The limited scar mastopexy: current concepts and approaches to correct breast ptosis

The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy.     

Otoplasty: the experience of 100 consecutive patients

Although prominent ears are the most common congenital deformity in the head and neck region, only approximately 8 percent of patients who present for treatment of this deformity will have some family history of the abnormality. More than 200 techniques have been described for correction of this deformity, indicating that there is no single widely accepted procedure that has been adopted by most surgeons. The authors of this study present their choice of a procedure that combines the most beneficial features of three previously described techniques and that provides consistently satisfactory results.The surgical technique consists of scoring of the antihelical cartilage on its anterior surface in a subcutaneous position (as described by Stenstrom), suturing to recreate the fold of the antihelix (in the fashion of Mustarde), and concha-mastoid suturing applied to the back of the ear to decrease the concha-scaphoid angle (in the manner of Furnas). The last 100 consecutive patients operated on by the senior author (J.A.F.) over a 10-year period were evaluated. Follow-up data were analyzed using the Kaplan-Meier survival method. The postoperative analysis focused on the incidence of postoperative complications and the overall results of the technique.Most operations were performed bilaterally, on women, and with the patient under local anesthesia. There were few complications, and the incidence of complications was much lower than had been noted in previously reported series. All patients were very satisfied with the improvement in the appearance of their ears.The combined technique presented is safe, easy to perform, and has few complications, and its final outcome is reproducible and long-lasting. It can be considered a standard technique to be used for treating patients of any age and with any magnitude of defect.     

The changing role of platysma in face lifting

Since the 1970s, surgical procedures on platysma muscle, aiming to achieve better results in face lifting, became popular and turned out to be an important surgical step for the plastic surgeon. Many plastic surgeons have contributed to the topic throughout these years, as several articles on the subject have been published. Articles dealing with platysma muscle still bring great interest among plastic surgeons. My concern with platysma muscle began in the mid-1970s and since then has grown continuously. I have steadily been studying the importance of the platysma muscle in the surgeries for facial rejuvenation, involving its anatomy, the techniques proposed, the results obtained, the recommendations for the best surgical procedure for each patient, and the complications. My experience and studies regarding platysma muscle, and the contributions I have brought into this field, are thoroughly described and discussed in this article.     

Quantitative studies of haematological values in long-term ovariectomized, ovariohysterectomized and hysterectomized rats

The effects of ovariectomy, ovariohysterectomy and hysterectomy on total and differential white blood cell counts, distribution of T and B lymphocytes and T/B cell relationship were studied. Changes in these parameters associated with the surgical operations were observed in total leukocytes and lymphocytes, absolute and relative band neutrophils and T/B cell relationship. Results suggest that the ovaries together with the uterus are potential regulatory organs upon the absolute number of circulating leukocytes and lymphocytes in female Lewis rats. In addition to their effects upon this important population of cells, the ovaries and uterus have moderate effects upon relative T and B lymphocyte numbers in peripheral blood. In general the changes depend mainly on the removal of the ovaries and to a lesser degree on hysterectomy.     

Brachioplasty technique with the use of molds

Over previous years many surgical techniques have been developed to correct lipodystrophy and brachial skin laxity while providing a natural, discreet contour and symmetrical scars, a goal that has not always been achieved. In this study, the authors classify the alterations of the arm into three degrees and propose a different surgical treatment, to be used alone or associated with another procedure, for each classification. They developed a new technique that uses a mold to mark the incision in an italic double S-shape. From 1996 to 1998, 20 patients who underwent this surgery showed symmetrical and smaller scars with better results and minimal complications.     

Identifying and preventing pain during and after surgery in farm animals

Pain research in farm animals has focused on routine husbandry procedures such as dehorning; much less known about the pain associated with the other surgeries such as those required for displaced abomasum and caesarean delivery. We review the literature on pain in farm animals due to non-routine procedures including laporatomy, caesarean sections, ovariectomy and ovariohysterectomy, displaced abomasums, cannulations, vasectomy and claw removal. Where there are gaps in the farm animal literature, we describe relevant studies on wildlife, companion and lab animals. This review addresses both pain responses during surgery and the pain that animals experience in the hours and days that follow. Surgical procedures sometimes cause pain responses due to damage of somatic tissues (skin, muscle, joints, etc.) and the viscera, and there is some evidence that these pain responses differ. Overall conclusions from this review are that surgical pain in farm animals is under studied, and the resulting lack of knowledge, awareness, assessment tools and treatment protocols means that both intra-operative and post-operative pain are often under treated.     

