A new resorbable tack fixation technique for endoscopic brow lifts.

The endoscopic brow lift is now widely accepted in aesthetic plastic surgery, and various fixation techniques have been described in the literature. New developments and technology have expanded the use of resorbable devices in different surgical specialties, including plastic surgery. The authors present a technique that offers simple, fast, and reliable forehead fixation for endoscopic brow lifts using resorbable tacks. Successful facial rejuvenation was obtained in the majority of the patients without complications, need for follow-up visits to tighten the flap fixation system, or secondary procedures to extract the fixation system.

The use of intraoperative autotransfusion during cranial vault remodeling for craniosynostosis.

Intraoperative autotransfusion salvages blood shed during surgery for use in immediate resuscitation of the patient. The purpose of this study was to determine whether such autotransfusion decreases the volume of homologous blood transfused in patients undergoing primary cranial vault remodeling for craniosynostosis. The Cobe-Bret 2 autologous blood recovery system (Hemo Concepts, Union, N.J.) was used in 11 cases, and an equal number of consecutive cases did not receive intraoperative autotransfusion. There were no significant differences between the groups with respect to age, sex, and weight. Mean estimated blood loss was 43.2 ml/kg (range, 20.3 to 65.0 ml/kg) in the intraoperative autotransfusion group and 40.2 ml/kg (range, 6.8 to 72.3 ml/kg) in the control group (not statistically significant; p < 0.05). There was no significant difference in volume of homologous blood transfusion between the two groups. The autotransfusion group received 34.1 ml/kg of homologous blood (range, 0 to 60.7 ml/kg), and the control group received a mean of 32.7 ml/kg (range, 14.5 to 60.2 ml/kg). The autotransfusion group received a mean of 10.4 ml/kg of recovered autologous blood (range, 0 to 21.4 ml/kg). In four of the 11 autotransfusion patients, insufficient autologous blood was recovered intraoperatively to warrant transfusion. Results of this study suggest little benefit for the use of intraoperative autotransfusion in primary cranial vault remodeling for craniosynostosis in the young patient. It was hypothesized that this finding was a result of the following: (1) intraoperative autotransfusion blood was usually available only toward the end of the procedure, after homologous blood had already been administered, and (2) the volume of recovered intraoperative autotransfusion blood is minimal, compared with the homologous transfusion volume requirements during an extensive cranial vault remodeling and fronto-orbital advancement procedure. In the context of unproven cost benefit and increasing similar evidence from other comparative studies, emphasis should be directed to other medical and surgical strategies to minimize the need for perioperative blood transfusion.

Assessment of long-term nipple projection: a comparison of three techniques.

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.

Prevention and management of rhinoplasty complications.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify potential hemorrhagic, infectious, traumatic, functional, or aesthetic complications arising from rhinoplasty. 2. Gain a better understanding of the prevention of these complications. 3. Have a thorough knowledge of the principles of postoperative management of these complications, so as to minimize their deleterious effects and preserve aesthetic outcomes in rhinoplasty. SUMMARY: Meticulous attention to detail in the operating room and in the postoperative period is paramount to achieving success in rhinoplasty. Nevertheless, both complications and suboptimal results do occur, even for experienced surgeons.

Harvesting rib cartilage grafts for secondary rhinoplasty.

BACKGROUND: Reconstruction of the nasal osseocartilaginous framework is the foundation of successful secondary rhinoplasty. METHODS: Achieving this often requires large quantities of cartilage to correct both contour deformities and functional problems caused by previous procedures. Satisfactory and consistent long-term results rely on using grafts with low resorption rates and sufficient strength to offer adequate support. Auricular cartilage, irradiated cartilage, and alloplastic materials have all been used as implantable grafts with limited success. RESULTS: In the senior author's experience (J.P.G.), rib cartilage has proven to be a reliable, abundant, and relatively accessible donor with which to facilitate successful secondary rhinoplasty surgery. CONCLUSIONS: : The authors describe in detail the techniques that they have found to be integral in harvesting rib cartilage grafts for secondary rhinoplasty.

Frequently used grafts in rhinoplasty: nomenclature and analysis.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft. SUMMARY: In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.

Ultrasound-assisted lipoplasty (UAL) in breast surgery.

Breast surgery has evolved significantly since the increased demand for reduced scars led to the development of minimal incision techniques. Ultrasound-assisted lipoplasty (UAL) presents important advantages when compared to traditional liposuction, such as preservation of connective structures and significant skin retraction capability. Other factors such as a favorable side-effect profile, satisfactory aesthetic results, and virtually inconspicuous scars have led us to utilize UAL in virtually all of the different breast surgery modalities carried out in our practice. Important aspects of patient selection, markings, surgical technique, and postoperative care are outlined. Ultrasonic energy is applied through superficial tunnels that lie radial to the mammary cone, with preservation of elements such as the areola, mammary ducts, and the central part of the breast's base which contains the perforators that supply the gland. Deep treatment should be applied onto adipose tissue regions and should preferably be performed in the peripheral and subcutaneous layers of the breast, with conservation of the central glandular cone to ensure maintenance of anterior projection. In selected cases, UAL is a valuable adjunct to procedures such as symmetrization, reduction mammaplasty, and breast reconstruction, permitting both volume reduction and shaping through three-dimensional retraction of connective tissue and skin. The excellent preliminary results support new indications and future developments of the technique.

