Breast capsulorrhaphy

The malposition of breast prostheses without capsular contracture has become an increasingly frequent event. In our experience with 40 patients over the last 5 years, we have found multiple-layer breast capsulorrhaphy to be a simple, safe, and reliable technique. With this method, repositioning of the breast is easier, more accurate, and more permanent than single-layer closures, which attempt ideal correction of the malpositioned implant on the first try.     

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.     

Restoring palpebral fissure shape after previous lower blepharoplasty

The youthful palpebral fissure can be described as long and narrow. Both the aging process and transcutaneous lower blepharoplasty can cause descent of the lower lid margin and medial migration of the lateral canthus, resulting in a rounding of the palpebral fissure. This article presents a technique to correct significant postsurgical lower lid malposition and palpebral fissure distortion without the use of outer or inner lamellar grafts. In overview, subperiosteal dissection frees scarred lid structures and cheek soft tissues, creating a continuous composite flap. Elevation of the cheek soft tissues recruits deficient outer lamellae and allows the sub-orbicularis oculi fat to be positioned between the orbital rim and scarred lid structures, filling this space and helping to support the repositioned lid margin. Titanium screws placed in the lateral orbit provide a point for secure fixation of elevated cheek tissues. Transosseous wire fixation securely repositions the lateral canthus. This procedure not only restores lower lid position and the vertical height of the palpebral fissure, but it also restores the palpebral fissure's horizontal length and the lateral canthal angle. It has been effective in correcting palpebral fissure distortion after lower blepharoplasty in 15 patients during a 6-year period.     

Breast augmentation: choosing the optimal incision, implant, and pocket plane

A retrospective study of 220 patients was performed to review surgical design in breast augmentation. Three specific issues were studied: incision site, implant variables, and pocket plane selection. The influence of these three factors on aesthetic results in both primary and secondary cases was the focus of the analysis. No attempt was made to address long-term issues such as capsular contracture or saline implant deflation rates. In 77 primary augmentation patients and 80 unilateral augmentations for symmetry in breast reconstruction, there were the following untoward results: 11 revisions for unilateral malposition, change to a different implant shape, or change to a larger implant size; four deflations of saline implants requiring replacement; and four conversions of saline to silicone gel implants. In 63 secondary cases, there were two hematomas and two infections requiring implant removal and subsequent replacement. Operative technique in breast augmentation is described, as are recommendations for each of the options associated with the three variables studied.     

Improving periorbital appearance in the "morphologically prone"

Patients with prominent eyes are predisposed to lower lid descent and rounding of the palpebral fissure. This deformity may be exaggerated and symptomatic after conventional lower blepharoplasty. Normalization of the periorbital appearance in "morphologically prone" patients involves three basic maneuvers. Augmenting the projection of the infraorbital rim with an alloplastic implant effectively changes the skeletal morphology, thereby providing support for the lower lid and midface soft tissues. Subperiosteal freeing and elevation of the lower lid and midface recruits soft tissues and allows lower lid repositioning. Lateral canthopexy restores palpebral fissure shape and provides additional lid support. The technique can be adapted for morphologically prone patients who are first seeking improvement in their periorbital appearance or for those whose lid malposition and round eye appearance have been exaggerated by previous lower blepharoplasty. This surgery has been effective treatment for 13 morphologically prone patients operated on over a 4-year period.     

Submammary flap for correction of severe sequelae from augmentation mammaplasty

A submammary flap was used in 20 patients with severe cicatricial retractions and loss of the inferior pole of the breast caused by inadequately treated mammary implant infections. This axial flap can be used with a medial pedicle, based on the perforating branches of the epigastric artery or the distal part of the internal mammary artery, or laterally based, nourished by the intercostal perforators. After 6 months, reimplantation was performed in 15 patients. The authors' follow-up ranged between 8 months and 6 years. This transverse adipocutaneous flap procedure is very simple to perform, the donor site is sutured primarily without additional undermining, and the resultant scar lies hidden within the submammary fold. It provides tissue with similar skin texture and color match. Its versatility allows it to be used as a full-thickness tissue replacement or partially or totally de-epithelialized for soft-tissue reconstruction. It can also be used as an island flap. For all of these reasons, in emotionally distressed patients with low compliance with surgical treatments and additional scars, this flap is the authors' flap of choice for reconstruction.     

