Personal Evolution in Thighplasty Techniques for Patients Following Massive Weight Loss.

BACKGROUND: Lockwood described the importance of Colles' fascia anchoring in medial thighplasty to reduce morbidity associated with the procedure. However, this maneuver may still have complications including traumatic dissection, prolonged edema, and potential wound healing ramifications form increased tension. Alternatively, we suggest orienting tension in medial thighplasty for massive weight loss (MWL) patients in the horizontal vector rather than a vertical direction, negating the need for Colles' fascia anchoring. OBJECTIVES: To compare the morbidities, complications, and outcomes between Colles' fascia suture fixation (CFSF) and horizontal vector fixation (HVF) in medial thighplasties in MWL patients. METHODS: A retrospective chart review was conducted on an Institutional Review Board approved database of MWL patients who had medial thighplasty between October 2004 and March 2014. Patient demographics and surgical outcomes were reviewed between those MWL patients with CFSF and HVF. RESULTS: Of 65 post-MWL patients, 26 (40.0%) patients were in the CFSF group, and 39 (60.0%) patients were in the HVF group. The 2 groups had statistically equivocal preoperative characteristics and comorbidities. Intraoperatively, the HVF group had increased use of barbed suture (92.3% vs 30.6%, P < 0.0001) and liposuction (71.8% vs 26.9%, P < 0.0001). Postoperatively, the HVF group had decreased incidence of infection (5.1% vs 23.0%, P = 0.051) and lymphocele/seroma (10.3% vs 34.6%, P = 0.0257). No statistical differences were observed for dehiscence, necrosis, or hematoma. CONCLUSIONS: HVF for medial thighplasty in MWL patients is a safe and effective procedure, with a lower complication profile than CFSF. Furthermore, the incorporation of barbed sutures and/or liposuction may help to achieve optimal results. LEVEL OF EVIDENCE: 3.

Technical Maneuvers to Decrease Warping of Peripheral Costal Cartilage Grafts.

BACKGROUND: Cartilage warping has plagued reconstructive and cosmetic rhinoplasty since the introduction of extraanatomical cartilage use. The authors' group theorized that, rather than focusing on the prevention of the innate tendency of rib graft warping, it may be possible to redirect the stressors toward themselves and use these forces with oppositional suturing techniques to compensate for these intrinsic characteristics. METHODS: Fresh cadaver cartilage was obtained from the costosternal junction of two rib cages (aged 77 and 99 years). The cartilage was cut manually into 4 × 2.5 × 20-mm cross-sections from the cephalic edges of each of the harvested specimens. The specimens from the right chest were used as the control and the left segments underwent an oppositional suturing technique (n = 10) of the cephalic peripheral segment of the cartilage. RESULTS: Overall, the control group experienced a 724.2 percent increase in the mean degree of warping (p < 0.001). In contrast, the oppositional suturing group experienced a mean decrease in warping angle relative to baseline of only 35.7 percent. At 1 month, the oppositional suturing group displayed significantly decreased warping compared with the control group. CONCLUSIONS: This is a novel cadaveric study evaluating the benefit of oppositional suturing techniques in peripheral costal cartilage grafts. Multiple techniques and maneuvers have been borne out of the frustration of these inherent characteristics of costal cartilage grafts. Oppositional suturing techniques are a useful tool available to surgeons performing nasal reconstruction and revision rhinoplasty to maximize the amount of useful costal cartilage graft. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Comparison of Limited-Undermining Lipoabdominoplasty and Traditional Abdominoplasty Using Laser Fluorescence Imaging.

BACKGROUND: Body contouring that involves abdominoplasty and/or liposuction is a common cosmetic surgery procedure. Although single-staged lipoabdominoplasty has gained popularity, safety concerns remain. OBJECTIVES: The authors compared abdominal flap perfusion and overall complication rates for traditional abdominoplasty and limited-undermining lipoabdominoplasty. METHODS: Eighteen abdominoplasty patients were evaluated in a prospective study. All patients were nonsmokers and lacked major comorbidities. The control group (n = 9) underwent traditional abdominoplasty with wide undermining. The study group (n = 9) underwent abdominoplasty with limited undermining as well as liposuction of the abdominal flap. The groups were similar with respect to age and body mass index. Patients received follow-up for an average of 97 days. Fluorescence imaging was utilized for perfusion studies. Results and complications were documented, and statistical significance was ascertained via the Student t test. RESULTS: Neither group had major complications or revisions. Minor complications included an exposed suture, resulting in delayed wound healing, in the control group. A patient in the study group had a small area of fat necrosis and a small seroma, neither of which required further treatment. No significant difference in abdominal flap perfusion was found between the control (57%) and study (50%) groups based on fluorescence levels relative to a designated baseline reference marker. CONCLUSIONS: Results of the study indicate that no significant differences exist between the 2 operations with respect to the rates of abdominal flap perfusion or complications. LEVEL OF EVIDENCE: 3.

