Lipoplasty Combined with Percutaneous Radiofrequency Dermaplasty: A New Strategy for Body Contouring.

BACKGROUND: A new technique in plastic surgery termed percutaneous radiofrequency dermaplasty (PRD) is described. Customized radiofrequency energy is applied via the percutaneous route to produce skin tightening and fascia contraction at body temperature, avoiding thermal injury. We combine PRD with lipoplasty and call this combined procedure dermaplasty-assisted lipoplasty (DAL). The purpose of this study was to review both the safety and efficacy of DAL. METHODS: We developed the required novel device and technique to perform DAL and then performed a clinical trial including Type I and Type II lipodystrophy female patients undergoing a primary liposuction of the circumferential trunk. The trial comprised two phases. In Phase I, 51 patients were included in a prospective, comparative, controlled trial and divided into two groups. In Group 1, 29 patients underwent DAL, and in Group 2, 22 patients underwent a standard suction-assisted lipectomy (SAL) alone. In Phase II, 84 patients underwent DAL, including 9 cases initially scheduled for a mini-abdominoplasty. RESULTS: Phase I: We found better aesthetic results with DAL (93.1%) than with SAL alone (72.7%) [p < .05]. Postoperative correction of flaccid skin was superior with DAL (93.1%) than with SAL alone (36.4%) [p < .01]. Phase II: DAL achieved good-to-excellent aesthetic results in 94% of the cases. CONCLUSIONS: DAL was found to be a reliable and safe treatment for fat removal with concomitant skin and fascia tightening but without compromising the viability of the overlying skin. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Evaluation of the histologic changes in the fat-grafted facial skin: clinical trial.

BACKGROUND: Fat grafting is increasingly common in plastic surgery procedures. The discovery of stem cells in fat tissue has given a new direction to the use of fat as a therapeutic tool for other patient conditions. Only one experimental study in rats shows dermal changes after application of lipofilling. For this reason, the authors conducted this study to evaluate skin changes in patients after application of the technique. This study aimed to observe histologic changes in the skin of patients undergoing fat grafting. METHODS: Fat grafting was performed in the preauricular region on one side of patients undergoing face-lifts at the Jalisco Reconstructive Surgery Institute, Guadalajara, Mexico. Preauricular skin was used in this procedure as a withdrawal study and control condition. Hematoxylin-eosin and Masson staining was performed to assess dermal and epidermal thickness, vascularity, and collagen behavior. No inferential statistics were registered with the Wilcoxon test. RESULTS: The study investigated 16 patients to observe statistically significant differences in dermal thickness, the presence of immature collagen (neoformation), and arteries. No difference in epidermal thickness was observed. CONCLUSIONS: The study showed a regenerative effect with fat grafting that included an increased thickness of the dermis, collagen neoformation, and the presence of increased vascularity in local skin subjected to treatment. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Controlled clinical trial with pirfenidone in the treatment of breast capsular contracture: association of TGF-ß polymorphisms.

BACKGROUND: Breast capsular contracture (BCC) is a commonly adverse event postmammoplastly characterized by an immune response mediated by cytokines and transforming growth factor (TGF)-ß1 resulting in excessive synthesis and deposit of extracellular matrix around the breast implant. Presence of TGF-ß1 polymorphisms has been associated as a risk factor to develop fibroproliferative diseases. METHODS: This open, controlled, prospective, and pilot clinical trial with 6 months duration was carried out to evaluate the efficacy of 1800 mg a day, of oral Pirfenidone (PFD) in the treatment of BCC (Baker Score III/IV) postmammoplasty. Twenty BCC cases received PFD and 14 BCC control cases underwent capsulectomy after 6 months of enrollment. Both groups were followed up for 6 more months up to 12 months to determine the relapse in the absence of PFD. Determination of TGF-ß1 polymorphisms was performed to establish a correlation with capsular contracture. RESULTS: PFD group experienced BCC-reduction in all breasts 6 months after enrollment. Only 1 of 20 cases relapsed after follow-up. In capsulectomy group, 2 of 14 cases presented progression to grade IV during presurgical period. All capsulectomy cases relapsed at end of follow-up. Nearly hundred percent of all patients studied in this protocol had a profibrogenic homozygous TGF-ß1 polymorphism (codon 25; genotype Arg25Arg). CONCLUSIONS: PFD is useful to improve BCC (Baker Score III/IV) postmammoplasty with no relapse after drug administration. There is also an association between capsular contracture and the presence of homozygous G/G TGF-ß1 genotype.