A technique of brachioplasty

Various techniques for the management of upper extremity contour deformities have been suggested since aesthetic brachioplasty was first described. Such deformities are commonplace with aging, after normal weight loss, and especially after massive weight loss such as is seen following bariatric surgery. Despite the multiplicity of procedures described for the correction of these deformities, there are still problems associated with current brachioplasty techniques, including incorrectly placed incisions, widened hypertrophic scars, and postoperative contour deformities. In addition, postoperative skin laxity and ptosis in the axillary region are frequently encountered in the more extreme deformities. The authors present their technique for upper extremity brachioplasty. This technique is suitable for patients with severe brachial ptosis and skin laxity, with relatively little lipomatous tissue, which may extend from the olecranon to the chest wall. The described surgical approach provides excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour deformities.     

Tattoo removal by CO laser dermabrasion

A method of tattoo removal by partial-thickness dermal ablation, using a microsurgically adapted CO2 laser, is described. Provided that meticulous attention is paid to each detail of surgical technique, the procedure can be relied upon to produce good cosmetic results with scant risk of complications.     

Bronchoscopic transillumination guidance for open standard surgical tracheostomy

The standard tracheostomy technique, described in 1909 by Jackson, has been increasingly used in intensive care units. Since 1957, several different types of percutaneous tracheostomy techniques have been described and performed with the support of bronchoscopic transillumination. The authors present the case of a respiratory failure due to obstruction of the upper airway by an exceptionally large goiter, which was successfully resolved by a standard open surgical tracheostomy. In this case, surgical tracheostomy was preceded by bronchoscopic transillumination, which facilitated identification of the appropriate tracheostomy site.     

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.     

A method of reconstructing a pendulous breast utilizing the tissue expander

It is possible to reconstruct a breast mound of almost any size by utilizing tissue expansion. In order to produce a pendulous breast which is also ptotic, the tissue-expansion technique has been combined with two other procedures. A new technique is being introduced. It is that of elevating the lower third of the mature breast capsule surrounding the tissue expander at the time the permanent prosthesis is to be exchanged for the expander. The established techniques of inframammary fold reconstruction of Pennisi and Ryan are used to provide pedicle skin coverage for the undersurface of the breast and the bed of the elevated capsule. Internal and external surgical approaches are described, and two examples of each are illustrated. Breasts reconstructed in this manner have remained pendulous structures. Some loss of the initial degree of ptosis has been noted in some cases.     

The crumpled-ear deformity.

The common characteristics of the crumpled-ear deformity, the steps for surgical correction, and the authors' experience are described in this article. Commonly, the ear has a folded-over appearance; a normal length and width when unfurled; and wrinkling of the skin and cartilage of the helical rim, scapha, antihelix, and concha. Principles of correction of this deformity include (1) superficial scoring of the concave segments of the cartilage to open the wrinkled segments, (2) creating the antihelical fold by a mattress-suture technique, (3) repositioning of the helical rim, and (4) repositioning of the prominent ear lobe, if present. A total of 12 crumpled ears were evaluated in six patients, three of whom underwent surgery during their teenage years. No complications have been observed. A new classification of an ear deformity has been proposed based on morphology that to the authors' knowledge has not been described in the literature. Identification of the common features of the deformity allows for precise correction using already well-defined techniques.     

Laser deepithelialization: an adjunct to reduction mammaplasty

A new use is described for the CO2 laser--that of deepithelialization. Deepithelialization is a technique used in a myriad of plastic surgical procedures. This paper introduces the use of the laser for deepithelialization and illustrates its advantages in 44 consecutive patients undergoing reduction mammaplasty. Advantages are the precise removal of the upper dermis and epidermis--a true deepithelialization--with preservation of the lower dermis and pilosebaceous units. Associated decreased blood loss and more rapid operating time without an increase in complications makes this an attractive adjunctive technique with a wide variety of applications. No adverse effects or contraindications to the use of the CO2 laser for deepithelializing have been found.     

Sepsis after autologous fat grafting

Autologous fat grafting is an increasingly popular technique, with numerous examples of excellent results. Adherence to key principles, including sterile technique and low-volume injection throughout layers of tissue, appears to be critical to obtaining good results. Reports of adverse outcomes are infrequent, but several case reports document both infectious and aesthetic complications. This case report represents an extreme complication, including abscess formation, life-threatening sepsis, and residual deformity. It serves as yet another reminder that early adoption of surgical procedures by those without a sound understanding of the underlying principles and techniques can have disastrous consequences. Furthermore, physicians operating on any patient must understand the potential for complications and be able to manage these appropriately when they occur.     

