The Management of Capsular Contracture: Conversion to "Dual-Plane" Positioning through a Periareolar Approach

PURPOSE: The capsular contracture has been the most common complication of augmentation with breast implant, a side effect quite difficult to treat. The latest trends in the correction of capsular contracture include total capsulectomy or conversion of implant pocket. In this study, in an attempt to correct capsular contracture, the authors performed reoperation which involved capsulectomy through peri-areolar approach and dual- plane conversion. The authors hereby report the clinical results of such correction of capsular contracture and examine the efficacy. METHODS: The authors selected 46 patients who were admitted to the clinic from January 2004 to January 2007 (37 months), and performed dual-plane conversion through solely peri-areolar approach. Two types of operation were done: dual-plane conversion from subglandular plane or from submuscular plane. RESULTS: The average follow-up time after conversion to the dual-plane position was 10 months. During the follow-up period, 83.1% of patients recovered from capsular contracture and were Baker class I, and in 10.9% the condition had relapsed into Baker class II or III contracture. CONCLUSION: This study has proven the effectiveness of the dual-plane conversion operation for correcting established capsular contracture after previous augmentation mammaplasty. In this study, all cases of dual-plane conversion operation was performed through peri-areolar approach, which can prevent the occurrence of visible scar on inframammary fold.

Endoscopic Transaxillary Dual Plane Breast Augmentation

PURPOSE: The transaxillary approach for breast augmentation has been advocated for patients and surgeons for several decades. However, this blind technique had many disadvantages including, traumatic dissection, difficult hemostasis, displacement of implants, and ill-defined asymmetrical location of inframammary crease. In the present study, the precise endoscopic electrocautery dissection was applied to eliminate the limits of blunt dissection throughout the procedures. METHODS: From December 2006 to December 2007, a total of 103 patients with an average age of 29.5 years underwent endoscopic assisted transaxillary dual plane augmentation mammoplasty. The mean implant size was 243 cc with the range between 150 and 350cc. Through a 4cm axillary incision, electrocautery dissection for submuscular pockets was carried out under the endoscopic control. The costal origin of pectoralis muscle was completely divided to expose subcutaneous tissue and to make type I dual plane. RESULTS: Using the endoscopic dissection, we achieved good aesthetic results including a short recovery period, less morbidity, and symmetrical well-defined inframammary crease. Type I dual plane procedure could support the consistent inframammary fold shape and be applied to most patients without breast ptosis. Minor complications did not occur, however, four major complications of capsular contracture occurred. CONCLUSION: In contrast to the era of the blind techniques, endoscopic assisted transaxillary dual plane breast augmentation can now be performed effectively and reproducibly. With Its advantage, the axillary application of endoscopy for augmentation mammaplasty is useful to achieve the optimal cosmetic outcomes.

A Case of Cervical Necrotizing Fasciitis

Necrotizing fasciitis is a relatively rare disease which mainly affects the extremities, inguinal area, and the trunk area, and it is by definition a severe acute bacterial infection which affects the fascia. One can misdiagnose the disease as simple cellulitis, thereby delaying an appropriate treatment, and the disease can rapidly spread through the fascia, causing complication such as sepsis, leaving severe loss of tissue as a sequelae. Necrotizing fasciitis of the cervical area is even a rarer disease. Once a person contracts, the disorder can spread through superficial musculoaponeurotic system and cervical fascia, quickly infecting important vascular systems and mediastinum of the craniocervical and thoracic area, which cause a serious complication from direct spread unto main organs. Therefore, in case of necrotizing fasciitis of the cervical area, active surgical treatment such as wide excision of necrotizing tissue and proper drainage of abscess and early administration of broad range antibiotics are necessary in order to prevent serious complications in main vascular system, mediastinum, or craniocervical system. We have experienced a case of necrotizing fasciitis of the cervical region in 2002, and obtained satisfactory results from wide excision, abscess drainage, local flap with skin graft, and hereby report the case with references.

A Effect of Pretreatment Period on CO2 Laser Resurfacing in Guinea Pig Skin: A Comparative, Histologic Study

For the pre-treatment prior to laser resurfacing, materials such as glycolic acid, tretinoin, and/or hydroquinone have been widely used. However, the optimal duration of pretreatment is still controversial. The authors chose guinea pig skin which is similar to human skin, pre-treated it with tretinoin and hydroquinone with different duration, and examined gross and histologic changes after performing laser resurfacing in an attempt to study the effect of pre-treatment period on CO2 laser resurfacing. Sixteen guinea pigs were divided into four groups, and the dorsal skin was pre-treated with 0.05% tretinoin cream and 4% hydroquinone for 4, 8, and 12 weeks respectively while groupI underwent no pre-treatment as control. During the pre-treatment period, the authors observed gross skin reactions, and also examined the number of epithelial layers, thickness changes, the extent of epithelial regeneration, and collagen tissue change within dermis layer with skin tissue samples before and after laser resurfacing. Compared to group I(control) which received no pre- treatment, pre-treatment groups showed rapid epithelial hyperplasia and increase in the number and thickness of squamous epithelial cells and granular cell layer. However, there was no statistically significant difference in epithelial regeneration and number and thickness of epithelial cell layer between the 4-weeks, 8-weeks, 12- weeks pretreated groups. Pre-treatment with tretinoin and hydroquinone prior to laser resurfacing helped epithelial regeneration after resurfacing, but as to the benefit of long-term pre-treatment more than 4 weeks was not necessary.

Conjunctivodacryocystorhinostomy with Rubber-Tipped Jones Tube

One of the problems of conjunctivodacryocystorhinostomy which employs the conventional Jones tube is that the end of Jones tube has to be manipulated by the surgeon so that the tube resides within the nasal cavity while not touching the middle turbinate and the nasal septum. As a result, for most of the patients who have high nasal septal deviation, paradoxical curvature, or middle turbinate hypertrophy, there wasn't enough room within the nasal cavity where one end of Jones tube could rest. Such patients required either septoplasty or turbinectomy before they underwent conjunctivodacryocystorhinostomy. In order to overcome such a problem, the authors connected a 4 Fr. rubber tube to the conventional Jones tube, and helped the end of the tube to reside within the nasal cavity regardless of the anatomical variation of either the nasal septum or the middle turbinate. When such modified procedure is used, the conven tional Jones tube will make contact with the conjunctiva, lacrimal sac, and the nasal mucosa while the rubber tube remained afloat within the nasal conjunctiva. Such modification helps the tube to reside within the nasal cavity without foreign body reactions and granulation tissue complications, and there is no need to change tubes in order to make up for the loss of tube length due to post operative tissue contracture. Between April 2000 and August 2001, the authors performed conjunctivodacryo cystorhinostomy with rubber-tipped Jones tube on 8 patients with nasolacrimal duct obstruction, and obtained satisfactory results without complications.