Aesthetic plastic surgery training at the Jalisco Plastic and Reconstructive Surgery Institute: a 20-year review.

BACKGROUND: Teaching aesthetic surgery within the different training programs worldwide sometimes presents significant challenges. The main difficulty lies in providing resident physicians with sufficient exposure to all of the conditions that they will likely encounter once their training ends. In many places, exposure to a totally comprehensive array of operations is almost nonexistent. METHODS: To analyze the work that residents perform in aesthetic surgery at the Instituto Jalisciense de Cirugía Reconstructiva "José Guerrerosantos" (Jalisco Plastic and Reconstructive Surgery Institute), a hospital affiliated with the University of Guadalajara in Jalisco, Mexico, the surgical records of 30 residents who finished their plastic surgery training between 1990 and 2009 were chosen at random and reviewed retrospectively. Only surgical procedures performed in operating rooms, in which residents acted as the primary surgeon or first assistant, were analyzed. RESULTS: Each resident performed an average of 309 aesthetic surgical procedures: 167 as surgeon and 142 as first assistant. The surgical procedures were divided into three general categories: body contouring procedures, breast procedures, and facial procedures. The numbers of procedures performed by residents as surgeons or first assistants according to each category were 55 and 37 (body contouring), 34 and 31 (breast), and 78 and 74 (facial). CONCLUSIONS: The experience is gratifying. At the Jalisco Plastic and Reconstructive Surgery Institute, all residents have an opportunity to perform a comparable number of aesthetic procedures of the most varied nature and complexity under the supervision of experienced plastic surgeons. It is therefore possible to teach aesthetic surgery to residents.

Contouring the gluteal region with tumescent liposculpture.

BACKGROUND: For quite some time, plastic surgeons have experimented with novel techniques for enhancing the gluteal region. However, all of the previously-described techniques have the disadvantage of postoperative scarring, most of which is visible. As an alternative, fat injection in the gluteal region has been shown to have permanent and satisfactory results. OBJECTIVES: The authors discuss the results of liposuction and lipoinjection in the gluteal region. METHODS: Between March 2000 and March 2007, 300 female patients who presented with lipodystrophy of the gluteal and paragluteal regions underwent liposuction with a modified tumescent technique. The treated sites were classified into six anatomical zones, and the patients were retrospectively grouped into types based on the frequency of treatment in each zone. RESULTS: The patients ranged in age from 16 to 54 years. The follow-up period ranged from six to 36 months. Fifty percent of patients underwent liposuction in Zone I, 90% in Zone II, 0% in Zone III, 40% in Zone IV, 30% in Zone V, and 75% in Zone VI. The largest percentage of patients underwent treatment in Zones I, II, and V, with subsequent lipoinjection. Comparison of pre- and postoperative photographs and measurements revealed gluteal lifting in all patients at the point of greatest projection. Improved contour was shown in Zones I, II, and IV when all zones were treated in a combined form. CONCLUSIONS: The concept of refining techniques for liposuction and lipoinjection according to individual anatomical zones is essential to the evolution of the procedure. In this series, the results indicated that improving the intraoperative treatment of the hip region resulted in improved aesthetic contouring. Therefore, the authors believe that this technique can reduce the need for more aggressive surgical procedures, which thereby decreases the risk of complications, recovery time, and sequelae.

Percutaneous selective myoablation in plastic surgery.

