Reports From the Annual Meeting of the American Society for Aesthetic Plastic Surgery
April 20–26, 2006
New Techniques in Bicompartmental Breast Lipostructuring
The controversy over silicone-gel-filled breast implants during the early 1990s restricted their use for primary aesthetic breast augmentation. Even now, patients are still concerned about them. Michele Zocchi, MD, PhD, of Turin, Italy, and coauthors, in an attempt to find alternatives, reconsidered fat transfer, but they abandoned the procedure because of its high complication rate.
However, a more recent literature review indicated that the complications were related to technical errors and to the anatomical harvesting site. Therefore, a new method that incorporated recent contributions in functional anatomy was developed. Roger K. Khouri, MD, of Key Biscayne, Fla, reported on this bicompartmental breast lipostructuring study.
Beginning in 1998, breast lipostructuring was performed on 103 patients (171 breasts). Fat was harvested in a closed system, minimally manipulated, and reimplanted into the retroglandular–prefascial plane and into the superficial subcutaneous tissue of the upper pole of the breast—bicompartmental grafting—avoiding any intraparenchymal placement. Grafted fat volume ranged from 160 to 340 mL per breast. All of the patients were monitored with preoperative and serial postoperative mammograms and ultrasonograms.
According to the results, complications were minimal and temporary. Fat survival ranged from 40% to 70% at 6 months. Fat reabsorption was reduced, thanks to an improved harvesting and grafting technique. Follow-up mammography revealed some calcifications in two patients. However the microcalcifications were typical of what develops in response to any trauma or surgery of the breast.
Local Anesthesia Is Safe for Facelifts
Yitzchak Ramon, MD, of Haifa, Israel, presented a study that examined the pharmacokinetics of lidocaine following subcutaneous infiltration of high-dose lidocaine with epinephrine in the face and neck to demonstrate that dosing is safe for facelift operations.
Seven patients who underwent elective facelifts were performed under local anesthesia following infiltration of a high-dose diluted lidocaine solution (22.7 mg/kg) with epinephrin and sodium bicarbonate. Plasma lidocaine concentrations were measured repeatedly over 24 hours, following infiltration and pharmacokinetic parameters.
None of the patients experienced any signs or symptom of lidocaine toxicity. Lidocaine absorption began immediately after infiltration.
The study’s results showed that the maximum safe dose of diluted lidocaine with epinephrine for local anesthesia is higher than the recommended dose. The administration of a lidocaine dose 4 times higher than the recommended dose for a facelift operation yielded a peak lidocaine plasma concentration that was 68.4% lower than the level accepted as toxic. This low level and the absence of signs or symptoms of lidocaine toxicity suggests that the recommended dosage for local anesthesia with lidocaine should be changed.
Return of Breast Augmentation with Autologous Fat
Thomas J. Baker, MD, of Miami presented a study that was done to determine whether, with all the available advances and refinements, breast augmentation with lipoaspirated fat could be a safe and effective breast-augmentation alternative.
Twenty-two women underwent 25 fat-grafting procedures in 48 breasts (one unilateral postcancer reconstruction grafted twice, 19 bilateral primary breast augmentations grafted once, and two bilaterals grafted twice). After they had a magnetic resonance imaging (MRI) exam, the patients wore an external breast-tissue expander 10 hours per day for 4 weeks. During the last 24 hours before their procedures, they were asked to maintain uninterrupted expansion and come to the surgical center still wearing the expander.
Under local tumescent anesthesia and sedation, fat was aspirated from their thighs, flanks, and trochanters. After the fat was separated from the serum, it was reinjected into their ipsilateral breasts through a multitude of needle-puncture sites in a 3-D fanning pattern. In 14 procedures, the injection was limited to the subcutaneous plane and to the deep retroglandular space with strict avoidance of the breast parenchyma. In the remaining 11, some of the grafts were deliberately placed intraglandular.
The patients were asked to attach the expander 12 hours after the procedure and wear it as much as possible for the next few days to support the grafts during revascularization. Three months later, a second MRI was obtained; and at 6 months, a third MRI and a mammogram were obtained.
Except for some bruising and skin blisters that healed uneventfully, there were no significant complications and all of the women returned to their daily activities within 3 to 4 days after the procedure. The breast-volume increases remained constant at the 3- and 6- month evaluations, indicating permanent graft survival.