Five parameters you must understand to master control of your laser/light-based devices.

In this article, the authors review basic fundamental principles of light characteristics and their interaction with the target tissue. It is imperative for the practitioner to understand these concepts to deliver appropriate, efficacious, and safe phototherapeutic treatment for their patients. Once a diagnosis is made and a laser is chosen as a treatment tool, a basic knowledge and understanding of the physics and properties of light/tissue interaction is essential to allow practitioners to provide their patients with optimal results.

Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping.

BACKGROUND: Cartilage warping has plagued reconstructive and cosmetic rhinoplasty since the introduction of extra-anatomical cartilage use. With the present level of knowledge, there is no evidence of the warping properties with respect to cartilage harvest and suture techniques and level of rib harvest. This report aims to improve understanding of costal cartilage warping. METHODS: The sixth through tenth costal cartilages were harvested from six fresh cadavers aged 54 to 90 years. Warping characteristics were followed with respect to level of harvest (i.e., sixth versus seventh), carving orientation, and oppositional suturing. Digital photography of the specimens was performed at various time points (immediately, 1 hour, and 1 month postoperatively). RESULTS: All specimens showed signs of warping beyond 1 hour of carving that continued in a linear fashion to 1 month. There was no statistical difference in the amount of warping specific to the level of harvest, orientation, or with or without oppositional suturing (p<0.05). CONCLUSIONS: Cartilage warping remains a problematic obstacle in nasal reconstruction and revision rhinoplasty, but costal cartilage remains the workhorse graft and is an excellent autologous option. Our findings are the first to be described in the literature regarding warping characteristics of costal cartilage with regard to the level of harvest, orientation of carving, and oppositional suturing techniques in a cadaveric model.

The Science and Theory behind Facial Aging.

SUMMARY: The etiology of age-related facial changes has many layers. Multiple theories have been presented over the past 50-100 years with an evolution of understanding regarding facial changes related to skin, soft tissue, muscle, and bone. This special topic will provide an overview of the current literature and evidence and theories of facial changes of the skeleton, soft tissues, and skin over time.

TUNEL assay to characterize acute histopathological injury following treatment with the active and deep FX fractional short-pulse CO2 devices.

BACKGROUND: This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. METHODS: The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. RESULTS: The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. CONCLUSIONS: The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.

Refinements in abdominoplasty: a critical outcomes analysis over a 20-year period.

BACKGROUND: The use of liposuction combined with abdominoplasty has been controversial. The combination of techniques has been associated with an increased rate of venous thromboembolism and wound-healing complications. Through improvements in venous thromboembolism prophylaxis, refinements in liposuction techniques, and an understanding of anatomy, this cumulative risk has decreased, although the negative stigmata persist. This study describes the evolution of abdominal body contouring through a critical review of a single surgeon's 20-year experience with abdominoplasty. This clinical outcome analysis will highlight the significant contributions that have led to the improvement in the safety and efficacy of this technique. METHODS: A retrospective review of patients undergoing abdominoplasty procedures was performed. Patient demographics and procedural information, including postoperative course and complications, were recorded. Preoperative and postoperative photographs were scored by blinded evaluators for aesthetic result and scar quality. RESULTS: Two hundred fifty patients undergoing abdominoplasty from 1987 to 2007 were included in the study. The use of a "superwet" liposuction technique in combination with abdominoplasty significantly decreased intraoperative blood loss (p < 0.04) and length of hospital stay (p < 0.05). Liposuction volume and region had no significant effect on abdominoplasty outcome, although refinements in operative technique, including abdominal and flank ultrasound-assisted liposuction, high superior tension, and limited abdominal undermining, did improve the postoperative aesthetic score. Venous thromboembolic events significantly decreased with aggressive venous thromboembolism prophylaxis (p < 0.001). CONCLUSIONS: The technical evolution of a single surgeon's 20-year experience demonstrates that liposuction can be safely and effectively combined with abdominoplasty. Preoperative trunk analysis, intraoperative surgical refinements including superwet technique and ultrasound-assisted liposuction, and perioperative venous thromboembolism prophylaxis significantly improve the outcome of abdominoplasty.