Microlaparoscopy in sex reassignment surgery

Sex reassignment (male to female surgery) is a standard operation which is aimed at constructing female genitalia and obtaining a cosmetic and functional result that is similar to that of a normal female subject. The ideal surgical procedure has not yet been described, but the various techniques which have been proposed in the literature are similar. The most cumbersome maneuver of the procedure is that of creating a neovaginal cavity inside the perineum. This step is generally carried out by means of blunt dissection between the rectal wall and the prostate, but most of the surgery is blindly performed without visual control. In these conditions, the risk of rectal injury is high, and may lead to severe intraoperative complications. Microlaparoscopy allows for a direct observation of the perineal dissection from inside the peritoneal cavity, thus avoiding risk of rectal injury. The technique is simple to perform, is non-invasive, and only 15 minutes are added to the operation.     

Four Anchor Repair of Jersey Finger

BackgroundVarious surgical techniques for treating avulsions of the flexor digitorum profundus tendon at the distal phalanx have been published but no ideal technique has emerged. We introduce a new all-internal 4-anchor flexor tendon repair technique and evaluate outcomes in three clinical cases.MethodsIn this retrospective case series, we reviewed three patients that sustained an avulsion of the flexor digitorum profundus tendon at the distal phalanx. All patients were surgically treated with the four-anchor repair technique. Two titanium anchors were inserted into the distal phalanx and two all-suture anchors were inserted distal to the first set of anchors. The tendon was then attached to these four anchors using a Krackow stitch pattern and the anchors were sown to each other. Active flexion and extension of the proximal and distal interphalangeal joint were measured at 3-month, 12-month, and 5-year follow-up. Postoperative complications were documented.ResultsAll patients achieved excellent clinical outcomes according to assessment criteria. At 3-month follow-up, all patients regained full flexion; two patients had full extension, while one patient was 3 degrees short of full extension. At 12-month follow-up, all patients had full flexion and extension. Five-year follow-up demonstrated the same results with no loss of function, sensation or grip strength. The repairs healed without rupture, and no complications were reported.ConclusionThe 4-anchor flexor tendon repair is a viable surgical technique for zone 1 flexor digitorum profundus tendon repair or reconstruction. Further studies are needed to replicate these promising results and biomechanically validate this technique.Level of Evidence: IV     

Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.     

Surgical treatment of hepato-pancreato-biliary disease in China: the Tongji experience

Hepato-pancreato-biliary (HPB) tumors are common in China. However, these tumors are often diagnosed at intermediate/ advanced stages because of the lack of a systemic surveillance program in China. This situation creates many technical challenges for surgeons and increases the incidence of postoperative complications. Therefore, Dr. Xiao-Ping Chen has made many important technical improvements, such as Chen’s hepatic portal occlusion method, the anterior approach for liver resection of large HCC tumors, the modified technique of Belghiti’s liver-hanging maneuver, inserting biliary-enteric anastomosis technique, and invaginated pancreaticojujunostomy with transpancreatic U-sutures. These techniques are simple, practical, and easy to learn. Owing to these advantages, complicated surgical procedures can be simplified, and the curative effects are greatly improved. These improved techniques have been widely applied in China and will benefit many additional patients. In this review, we introduce our experience of surgically treating intermediate/advanced hepatocellular carcinoma (HCC), hilar cholangiocarcinoma (HC), and pancreatic carcinoma, mainly focusing on technical innovations established by Dr. Chen in HPB surgery.     

The Mouse Round-window Approach for Ototoxic Agent Delivery: A Rapid and Reliable Technique for Inducing Cochlear Cell Degeneration

Investigators have utilized a wide array of animal models and investigative techniques to study the mammalian auditory system. Much of the basic research involving the cochlea and its associated neural pathways entails exposure of model cochleae to a variety of ototoxic agents. This allows investigators to study the effects of targeted damage to cochlear structures, and in some cases, the self-repair or regeneration of those structures. Various techniques exist for delivery of ototoxic agents to the cochlea. When selecting a particular technique, investigators must consider a number of factors, including the induction of inadvertent systemic toxicity, the amount of cochlear damage produced by the surgical procedure itself, the type of lesion desired, animal survivability, and reproducibility/reliability of results. Currently established techniques include parenteral injection, intra-peritoneal injection, trans-tympanic injection, endolymphatic sac injection, and cochleostomy with perilymphatic perfusion. Each of these methods has been successfully utilized and is well described in the literature; yet, each has various shortcomings. Here, we present a technique for topical application of ototoxic agents directly to the round window niche. This technique is non-invasive to inner ear structures, produces rapid onset of reliably targeted lesions, avoids systemic toxicity, and allows for an intra-animal control (the contra-lateral ear). Results stemming from this approach have helped deeper understanding of auditory pathophysiology, cochlear cell degeneration, and regenerative capacity in response to an acute injury. Future investigations may use this method to conduct interventional studies involving gene therapy and stem cell transplantation to combat hearing loss.