External ultrasonic lipoplasty: an effective method of fat removal and skin shrinkage

External ultrasonic lipoplasty is an effective method for the removal of localized fat and the fat due to moderate obesity. The ultrasound is externally applied and transmitted through the skin surface. The acoustic waves are selectively absorbed by previously injected tumescent fluid and fat. It is the combination of this acoustic wave and ultrasound-induced fluid streaming that facilitates fat removal. Multiple, 2.5- to 3.7-mm incisions are made, through which standard thin (2.3 to 3.5 mm) suction lipectomy cannulae are used to aspirate the emulsified fat and oil. A major advantage of this procedure is that superficial subdermal liposuction can be used safely, which enhances the thoroughness of fat removal and the contraction of the overlying skin. A total of 160 consecutive patients successfully underwent this procedure. Recovery was rapid, and patients returned to full activities within 24 to 48 hours. The skin remained soft, with minimal to no bruising throughout the entire postoperative period. The problems seen with internal ultrasonic liposuction, such as end hits and skin burns, were avoided. The large incisions required for internal ultrasound liposuction were not necessary. Previous models of externally applied ultrasound support current observations of the safety of external ultrasound lipoplasty. Only one small seroma was seen. External ultrasound lipoplasty is a safe, effective, and low-cost method of ultrasound-assisted removal of localized fat and the fat due to moderate obesity. Physician and patient satisfaction is high.     

Minimally invasive approach to familial multiple lipomatosis

Thirty-five abdominal wall lipomas were removed from a patient with familial multiple lipomatosis using a minimally invasive approach in a cost-effective, reliable, and cosmetically pleasing manner. The surgical technique used is described in this case report. Clinical findings and prior excisions provided the preoperative diagnosis. The abdominal wall was dissected through two small, vertical midline incisions in the suprafascial plane with the aid of a lighted breast retractor. A complete excision of all palpable lipomas was achieved with this approach. The patient had excellent cosmetic results with minimal postoperative scarring.     

Cosmetic and reconstructive breast surgery in blacks

Black women have not embraced cosmetic and reconstructive surgery of the breast with the same enthusiasm as their Caucasian counterparts because of fear of hypertrophic scars. The authors offer suggestions on how to minimize the scarring associated with breast surgery in black women. They feel that intraareolar incisions should be used whenever circumareolar incisions are indicated in augmentation mammaplasty, because the areola, being a favored area, is less likely to produce hypertrophic scars. The Marchac technique of reduction mammaplasty is recommended because it produces a short horizontal scar of 5 to 8 cm confined to the breast without medial and lateral extension, which may hypertrophy in black women. In the reduction of large breasts, secondary excision of dogears 6 or more weeks after mammaplasty reduces the medial and lateral extents of the scar. The use of liposuction as an adjunct to reduction mammaplasty may also accomplish the same thing. Amputation and free nipple-areola grafting should be used with caution in black patients because of the tendency of the grafted areola to hypopigment. In postmastectomy reconstruction, the authors suggest that the techniques described by Ryan and Radovan should be considered first before the techniques of reconstruction utilizing myocutaneous flaps. In these procedures, no new scars which may hypertrophy are created away from the site of reconstruction. Staples should not be used in skin closure in blacks because they cause cross-hatching of the wound even when removed early.     

Ultrasound-assisted lipoplasty treatment for axillary bromidrosis: clinical experience of 375 cases

Bromidrosis is a condition of abnormal offensive body odor caused mostly by apocrine gland secretion from the axilla. Although no morbid sequelae are known, the odor can be disturbing enough to cause social impairment and psychological distress. Medical care is available but is temporary and yields limited clinical benefit. Surgical treatment may provide a more definite remedy through reduction of the apocrine gland. However, there are risks for complication following surgical treatment such as subdermal excision, subcutaneous shaving, en bloc excision, and liposuction. The search for a less invasive but still effective procedure has led the authors to use ultrasound-assisted liposuction, which has reduced the risk of complication and recurrence. The purpose of this article was to evaluate the long-term outcome of ultrasound-assisted liposuction for the treatment of bromidrosis. From August 1998 to September 2002, 375 consecutive patients underwent ultrasound-assisted liposuction for bromidrosis of the axilla. The average age of the patients was 25.7 years (range, 15 to 55 years) and the average follow-up period was 18.8 months (range, 7 to 56 months). Subjective complaints of recurrences were noted in 22 patients (5.9 percent) and secondary ultrasound-assisted liposuction was performed, resulting in no further complaints. Complications other than recurrences were mild skin sloughing (3.2 percent), hematoma (1.3 percent), subcutaneous band (0.3 percent), and hypesthesia of the hand (0.3 percent), all of which healed spontaneously. Through a questionnaire that was answered by 264 patients, a subjective satisfaction rate was measured. Among the completed questionnaires, 91.7 percent reported satisfactory reduction of odor. Ultrasound-assisted liposuction to treat bromidrosis of the axilla provides advantages such as rapid recovery, less restriction of movement, unnoticeable scars, and a low rate of recurrence. The long-term outcome supports the benefits of this procedure. The authors recommend the use of ultrasound-assisted liposuction as first-line treatment for bromidrosis of the axilla.     

Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.     

Liposuction for fat biopsy

This is the first published report of the use of liposuction for removing fat while intentionally minimizing the resultant appearance change. Ten to 20 gm buttock fat were removed from 31 male volunteers for chemical analysis of dioxins. Unlike conventional techniques of fat biopsy, liposuction allows larger quantities to be removed for study without noticeable scarring or deformity.     

Abdominal dermolipectomy in an abdomen with pre-existing scars: a different concept

Although abdominal dermolipectomy is a frequently performed procedure, few publications have reported on the safety of the procedure in the scarred abdomen. The aim of this study was to stress the possibility of performing a natural-looking abdominoplasty with no complication such as skin necrosis or liponecrosis in the presence of abdominal scars and to clarify that the scarred abdomen is not a great limitation for full abdominoplasty as reported in the literature. Seventy-six abdominoplasties were performed on scarred patients from July of 1997 to June of 2003. Twenty-five patients had oblique subcostal scars, six patients had median supraumbilical scars, three patients had median infraumbilical scars, 10 patients had appendectomy scars, nine patients had paramedian supraumbilical scars, eight patients had paramedian infraumbilical scars, seven patients had long transverse scars of repaired ventral hernias, and eight patients had multiple small scars after laparoscopy. In addition, there were concomitant transverse cesarean delivery scars in 40 patients. All patients underwent full abdominoplasties, plication of the musculoaponeurotic system, and liposuction assistance if required (45 patients). Of 76 subjects, three patients had very limited liponecrosis at the watershed area. Eleven patients (14.5 percent) were morbidly obese and heavy smokers. In comparisons of postabdominoplasty complications, such as liponecrosis, wound infection, and dehiscence with and without liposuction in scarred abdomen, no significant differences were found. Secondary revision was more common among abdominoplasties without liposuction [seven of 45 (15.6 percent) versus 12 of 31 (38.7 percent); p = 0.02]. In conclusion, there is no limitation or contraindication for abdominal dermolipectomy with or without liposuction assistance on the previously scarred abdomen as long as the vascular zones of the abdomen are respected. The abdominal wall dissection is limited to allow only the plication of the musculoaponeurotic system, and aggressive liposuction is avoided.     

Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver

Gynecomastia is the most common benign condition of the male breast. The authors present a new method of treatment for gynecomastia that combines traditional liposuction in conjunction with a shaver technique to effectively remove the fibrofatty and the glandular tissues of the male breast and avoid areolar incisions. Twenty-five patients were treated in this fashion, and each patient demonstrated a smooth, masculine breast contour with well-concealed scars in the inframammary folds, eliminating the stigma of breast surgery. The procedure is technically straightforward and provides consistent results. It is offered as an additional option for the treatment of gynecomastia.     

Lipomas as an Extremely Rare Cause for Brachial Plexus Compression: A Case Series and Systematic Review

Introduction  Brachial plexus lipomas are extremely rare benign tumors that may cause slow progression of neurological deficits leading to thoracic outlet syndrome. Up to now, surgery remains challenging. The aim of this study is to present our surgical treatment regime and long-term neurological outcome in three cases of giant brachial plexus lipomas and to show results of systematic review. Patients and Methods  Retrospective analysis of our database “peripheral nerve lesion” to identify patients suffering from brachial plexus lipomas between January 1, 2012, and December 31, 2019. Systematic review was performed for literature published until March 31, 2020, analyzing PubMed, Google Scholar, Scopus, and the Cochrane Collaboration Library independently by two authors. Results  Over the past years, three patients suffering from giant brachial plexus lipomas attended to our neurosurgical department. All patients underwent preoperative magnetic resonance imaging (MRI), ultrasound examinations, and electrophysiological testing. Tumors were removed microsurgically via anterior/posterior, supraclavicular/infraclavicular, and combined approaches. The patients were accessed postoperatively by MRI and clinical follow-up. Systematic review of the literature revealed 22 cases, which were analyzed in regard to demographics, surgical treatment, and neurological outcome. Conclusion  Brachial plexus lipomas are an extremely rare cause for brachial plexus compression. Total microsurgical removal with intraoperative electrophysiological monitoring is the treatment of choice with excellent long-term MRI and clinical outcome.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