In vivo histopathologic comparison of the acute injury following treatment with five fractional ablative laser devices.

BACKGROUND: Both erbium (Er:YAG) and carbon dioxide (CO(2)) devices are commonly-used, efficient laser systems for aggressive skin resurfacing procedures. The devices each have different adjustable parameters (density, spot size, number of pulses, pattern, etc) and utilize variable energy capabilities to tailor individual treatments depending on the skin pathology and goals of treatment. Overall, the consensus has been that multiple-pass erbium treatments needed for efficacious wrinkle reduction had similar downtime and comorbidity to the traditional CO(2) treatments. Unfortunately, there were limited data comparing the histological differences and changes throughout the wound-healing process over time between the two treatment methods. OBJECTIVES: The authors compare the difference in injury following treatment with five novel fractional ablative laser systems in vivo. Differences in damage pattern, treatment depth, and degree of surrounding cellular injury following treatment with each device at common clinical settings are evaluated in a side-by-side histopathologic comparison. METHODS: Prior to planned excisional surgery, the panni of 20 abdominoplasty patients were treated with five novel ablative fractional carbon dioxide or Er:YAG laser systems at various clinical parameters, in accordance with the manufacturers' treatment guidelines. After tissue removal two to four hours later, the skin was biopsied and processed for histopathologic evaluation. Specimens were stained with hematoxylin and eosin, along with a terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) assay, to highlight the degree of irreversible cellular injury. RESULTS: The acute damage profile differed between the fractional Er:YAG and CO(2) devices with respect to depth of penetration and extension of coagulation surrounding the microcolumns. The damage pattern was dependent on the parameters set with each device (eg, fluence, pulses, density, pulse width). The TUNEL-stained sections demonstrated more collateral cellular injury surrounding the ablated columns with the CO(2) devices than with the Er:YAG systems. CONCLUSIONS: Following treatment with the fractional Er:YAG and CO(2) devices, deep tissue injury with various coagulative and ablative properties was observed, and it was confirmed that carbon dioxide and erbium devices result in different patterns of injury. As such, each may be better suited for different clinical situations. It is important for practitioners to understand the limitations of a specific device, as well as the tissue injury following a given treatment pattern or protocol, to appropriately tailor their treatment algorithm for a given patient. This extensive histopathologic evaluation of the acute characterization of injury across devices is helpful in clarifying the differences/similarities in laser-tissue interaction following treatment in an in vivo human model.

Micro-island damage with a nonablative 1540-nm Er:Glass fractional laser device in human skin.

BACKGROUND AND OBJECTIVES: Fractional photothermolysis produces micro-islands of thermal injury to the skin while preserving areas among treated tissue sites in order to promote wound healing. Histological changes associated with single and multiple passes of the 1540-nm Er:Glass fractional laser were examined using in vivo human skin. METHODS AND MATERIALS: Panni of five abdominoplasty patients were treated intraoperatively with a Fractional Lux1540 erbium glass laser system at various laser parameters, with single and multiple passes. Biopsies were removed and examined using standard histological stains. RESULTS: Deep coagulated columns of collagen separated by regions of unaffected tissue were observed at variable fluence parameters. A direct correlation between the depth of penetration of the coagulated microcolumns and increasing energies was observed. Micro-islands of coagulation were approximately 250 microm in diameter and separated by approximately 800 microm of unaffected tissue. With multiple passes, significantly more disruption of the dermal-epidermal junction (DEJ) occurred at higher fluences. In contrast to the controlled fractional columns observed with single-pass treatments, nonuniform coagulated columns were distributed randomly throughout the tissue when instituting multiple passes over the same treatment region. CONCLUSION: Micro-islands of thermal damage were observed at variable energy parameters. Pathological changes within the skin were clearly dependent on amount of energy and number of passes of the laser treatment. Significantly more superficial damage, accompanied by disruption of the DEJ was observed with multiple passes when compared with single pass at similar fluences. However, with multiple passes, depth of thermal injury did not increase with increasing energies but did disrupt the micro-island array observed with single-pass fractional treatments.

Preventing and managing dry eyes after periorbital surgery: a retrospective review.