Failure mechanism of the all-polyethylene glenoid implant

Fixation failure of glenoid components is the main cause of unsuccessful total shoulder arthroplasties. The characteristics of these failures are still not well understood, hence, attempts at improving the implant fixation are somewhat blind and the failure rate remains high. This lack of understanding is largely due to the fundamental problem that direct observations of failure are impossible as the fixation is inherently embedded within the bone.Twenty custom made implants, reflecting various common fixation designs, and a specimen set-up was prepared to enable direct observation of failure when the specimens were exposed to cyclic superior loads during laboratory experiments. Finite element analyses of the laboratory tests were also carried out to explain the observed failure scenarios.All implants, irrespective of the particular fixation design, failed at the implant–cement interface and failure initiated at the inferior part of the component fixation. Finite element analyses indicated that this failure scenario was caused by a weak and brittle implant–cement interface and tensile stresses in the inferior region possibly worsened by a stress raiser effect at the inferior rim.The results of this study indicate that glenoid failure can be delayed or prevented by improving the implant/cement interface strength. Also any design features that reduce the geometrical stress raiser and the inferior tensile stresses in general should delay implant loosening.     

Intracapsular allogenic dermal grafts for breast implant-related problems

Despite advances in surgical techniques and breast implant design, certain problems unique to breast implant surgery remain. The historically most onerous problem, capsular contracture, is relatively uncommon now. However, problems related to thin capsules and periprosthetic atrophy are becoming more common; these problems include rippling, symmastia, implant malposition, and bottoming out. Options for treatment of these conditions remain extremely limited, particularly with saline implants. Allogenic dermal grafting provides one satisfactory option. Techniques for use of allogenic dermal grafts and early results from 10 patients are summarized in this article, along with histologic analysis confirming viability of the grafts at 6-month follow-up in one patient. No graft-related complications were identified.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes

Little has been published regarding the treatment of patients with long-established capsular contracture after previous submuscular or subglandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly subpectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999. Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a subglandular or submuscular plane. All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located subglandularly. Of 85 patients reviewed, 54 had their original implants in a submuscular position and 31 had their initial augmentation in a subglandular position. Of the 54 patients whose implants were initially submuscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants. Of the 31 patients whose implants were initially subglandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months. The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required reoperation for complications, all of which involved some degree of implant malposition. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up. The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.     

Aesthetic augmentation of the malar-midface structures

Based on extensive experience with bone grafts for augmentation of the midface-malar region, an implant design has been developed using Proplast. After careful preoperative assessment, a very specific surgical method, described herein, allows precise implant positioning without the need for suture fixation. In many instances, the 6-mm implant can be inserted unchanged. One-hundred and six patients have been operated on using 176 implants over the past 6 years. There were four unilateral infections (2.3 percent of implants and 3.8 percent of patients). None had permanent motor or sensory nerve problems. Fifteen implants (8.5 percent) in 12 patients (11.3 percent) were either removed or repositioned. In those having augmentation for entirely aesthetic reasons, 3 of 60 patients (5.0 percent) required implant removal or repositioning. The incidence of needing to remove or reposition implants has decreased as the technique has evolved.     

Achieving aesthetic balance in the brow,eyelids, and midface

An approach to the brow, eyelids, and midface emphasizing release and advancement of the orbicularis oculi muscle, conservative removal of orbital fat, preservation of the nerve supply to the orbicularis oculi muscle, and avoidance of canthal division was evaluated in 100 consecutive patients. The technique describes the selected release of three key retaining ligaments to the forehead, brow, and upper eyelid; mobilization of the lateral retinaculum and division of the lower lid retaining ligament; and division of the midface malar retaining ligament (zygomatic-cutaneous ligament). Preservation of motor branches to the lower lid orbicularis is stressed. Of significance to this series of patients is the inclusion of 50 patients with morphologically prone lower eyelids defined as atonic lower lids, exorbitism, and/or negative vector orbits. Three sites had failure of brow fixation, two patients had midface asymmetry requiring revision, and three patients failed to have complete correction of their preoperative lower lid retraction. There was zero incidence of scleral show or lower lid retraction that was not present preoperatively. No patients required division of the lateral commissure with canthoplasty, taping or suture suspension, massage, or steroid injections. Only two patients required division of the deep head of the lateral canthus, and these patients were noted to have had lateral canthal malposition preoperatively.     

Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty

Many authors have indicated the presence of ectopic or accessory upper eyelid fat pads, but the effective rate of eyelid fat variations and the corresponding clinical features are still unclear. The purpose of this study was to evaluate the variability of upper lid fat and to define the anatomical landmarks of the adipose pockets of the upper lid. From January of 1998 to January of 2002, the authors investigated the upper eyelid fat compartments of 47 patients who underwent upper blepharoplasty. To support surgical findings, 11 fresh cadavers were also investigated; the anatomy of the intraorbital fat and of the upper eyelid fat compartments was reviewed. Ten patients (21.3 percent) showed an accessory fat pad in the upper lid, which was found on both sides in nine cases. In all patients, the third fat pad was situated lateral to the two classic compartments described by Castanares, behind the orbital septum. Surgical dissections demonstrated that this fat pad derived from the preaponeurotic fat. Anatomical dissections in three cadavers demonstrated an accessory fat compartment protruding under the inferior border of the lacrimal gland. This protruding fat derived from the preaponeurotic fat in all cases and might justify the clinical appearance of a bulge or fullness in the lateral third of the upper eyelid. In the authors' experience, the presence of an accessory upper eyelid fat pad was a frequent finding during blepharoplasty; it could be found and actually resected in about 21 percent of all cases. Surgical and experimental findings put this element as a lateral physiological extension of the preaponeurotic fat that can anteriorly protrude under the inferior border of the lacrimal gland toward the orbital septum. The clinical appearance may be a bulge or fullness in the upper eyelid, and its resection can better define the lateral one third of the supratarsal fold.     

Friction in metal-on-metal total disc arthroplasty: effect of ball radius

Total disc arthroplasty (TDA) can be used to replace a degenerated intervertebral disc in the spine. There are different designs of prosthetic discs, but one of the most common is a ball-and-socket combination. Contact between the bearing surfaces can result in high frictional torque, which can then result in wear and implant loosening. This study was designed to determine the effects of ball radius on friction. Generic models of metal-on-metal TDA were manufactured with ball radii of 10, 12, 14 and 16 mm, with a radial clearance of 0.015 mm. A simulator was used to test each sample in flexion-extension, lateral bending and axial rotation at frequencies of 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75 and 2 Hz under loads of 50, 600, 1200 and 2000 N, in new born calf serum. Frictional torque was measured and Stribeck curves were plotted to illustrate the lubrication regime in each case. It was observed that implants with a smaller ball radius showed lower friction and showed boundary and mixed lubrication regimes, whereas implants with larger ball radius showed boundary lubrication only. This study suggests designing metal-on-metal TDAs with ball radius of 10 or 12 mm, in order to reduce wear and implant loosening.     

Multi-factorial analysis of variables influencing the bone loss of an implant placed in the maxilla: Prediction using FEA and SED bone remodeling algorithm

The aim of this study was to investigate the interactions of implant position, implant–abutment connection and loading condition influencing bone loss of an implant placed in the maxilla using finite element (FE) analysis and mathematical bone remodeling theory. The maxilla section contours were acquired using CT images to construct FE models containing RS (internal retaining-screw) and the TIS (taper integrated screwed-in) implants placed in SC (along the axis of occlusal force) and RA (along the axis of residual ridge) positions. The adaptive strain energy density (SED) algorithm was combined with FE approach to study the preliminary bone remodeling around implant systems under different load conditions. The simulated results showed that the implant position obviously influenced the bone loss. An implant placed in the RA position resulted in substantially increased bone loss. Implant receiving a lateral load slightly increased bone loss compared with an axial load. The implant type did not significantly influence bone loss. It was found that buccal site suffered the most bone loss around the implant, followed by distal, lingual and mesial sites. The implant position primarily influenced bone loss and it was found most obviously at the buccal site. Implant placed along the axial load direction of a proposed prosthesis could obtain less bone loss around the implant. Attaining proper occlusal adjustments to reduce the lateral occlusal force is recommended in implant–bone–prosthesis system. Abutments of internal engagement with or without taper-fit did not affect the bone loss in the surrounding bone.     