Graft survival was lower in the group in which some of the grafts were injected intraglandularly. There was no fat necrosis in the group with strict periglandular grafting, compared to the isolated intraparenchymal foci of fat necrosis in the breasts that also received intraglandular grafts.
Quantitation of Eyelid Ptosis Repair by a Three-Step Technique
Prediction of postoperative lid levels in ptosis surgery continues to be a challenge. Hisham Seify, MD, of Rancho Santa Margarita, Calif, presented a study that looked at the effectiveness of a three-step technique for the quantitation of aponeurotic repair that requires no mathematical formula or voluntary patient cooperation, and can be performed under local anesthesia. The technique combines the approximation of anatomic surgical landmarks, the evaluation of intraoperative gapping of the upper and lower eyelid, and the use of an intraoperative eyelid “spring-back” test for further refinement.
Patient charts that identified age, sex, clinical exam, levator function, and outcomes—including revision rate and patient satisfaction—were reviewed. A total of 144 procedures were performed on 80 patients; the mean age was 62. The average follow-up was 18 months. Twelve patients were considered slightly asymmetric postoperatively. Eight patients presented with overcorrection, and four presented with undercorrection.
The study results showed that tarso-levator surgery under general anesthesia using the three-step technique is an effective method for ptosis correction for patients with good levator function. The criterion for surgical revision was greater than 1-mm asymmetry between the eyelids or patient dissatisfaction. Only two patients required surgical revision in the early postoperative period, four patients presented with asymmetry after 1 year, and two patients required revision surgery.
Reducing the Risks of Breast Reoperation
Leo R. McCafferty, MD, of Pittsburgh presented some “pearls” for reducing reoperation rates in primary breast augmentation.
Three plastic surgeons pooled their data on 209 primary breast-augmentation patients with a 12-month follow-up. The 209 patients received augmentation with 403 saline and 10 silicone implants; 63 patients received subglandular implants; and 146 patients received submuscular implants.
The follow-up revealed the following complication rates: 4.8% reoperation rate, 0.5% capsular contracture, 0.7% explantation, 0.5% deflation, 0% rupture, 1.5% malposition, and 0.5% asymmetry. Of the 10 patients who underwent reoperation, five had asymmetry, which required volume modification in one of the two implants; three had malposition; two had capsular contracture; two had hematoma; two had an implant deflation; and one had an implant inflation. One patient chose explantation at the time of reoperation for severe unilateral capsular contracture. No patient was reoperated on within the first 12 months for bilateral-implant size change.
Further research will be conducted to explore the low reoperation rates. Data will include the number of preoperative visits prior to surgery, days from the initial consultation to surgery, patient age, implant volume, and use of differential volume in many cases due to preexisting asymmetries.
Endoscopy-Assisted Facial Rejuvenation Shows Lasting Results
Since its introduction at a Rio de Janeiro meeting in 1995, the endoscopy-assisted facelift has been performed on 314 patients. Each procedure was analyzed based on its subjective results, and on patient satisfaction reported 1 month and 7 or more years postsurgery. Three different types of treatment were considered: global forehead endoscopy, 284 patients; lateral forehead and temporal endoscopies, 22 patients; and forehead–glabellar endoscopy, eight patients. The results were presented by Enzo J. Rivera Citarella, MD, of Rio de Janeiro.
The endoscopic methods showed satisfactory results and allowed expedient recoveries, allowing the patients to return quickly to their daily lives. General complications were seen in 11 patients; four presented with localized hematoma; two suffered iatrogenic burns; and five had foreign-body-type granulomatous inflammatory process. No complications related to asymmetry or nerve injury were reported.
Review Supports Safety of Subplatysmal Facial Rejuvenation
The use of subplatysmal procedures—including the partial removal of the submandibular glands, digastric muscles, and subplatysmal fat—in facial rejuvenation is controversial. Critics of these procedures maintain that an aesthetic result can be achieved through procedures that remain superficial to the platysma and avoid the perceived increased risks of nerve injury, bleeding, contour deformities in the neck, and dry mouth.
A review of 100 cases, presented by Farzad R. Nahai, MD, of Atlanta, compared complication rates between patients who had subplatysmal procedures and those who did not. One hundred facial-rejuvenation cases (facelifts and neck lifts, or neck lifts alone) performed between January 2003 and January 2005 were reviewed.
The patients were separated into those who had subplatysmal procedures—submandibular gland resection, partial subplatysmal fat-pad resection, digastric excision, or a combination of these procedures—and those who did not. Complication-rate comparisons were then performed between the two groups—specifically of postoperative hematoma, facial-nerve injuries, dry mouth, and contour irregularities that required further surgical intervention.