Optimizing outcomes in breast augmentation: seven years of experience with the subfascial plane.

INTRODUCTION: Breast augmentation has enjoyed worldwide acceptance in the last few decades. In order to optimize the outcomes of this operation, numerous variables such as incision location, pocket plane, implant design, and materials, and individual tissue characteristics must be carefully considered. Although no combination of choices may be considered superior, satisfactory results depend on adjusting the available options to each patient's requirements. In this paper, the authors present a seven-year experience with augmentation mammaplasty using the subfascial plane, analyzing important aspects of surgical technique, benefits and trade-offs when compared to other approaches, and the resulting outcomes. METHOD: A total of 241 primary and secondary breast augmentation procedures were performed over a seven-year period, employing anatomical high-cohesivity gel textured implants (McGhan 410 Style). After choosing the appropriate approach and performing the skin incision, dissection proceeds parallel to the skin (as in skin-sparing mastectomies) for approximately 4 cm. The breast's parenchyma is then incised in a radial direction (perpendicular to the skin incision) and vertically until the fascial layer is reached. Dissection of the implant's pocket is then performed in the well-defined subfascial plane. After insertion of the implants, the distance between the areola's inferior border and the inframammary fold should be approximately equal to 6-7 cm (or X). The distance between the areola's superior border and the uppermost point of the breast should be approximately equal to 9-10.5 cm (or 1.5 X). Another important parameter is the distance between the implants, which should be approximately 2-3 cm. Finally, the distance between the areola's medial border and the midsternal line should be about 9-10 cm. Postoperative care issues are specified. RESULTS: Pleasing long-term results have been obtained, with maintenance of a natural breast shape, a smooth transition between the soft tissues and implant in the upper pole, and low morbidity. The rate of capsular contracture was extremely low and there were no complaints regarding displacement of the implants with contraction of the pectoralis major muscle. CONCLUSION: The presented technique offers improved long-term aesthetic results due to the creation of a stronger supporting system for the implant's superior pole. This tends to keep the implant's upper third from altering its shape and position over time and combines the potential benefits of the subglandular approach with the improvements that may be achieved by having more tissue available to cover the implant's upper pole. The trade-offs of the subpectoral approach have been significantly reduced and factors such as morbidity and postoperative recovery are acceptable. The presented technique is extremely versatile and may also be used in patients requiring removal and replacement of breast implants.

Rejuvenation of the nasolabial complex with inverted triangular-shaped SMAS grafts.

INTRODUCTION: One of the most challenging aspects of facial aesthetic surgery is rejuvenating the nasolabial complex. Unfortunately, the numerous existing techniques for this purpose have shown limited results due to factors such as long-term unpredictability, modest levels of improvement, and failure to address all of the anatomic/biomechanical alterations simultaneously. In this paper we present our experience with the use of inverted triangular SMAS grafts to rejuvenate the nasolabial complex, analyzing important aspects of surgical technique, indications, and outcomes. METHOD: Fifteen patients underwent rejuvenation of the nasolabial complex using inverted triangular SMAS grafts, with a mean follow-up period of 18 months. Treatment of the nasolabial complex was performed concurrently to an extended SMAS facelift. The triangular-shaped grafts were harvested from the redundant tissue resulting after traction and inset of the SMAS flaps in the preauricular area. Dissection of the graft's pocket is carried out in the subcutaneous plane through a perialar incision. The resulting shape of the pocket resembles an inverted triangle or funnel, with more extensive dissection in the superior area. A Reverdin needle is inserted through a small 2-3-mm incision at the end of the nasolabial crease, adjacent to the oral commissure. The graft is then tied to the needle and inserted by simply extracting the latter from the inferior incision; the tied triangular graft falls naturally into position inside the pocket. RESULTS: Rejuvenation of the nasolabial complex was performed satisfactorily in all patients. The graft's design provided enough tissue to appropriately fill and attenuate the depressed triangular area in the upper region of the crease. Contour of the inferior two-thirds of the crease was improved by the narrower portion of the graft. Postoperative recovery occurred uneventfully, the grafts were not palpable/perceptible, and there was no need for complementary treatment modalities. CONCLUSION: The presented procedure offers an additional means of rejuvenating the nasolabial complex with excellent results in selected patients. When compared to more conservative techniques such as the injection of alloplastic materials, the use of more consistent autogenous tissue offers permanent integration and less reabsorption, without the need for complementary treatments. The presented technique addresses all the fundamental treatment principles and provides an anatomically based, natural, and long-lasting solution for this challenging problem.

Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty.