Mandibular matrix implant system: a method to restore skeletal support to the lower face

Disharmony between the skeletal support and the softtissue envelope is a common cause of aesthetic concerns regarding the lower face. A loss of volume or a genetically small mandible affects the aesthetics and function of the mouth, chin, and neck. Because of the limitations of correcting such problems with current implants made of silicone or porous polyethylene, the author developed an implant system and a method of restoring the entire volume of the mandible called the mandibular matrix implant system. This implant system is made of high-density porous polyethylene and is composed of an articulated wraparound geniomandibular implant and a wraparound gonial angle implant. A prejowl implant can be integrated in the system as an addition or as a replacement for a chin implant. This implant system has different sizes and projections, and it can be modified by carving to fit the requirements of most patients. Carving is done using an appropriate sizer. This implant system is indicated for use in patients with a congenitally small mandible, edentulous patients, and patients requesting facial enhancement. The mandibular matrix implant system is implanted either during a single procedure or simultaneously with a facial rejuvenation. The extended geniomandibular implant is introduced through an anterior oral sulcus incision or a submental incision. The mandibular angle implant is introduced through a retromolar incision. The posterior end of the chin implant overlaps the anterior end of the gonial implant, and screw fixation of each chin component helps to stabilize the entire system. Antibiotics, irrigation, and closure of the incisions are performed before any additional operative procedure. The complete system has been used in 13 patients; one additional patient had the complete system plus an overlapping additional left prejowl implant for correction of asymmetry. Complications were manageable; these included one mandibular angle implant displacement and one infection. The implant displacement required a reoperation to reset the implant. The infection was treated with irrigation and closed system suction; the implant was salvaged. The satisfaction of patients has been high, and the author can now solve aesthetic problems that in the past were considered unsolvable.     

Five long-term case reports (average 15 years) of saddlenose correction using cast Silastic implants

A 15-year review of patients who underwent silicone implants to the nasal bridge was conducted. None of my implants had to be removed because of either hematomas or infection. To my knowledge, only one implant has been removed for any reason over the last 10 years. Another nasal implant was removed by a surgeon in New Orleans and was replaced by a rib cartilaginous graft, which, within 2 years, severely curled, causing a nonacceptable result. This cartilage graft was removed and replaced with a second silicone implant and, to my knowledge, was still satisfactory and in place 10 years postoperatively. Insertion of implants with lateral nasal bone infracturing and submucous resection, along with tip reduction, is now performed in almost all patients. Tip elevation, when necessary, is accomplished by rotation of the nasal floor and columella up the maxillary spine (and septal cartilage) to obtain a maximum of 6 mm of elevation, some of which is lost following subsidence of swelling and/or dissolution of the suture material.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

Nose surgery: how to prevent a middle vault collapse--a review of 50 patients 3 to 21 years after surgery

There is a conception, likely a misconception, that when performing a nasal osteotomy with a concomitant dorsal hump removal, the upper lateral cartilages are detached or damaged and, over the long-term, respiratory difficulties result because of a middle vault collapse or interference with the internal nasal valve. A follow-up of 50 patients between 3 and 21 years postoperatively provides evidence that this can be prevented. The vast majority (82 percent) reported they were breathing very well for an average of 6.5 years postoperatively. Of the authors' own 38 primary rhinoplasty patients, only two patients (5 percent) reported respiratory difficulties. The authors are unable to substantiate that either the osteotomy or the dorsal hump removal was responsible. Of the 12 patients who had their primary rhinoplasty performed elsewhere, six (50 percent) reported respiratory difficulties before the secondary rhinoplasty at this clinic. Furthermore, an appreciable improvement in breathing was reported by 66.7 percent of these patients after the secondary rhinoplasty. The authors conclude that their gentle proper surgical technique, combined with a good understanding of nasal physiology (with respect to the septum, inferior turbinates, and external and internal valves), allows them to perform a concomitant dorsal hump removal and osteotomy without interfering with nasal physiology.