de l'étude. CONCLUSION: Au sein de cette population de sujets, la bupivacaïne liposomique s'associait à de faibles scores d'intensité de la douleur et à une consommation réduite d'opioïdes par rapport aux expériences passées des chercheurs. Les sujets étaient très satisfaits de l'analgésie postchirurgicale et présentaient un faible fardeau d'effets secondaires liés aux opioïdes.

SAFE circumferential liposuction with abdominoplasty.

The SAFELipo technique allows for safe, consistent liposuction that does not damage flap blood supply and is easily taught to, and reproducible by, other surgeons. The fat separation used in the SAFELipo technique is performed without suction, which prevents suction avulsion injury to blood vessels by the cannula. Blood vessels then remain intact while free, separated fat is aspirated with small diameter cannulas.

Grafting the nasal dorsum with tandem ear cartilage.

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.