Reduction malarplasty through an intraoral incision: a new method

Until recently, osteotomies and surgeries to reposition prominent zygoma have been performed by means of a coronal incision or intraoral and preauricular incisions. Such incisions have penalties such as scars, the possibility of facial nerve injury, and long operative times. After reflecting on their past experiences with facial bone surgery, the authors developed an alternative approach. In this method, the cheekbone protrusion is corrected by performing an osteotomy and repositioning through an intraoral incision only. During the past 3 years, the authors have operated on 23 patients with malar prominences. The amount of bone to be removed is determined by preoperative interviews, physical examinations, and x-rays. Intraoral incisions provide access to the zygomatic body and lateral orbital rim. After L-shaped osteotomies (two parallel vertical and one transverse osteotomy at the medial part of the zygomatic body), the midsegment is removed. The posterior portion of the zygomatic arch was approached through the medial aspect and was outfractured using a curved osteotome. After completing the triple osteotomy, the movable zygomatic complex was reduced medially and fixed with miniplates and screws on the zygomaticomaxillary buttress. The patients were followed for 9.5 months, with acceptable results and few complications. The authors conclude that this technique is an effective and safe method of reduction malarplasty.     

Gradual and Controlled Decompression for Brain Swelling Due to Severe Head Injury

Patients suffering from uncontrollable intracranial hypertension due to posttraumatic brain swelling (BS) generally either die or survive in an extremely disabled state. Decompressive craniectomy (DC) with dural augmentation may be the best method to assist these patients. However, the efficacy of DC on functional outcomes remains controversial. One of the factors contributing to poor outcomes could be intraoperative brain extrusion, which is an acute potential complication of DC. The authors have adopted a new surgical technique for traumatic BS that can prevent and control massive intraoperative BS (IOS). In the past 3 years, the authors have used a unique technique, called “gradual and controlled decompression”, in the treatment of posttraumatic BS. This procedure consists of creating numerous small dural openings and removing clots; enlarging fenestration in the frontal and temporal basal regions to detect and treat brain contusion; making U-shaped, discontinuous, small dural incisions around the circumference of the craniotomy; and performing an augmentation duraplasty through the discontinuous small opening with dural prosthetic substances. This technique has been employed in 23 patients suffering from posttraumatic BS. In all cases, IOS was prevented and controlled through gradual stepwise decompression, and expanded duraplasty was performed successfully. This new surgical approach for posttraumatic BS can prevent severe extrusion of the brain through the craniotomy defect and allows the gradual and gentle release of the subdural space. Further clinical studies should be conducted to estimate the impact of this new technique on morbidity and mortality rates.     

Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies

The authors report consistent improvement in 65 patients with lateral brow ptosis by using a lateral subcutaneous brow lift at the temporal hairline. In 48 of these patients, vertical glabellar wrinkles were improved by the direct excision of procerus, corrugator, and orbicularis muscles through 3-mm medial brow incisions. Anatomic dissections in 10 cadavers and examinations of 50 skulls were used to study the location of the supraorbital and supratrochlear nerves. Dissections revealed that the supratrochlear nerve was never closer than 1.6 cm to the midline at the level of the supraorbital ridge. In no dissection was a supratrochlear foramen noted. Lateral subcutaneous brow lift was consistently successful in elevating the lateral brow. In no patient was nerve damage to the supraorbital nerve noted. In most patients, the temporal hairline was improved by excising a triangle of balding scalp. Through 3-mm medial brow incisions, the interbrow musculature can be excised by using a small rongeur in an area 3.2 cm wide without risk of nerve damage, improving vertical glabellar wrinkles.     

Revision surgical hair restoration: repair of undesirable results

Surgical hair restoration has been performed as a treatment for male pattern hair loss for more than 40 years. Although techniques have changed dramatically over the past several years, making it possible to achieve natural-appearing results, there are still many patients with unacceptable outcomes. These patients may have had procedures performed in the past with antiquated techniques or performed recently with substandard techniques. The causes of unfavorable results can be classified into one of three categories: technical errors, poor planning, or complications. The results in these patients can be dramatically improved through a number of different reparative surgical techniques. The majority of these techniques can be performed in an office outpatient setting. More than 40 patients unsatisfied with previous surgical hair restoration have been treated with the different techniques reviewed in this article. All patients had successful outcomes with significant improvement in appearance. Despite the increased challenges when performing reparative surgery, outcomes were favorable in all patients, with small to significant improvements in appearance achieved. Some of these challenges include the limited supply of donor hairs, reduced scalp laxity, and theoretically reduced vascularity due to scarring and transected blood vessels, and patient skepticism. Furthermore, the few complications that occurred were minor and correctable, including one case each of poor hair growth associated with extensive small graft (consisting of one to four hairs) transplanting, and of scalp scarring associated with the removal and primary closure of a large number of "plug" grafts (typically grafts 3 to 4 mm in size consisting of seven or more hairs) in a single procedure.     