BACKGROUND: Dry eye syndrome is a common sequela associated with periorbital surgery. As more patients seek periorbital rejuvenation, understanding the pathophysiology, diagnosis, and treatment of this condition perioperatively is essential for managing patient expectations and maximizing outcomes. METHODS: A retrospective review of charts for 202 consecutive patients (180 women and 22 men) who underwent upper and/or lower blepharoplasty was performed. Additional facial cosmetic procedures were performed in 91 percent of patients. Data were collected identifying associated risk factors and the incidence of persistent dry eye symptoms. Key elements of perioperative care are described and algorithms for detection of those at risk, prevention, and management are outlined. RESULTS: Dry eyes persisting longer than 2 weeks after surgery were noted in 22 patients (10.9 percent) and longer than 2 months in only four patients (2 percent). In most cases, dry eyes resolved with conservative management, including artificial tears, lubrication, topical and systemic steroids, and night taping. One patient (0.5 percent of all studied patients) eventually needed surgical correction of lower eyelid retraction after failure of the punctate plug. Persistent chemosis occurred in 15 patients (68.2 percent) who had symptomatic dry eyes (p < 0.01). CONCLUSION: Recognizing and addressing risk factors before surgery and an algorithmic approach to prevention and management of patients undergoing periorbital surgery are essential for minimizing the occurrence of dry eye syndrome.

Effects of common laser treatments on hyaluronic acid fillers in a porcine model.

BACKGROUND: Injectable hyaluronic acid fillers (HAFs) and laser/light procedures have become increasingly popular for noninvasive facial rejuvenation in many cosmetic practices. However, the effect of laser/light treatments on HAFs is unknown. OBJECTIVE: Our objective was to examine the effect of laser/light treatments on HAFs in a porcine model. METHODS: The abdomens of 6 Yorkshire pigs were injected with 3 different HAFs: Restylane (Medicis, Scottsdale, AZ), Perlane (Medicis), and Juvéderm (Allergan, Santa Barbara, CA). Two weeks after injection, the injection sites were treated with 1 of 7 common laser/light ablative or nonablative devices. Following laser treatment, 8-mm punch biopsies were collected from the treated tissue and fixed for histopathologic evaluation. Sections were stained with hematoxylin-eosin and alcian blue stains for identification of the preinjected HAF. RESULTS: The filler was identified in different areas of the dermis in different sections. The Sciton intense pulsed 560 nm filter (Sciton, Palo Alto, CA), the Sciton Nd: YAG, Lux1540 (Palomar Medical Technologies, Burlington, MA), or ActiveFX (Lumenis, Yokneum, Israel) treatments showed no sign of interaction with superficial or deep dermal filler. No evidence of morphologic changes to the filler or the surrounding tissues was observed. Obvious interaction between the HAFs and the laser injury was demonstrated in sections treated with the deep ablative systems fractional erbium 2940 (Profractional; Sciton) and DeepFX CO(2), (Lumenis). However, no uncharacteristic tissue injury or morphologic change in the filler was appreciated in any of the preinjected specimens. CONCLUSIONS: Injected HAFs were unaffected by the nonablative laser/light and superficial ablative treatments. The more aggressive deeper laser treatments demonstrated laser/filler interaction and may have a clinical effect on the longevity of the filler and/or efficacy of laser treatments. Novel ablative fractional lasers have the capability of deep dermal penetration, and this should be taken into consideration when planning to use them in combination with soft tissue fillers for noninvasive facial rejuvenation.

TUNEL assay for histopathologic evaluation of irreversible chromosomal damage following nonablative fractional photothermolysis.

BACKGROUND: Fractional photothermolysis is extremely popular in skin rejuvenation and remodeling procedures. However, the extent of thermal cellular injury beyond the borders of the coagulated microcolumns produced with fractional phototherapy is undefined. METHODS: Six abdominoplasty patients were pretreated with the Lux1540 Fractional Erbium device (Palomar, Inc., Burlington, Mass.) at various clinical laser settings. After tissue excision, the panni were immediately biopsied. Biopsy specimens were fixed in formalin, embedded in paraffin, sectioned, and evaluated with the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) procedure for cellular necrosis/apoptosis. Tissue was sectioned horizontally and longitudinally to help define the depth and distribution of the microcolumns of injury in a three-dimensional plane. RESULTS: The extent of cellular necrosis/apoptosis at variable depths within the epidermis and dermis was demonstrated successfully with the TUNEL technique. After the Lux1540 treatment, TUNEL-positive nuclei were identified in a vertically oriented fashion that extended from the epidermis into the papillary and reticular dermis, highlighting the areas of injury. The TUNEL-positive nuclei defined lesions that were approximately 175 to 225 microm in diameter and penetrated to variable depths (200 to 900 microm), depending on the fluence used for treatment (18 to 100 mJ). CONCLUSIONS: TUNEL immunofluorescent labeling provided an accurate assessment of cellular damage within and surrounding the microthermal zones of coagulated collagen with respect to column depth and width. Because of its specificity, the TUNEL assay can be a useful adjunct to other histologic stains used to characterize cellular damage and matrix denaturation in skin treated with any fractional ablative or nonablative laser device.

Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery.

BACKGROUND: There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner. METHODS: Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors' (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures. RESULTS: The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates. CONCLUSIONS: Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

Heat shock proteins 47 and 70 expression in rodent skin model as a function of contact cooling temperature: Are we overcooling our target?

BACKGROUND AND OBJECTIVES: The degree of protective cooling required during laser therapy to achieve an optimal result is unknown. The expression of heat shock proteins, Hsp47 and Hsp70, were examined in the epidermis and dermis as biomarkers to quantify the degree and depth of tissue affected by non-ablative laser treatment using variable protective cooling parameters. STUDY DESIGN/MATERIALS AND METHODS: Twenty-one male Sprague-Dawley rats were treated with a 1,319 nm Nd:YAG laser using a sapphire cooling plate attached to the hand piece. A 4 cmx4 cm area on each side of the rat was treated with the same energy and pulse settings, with variable contact cooling. Protective cooling parameters, for each degree increment, ranging from 0 to 25 degrees C were studied. Immunohistochemistry (IHC), Western blot and PCR were performed to evaluate the effects of superficial cooling on Hsp47, and Hsp70 expressions. RESULTS: Our data showed the extent of topical cooling needed to produce a thermal effect at different depths in the dermis, quantified by the expression of Hsp47 and Hsp70. Significant Hsp expression was observed with cooling of 13 degrees C and warmer; no identifiable cellular reaction was observed when cooling below 5 degrees C. There was no evidence of epidermal injury when treating the skin with any protective cooling ranging from 0 to 25 degrees C. CONCLUSION: Our data would suggest contact cooling temperatures 5 degrees C and below completely protects through the entire dermis. There was no evidence of epidermal injury with protective cooling at any temperature between 0 and 25 degrees C. Warmer temperatures are safe and adequately protect the epidermis in this model.

The effect of blood pressure on hematoma formation with perioperative Lovenox in excisional body contouring surgery.

BACKGROUND: Prophylactic use of low molecular weight heparin (LMWH) has been shown to be efficacious in decreasing thromboembolism. LMWHs are associated with increased rates of bleeding. OBJECTIVE: We reviewed perioperative blood pressure dynamics for patients who experienced hematomas while undergoing body contouring procedures while receiving enoxaparin (Lovenox), compared with similar patients who did not have development of a postoperative hematoma. METHODS: A retrospective chart review was performed examining 2 patient groups: 10 patients who experienced a hematoma after excisional body contouring surgery with perioperative Lovenox; and 10 similar patients with respect to sex, surgery type, massive weight loss status, and Lovenox administration, who did not have a hematoma. Preoperative and postoperative blood pressures were recorded, as were blood pressures during the last 2 hours of surgery. Mean arterial pressures (MAPs) were calculated for all time points, and mean intraoperative MAP was statistically compared with preoperative and postoperative MAP, for the two groups. RESULTS: The mean preoperative MAP for each group was the same (97.5 mm Hg vs 95.8 mm Hg; P = .61). The mean MAP for the last 2 hours of each case was significantly lower in the hematoma group (66.7 mm Hg vs 82.4 mm Hg; P < .0001), and a higher mean postoperative MAP reached significance in the hematoma group (96.3 mm Hg vs 88.5 mm Hg; P = .05). Both the difference between intraoperative and preoperative blood pressure (30.7 mm Hg vs 13.4 mm Hg; P < .0001) and between intraoperative and postoperative blood pressure (29.6 mm Hg vs 7.0 mm Hg; P < .0001) were increased in the hematoma group versus the non-hematoma group. CONCLUSIONS: Many patients undergoing excisional body contouring surgery are at risk for VTE and may need perioperative chemoprophylaxis. However, maintaining a normal intraoperative blood pressure and vigilance in recognizing and treating postoperative hypertension may reduce the hematoma rate seen with perioperative administration of LMWH.