Of the 100 cases reviewed, 56 involved subplatysmal procedures and 44 did not. The overall complication rate was 3%; this included three hematomas—two of which occurred in patients who had subplatysmal procedures and the other in a patient who had plication only. There were no nerve injuries or occurrences of dry mouth.
Three cases of temporary depressor anguli oris weakness resolved within the first 24 hours after the procedure. In each case, the bleeding point was superficial and not deep into the platysma. There were eight minor revisions in this group; seven were for contour irregularities in patients who had undergone liposuction of the submental area.
This review did not identify high rates of hematomas or contour irregularities among subplatysmal procedures compared to those who did not. According to the researchers, the series of cases studied was small. Therefore, they plan to extend the study to several hundred additional patients.
Report From the 16th Biennial Meeting of the Ibero-Latin American Federation of Plastic Surgery
March 28–April 1, 2006
The Ibero-Latin American Federation of Plastic Surgery (FILACP) held its biennial convention in Buenos Aires, Argentina, from March 28 to April 1, 2006. The event was a combined effort with the Argentine Society of Plastic and Reconstructive Surgery (SACPER). The congress is held every other year in a Spanish-speaking country.
The 23 member countries, with the exception of Spain and Portugal, are located throughout Latin America. Spanish is the congress’ official language, although Portuguese is dominant in member nations Portugal and Brazil. The United States is represented by the Society of Latin American Plastic Surgeons (SLAPS), an organization of US-based Spanish-speaking plastic surgeons.
“As Spanish-speaking plastic surgeons, we have an opportunity to provide a bridge between the United States and Latin America,” says Gustavo Colon, MD, vice secretary of FILACP.
Countries vie years in advance to host the event. Previous meetings have been held in almost all member countries, and most recently, in Seville, Spain. A committee selects FILACP venues in much the same way as sites for the Olympics Games are selected. One of the duties of the organizing committee of this year’s meeting was to select the next host city. Quito, Ecuador, was selected for the 2008 meeting.
FILACP, with a membership of more than 2,300 plastic surgeons worldwide, is the largest Spanish-language congress in the world. The event in Buenos Aires drew 1,400 plastic surgeons from all member nations, as well as France, Belgium, Germany, Israel, and Canada.
According to FILACP President Manuela Berrocal, MD, of Cartagena, Colombia, “This event creates the unique opportunity to bring together surgeons, bound by a common language and historical traditions, to understand and analyze our common problems and seek solutions. Our congress is an open door for scientific and social exchange among surgeons in our specialty.”
The week-long event included programs that spanned the entire gamut of aesthetic and reconstructive surgery. Four meeting halls hosted workshops, minicourses, roundtable discussions, and keynote lectures. Invited speakers from the United States included James Hoehn, MD, of Albany, NY; Jorge Perez, MD, of Fort Lauderdale, Fla; Hilton Becker, MD, of Boca Raton, Fla; Mutaz Habal, MD, of Tampa, Fla; and Luis Vasconez, MD, of Birmingham, Ala.
“Talent in plastic surgery is ubiquitous,” says Bruce Connell, MD, of Santa Ana, Calif. “International meetings like this allow for some of the very best ideas in plastic surgery to be exchanged worldwide.”
Among the topics discussed at the congress was breast surgery—specifically, silicone gel breast prostheses—which are still the dominant implant outside the United States. Body contouring—including gluteoplasty, postbariatric dermolipectomy, abdominoplasty, and lipoplasty—was also addressed at length.
Physicians discussed the trend in Colombia and Brazil toward internal laser-assisted lipoplasty. Gluteal contouring, a popular procedure in South America, was also a hot topic.
Sylvie Testelin, MD, of Amiens, France—part of the team that performed the first facial-skin transplant—was a keynote speaker. She discussed facial aesthetic surgery, including traditional face- and neck-lift procedures, limited-incision facelifts, minimal-access cranial-suspension lifts, thread suspension, lipografting, and newer injectables that are not yet available in the United States. She also presented a 3-month follow-up of the first facial-transplant patient, as well as a detailed description of the case, including surgical, logistical, and ethical aspects.
Rhinoplasty, blepharoplasty, and other reconstructive topics, including burns, craniofacial, and hand surgery, rounded out the comprehensive international biennial event.