THE REPAIR OF DIFFICULT INGUINAL HERNIAS—Resection of the Spermatic Cord

A method of removing the cord structures from the inguinal canal and preserving the testis and the portion of the spermatic cord distal to the external ring was used in repair of large or recurrent hernias in 14 patients. Only one patient had pronounced testicular atrophy. In one case there was recurrence through the femoral canal. The procedure is simpler and shorter than removal of the testicle as well as the cord.     

Outcome study in liposuction breast reduction

Liposuction as a primary modality of treating breast hypertrophy has been reported in the literature; however, many of these reports are small series and personal experiences. This report is the first outcome study to attempt to validate the effectiveness of liposuction as a primary method of breast reduction surgery. Questionnaires were sent to 117 patients who had undergone liposuction breast reduction surgery in our office during a 4-year period. Seventy-eight questionnaires were returned (67 percent response rate). The patients were asked about their complaints, their surgical results, and their satisfaction with the operation. Complaints such as neck and back pain, shoulder ruts, and intertrigo were improved or eliminated in the vast majority of patients. Women returned to work in 5 days on average and resumed full exercise in 2 weeks. Eighty percent of patients were either very or completely satisfied with their outcomes, 87 percent would choose the liposuction method again, and 92 percent would recommend the liposuction method to a friend. This study demonstrates that liposuction breast reduction is an effective method of breast reduction surgery.     

Endoscopic forehead lift: review of technique,cases, and complications

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.     

Free-fat injections for the correction of hemifacial atrophy

Three adult patients with long-standing hemifacial atrophy were treated with repeated free-fat injections at 4- to 8-week intervals. The longest follow-up study to date is 18 months, and following the expected postoperative resorption, no further loss of bulk of injected fat has been observed. On palpation, the feel of the fat is normal, and facial expression is also good. The relative ease of this procedure, which does not entail any scarring, appears to justify more widespread use of free-fat injections to restore facial soft-tissue depressions.     

Is there evidence for excessive free radical production in vivo during ultrasound-assisted liposuction?

The surgical technique of ultrasound-assisted liposuction has become a standard procedure for the treatment of lipodystrophy. However, little is known about the impact of this therapy on fatty tissue on the molecular level. There are concerns about possible adverse effects related to the high-intensity ultrasound energy, because in vitro studies have shown a substantial generation of free radicals. In this study, the authors investigated whether ultrasound waves can create an excessive free radical production in vivo by measuring lipid peroxidation products in the form of malondialdehyde equivalents. For this purpose, the thiobarbituric acid-reactive substances (TBARS) assay was chosen. In this test, malondialdehyde, a major product of lipid peroxidation, reacts with thiobarbituric acid to produce a pink adduct that can be measured spectrophotometrically. The authors determined oxidation products in 28 aspirates of 17 treated patients before ultrasound-assisted liposuction (0 minutes) to establish a baseline concentration and at 2, 5, and 10 minutes after the treatment was begun. Median malondialdehyde concentration of the control group (conventional liposuction, 0 minutes) was 3.40 nmol of malondialdehyde per gram of adipose tissue. Median concentrations after 2, 5, and 10 minutes of ultrasound-assisted liposuction were 7.45 (n = 28), 8.84 (n = 21), and 4.07 (n = 8) nmol malondialdehyde per gram adipose tissue, respectively. The differences were not statistically significant. The data suggest that there is no excessive formation of lipid oxidation products in response to free radicals. The antioxidative capacity of adipose tissue does not seem to be overwhelmed by the standard application regimen of ultrasound-assisted liposuction.     

Progressive tension sutures: a technique to reduce local complications in abdominoplasty

Abdominoplasty has evolved as a very effective and satisfactory procedure, especially when combined with liposuction and the repair of diastasis recti. However, local complications, including hematoma and seroma formation, flap necrosis, and hypertrophic scars, continue to plague this procedure. The authors present a relatively simple and reproducible technique that allows extensive liposuction in conjunction with abdominoplasty; they think this technique reduces the incidence of local complications. This technique, the use of progressive tension sutures, has been used in their practice for more than 15 years. A retrospective review of 65 consecutive abdominoplasty patients demonstrates a very low local complication rate when compared with historical controls. In this series of both full and modified abdominoplasty patients who were followed for an average of 18 months, the authors had no hematomas, seromas, or skin flap necrosis.