In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional abdominoplasty techniques often fail to maximally improve body contour in these cases because adjacent sites such as the hip rolls and flanks are not treated, leaving the patient with large lateral tissue redundancies and dog-ears. In an attempt to solve these challenging problems, the authors present the modified vertical abdominoplasty technique, a single-stage procedure that involves a combined vertical and transverse approach in which an "en bloc" resection of the redundant tissues is performed without undermining, drainage, or reinforcement of the abdominal wall. The latter is only carried out when diastasis and/or hernias are present, and Marlex mesh may be utilized when indicated. In patients with simultaneous large umbilical hernias and/or excessively long stalks, neoumbilicoplasty is recommended. A significant improvement of abdominal contour was obtained in the vast majority of patients because the resection design offers simultaneous treatment of both vertical and transverse tissue redundancies in the abdomen and neighboring regions, with more harmonic results when compared with purely vertical or transverse approaches. The modified vertical abdominoplasty technique is an easy, fast, and reliable alternative for treating these patients, with less intraoperative bleeding, reduced overall cost, and low morbidity rates. In selected cases, the technique is capable of offering excellent results in terms of contouring and maximizes the overall outcome of treatment protocols for these patients, who can then be integrated into normal life with heightened self-esteem, happiness, and productivity.

Panniculectomy as an adjuvant to bariatric surgery.

A large hanging panniculus can cause problems such as intertrigo, chronic infection, and immobility. Many patients undergoing weight reduction surgery can benefit from panniculectomy either done concomitantly with bariatric surgery or later after significant weight reduction. Over the last 5 years we performed 123 panniculectomies on patients (34 males, 89 females; mean age 44.5 +/- 10.3 years) undergoing bariatric surgery. The panniculectomy was either done at the same time as the bariatric surgery in 21 patients or after a time period of 17 +/- 11 months in 102 patients. The prebariatric surgery weight ranged from 107 to 341 kg (mean: 168.6 +/- 47.2 kg) with a mean body mass index (BMI) of 59 +/- 14 kg/m. After the bariatric surgery the patients had an average weight loss of 57.6 +/- 27 kg. The prepanniculectomy weight was 121.9 +/- 39.3 kg (BMI = 43.1 +/- 12.4 kg/m) for the patients who had the panniculectomy after the bariatric surgery. Ninety-two percent of the patients had multiple comorbidities. The weight of the panniculectomy specimen ranged from 4 to 54 kg. Any abdominal wall hernias (35.4% incisional and 8.9% umbilical) were fixed during the panniculectomy. Overall, patients who had panniculectomy simultaneously with the bariatric surgery had more complications than patients who had panniculectomy after their bariatric surgery. The wound infections were 48% versus 16% and respiratory distress was 24% versus 0%, respectively. The skin necrosis was 10% versus 6%, dehiscence was 33% versus 13%, and hematoma formation was 10% versus 2%, respectively. Overall, the patients had good outcomes, with 3 postoperative deaths in the group with panniculectomy at the same time of bariatric surgery. An interval of weight loss prior to the procedure makes this procedure safer and more effective.

The application of mesh support in periareolar breast surgery: clinical and mammographic evaluation.

BACKGROUND: Numerous techniques have been described for the treatment of breast hypertrophy and ptosis. Unfortunately, recurrent ptosis after mammaplasty can occur regardless of the technique used. To avoid this problem, different kinds of supporting devices have been described with variable rates of success. However, the true implications of incorporating prosthetic materials into breast surgery have never been clarified. Therefore, surgeons have traditionally been reluctant to apply any kind of prosthetic material to the breast, fearing inflammation, an unfavorable aesthetic outcome, palpable or visible deformities, and interference with the mammographic evaluation of breast cancer. This study analyzed the aesthetic, clinical, and mammographic implications of using mesh as a supportive device in periareolar breast surgery. METHODS: For this study, 18 patients (mean age, 42 years) with breast hypertrophy, ptosis, or both were managed with the double-skin periareolar mammaplasty technique, with placement of mixed (60% Polyglactine and 40% polyester) mesh. Clinical assessment was performed by three breast surgeons actively working on cancer surveillance who knew that the patients had experienced mesh application. After a mean follow-up period of 30 months, a standard mammogram was performed for each patient and analyzed by both the surgeons and an expert radiologist. The evaluated factors were hyperemia, calcifications, contour irregularities, capsular contraction, thickening or widening of the scar with extrusion of the mesh, and any palpable or hardened areas. RESULTS: According to the authors' clinical observations, there were no mesh-related abnormalities in the breast; the mesh was not palpable after the operation; and there was no recurrent ptosis. In terms of mammographic imaging, the mesh was visible as a very fine line in the periphery of the breast's parenchyma (measuring 0.2 mm on the lateral views) in three patients (17%). The mesh did not interfere with the visualization and analysis of the breast's parenchyma. In seven patients (39%), benign localized microcalcifications were detected in the breast and no further investigation was performed. In two patients (11%), grouped calcifications were detected and biopsied, with histopathologic analysis demonstrating epithelial hyperplasia with atypia. In two patients (11%), nodules smaller than 1 cm were detected and biopsied, with histopathologic analysis demonstrating a fibroadenoma in one patient and an invasive ductal carcinoma in the other. CONCLUSIONS: The use of mesh support in breast surgery can enhance the aesthetic results without inducing visible or palpable deformities or mammographic abnormalities. In terms of surveillance mammograms, the presence of the mesh did not interfere with the diagnosis and treatment of minute lesions such as calcifications and small nodules.