A new technique in aesthetic plastic surgery termed "myoablation" is described. Thermal energy is applied via the percutaneous route for ablation of selected facial muscles to modify the facial dynamics. Myoablation was found to be useful in ameliorating noticeable frown wrinkles caused by muscular hyperactivity. A series of 30 patients underwent myoablation as the sole procedure with encouraging results. In 80% of the cases, good to excellent aesthetic results were achieved. This report presents the electrophysiologic bases, technique, animal experiments, and initial clinical experience of myoablation.

Interpositional cartilage grafts to improve vertical length of the face.

BACKGROUND: Most plastic surgeons in the past used bone grafts for nasal augmentation and for augmentation of the middle third of the face, and we, in our service, also used bone grafts at that time. Later, however, most plastic surgeons changed, and cartilage grafts are now the favorite material for rhinoplasty. For many years, we used cartilage grafts in rhinoplasty, and we now report the use of cartilage grafts to augment the length of the middle third of the face. METHODS: We performed an osteotomy Le Fort I and harvest cartilage grafts from the costal region; then, we placed cartilage grafts between the upper portion and the lower portion of the maxilla to augment the vertical dimension of the middle third of the face. RESULTS: Results in our patients were excellent. CONCLUSIONS: Instead of bone grafts, cartilage grafts can be used as a good alternative to augment the vertical dimension of the maxilla.

Behavior of visfatin in nonobese women undergoing liposuction: a pilot study.

INTRODUCTION: The adipocyte has recently begun to be considered not just as a fat deposition tissue, but also as a true endocrine organ. Adipose tissue produces a wide variety of adipocytokines, of which visfatin is one. OBJECTIVE: Since visfatin has recently been described as a mimic of insulin action, the authors evaluate visfatin behavior in women undergoing liposuction. MATERIALS: Nineteen nonobese women underwent liposuction of abdominal fat. Patient visfatin levels and a lipid profile were obtained preoperatively, and the results were compared with the results of the same tests immediately postoperatively and one month postoperatively. RESULTS: The mean age of the 19 study participants was 33 years; mean body mass index was 24.7±2.2 kg/m2. The amount of subcutaneous fat obtained was an average of 4468±1403 kg. Visfatin increased from 51.8±24.4 ng/mL preoperatively to 76.3±39.8 ng/mL (P=.02). Pre- and postoperative lipid profiles reflected, respectively, the following: total cholesterol, 159.1±37.1 vs 164.6±31.7 mg/dL (P=.420); high-density cholesterol, 41.4±8.6 vs 39.3±9.9 mg/dL (P=.421); low-density cholesterol, 97.1±25.4 vs 100±19.2 mg/dL (P=.507); and triglycerides, 92.3±57.1 vs 126.3±72.5 mg/dL (P=.058). CONCLUSIONS: Visfatin levels were shown to increase after liposuction of subcutaneous fat. The authors conclude that this adipocyte may play an important role as a regulatory reciprocal mechanism.

Managing platysma bands in the aging neck.

The author demonstrates his method of achieving optimal contour in the aging neck. Primary features of the technique are horizontal cuts in the vertical bands of the platysma muscle combined with a corset Z-plasty medial suture and bilateral rein plication suture. This combined procedure, which effectively lifts the sagging neck, is useful in treating vertical platysma bands in primary cases, as well as recurrent platysma bands.

Evolution of technique: face and neck lifting and fat injections.

Plastic surgeons try to restore the youthful and beautiful appearance of their patients when performing facial and cervical surgical rejuvenation operations. Rhytidoplasty combined with pursing plication suspension sutures and lipoinjection offers us the opportunity to produce a stable, effective, and long-lasting tissular lifting of the face and neck, including jowls, malar fat pad, and cheeks, and correction of the melolabial sulcus. This combination of procedures also provides a three-dimensional aesthetic improvement in contour and volume and a short time of convalescence and recovery, and offers less risk for complications, especially in the facial nerves.

Classification and treatment of facial tissue atrophy in Parry-Romberg disease.

BACKGROUND: This report aims to show procedures that the senior author has used for the rehabilitation of facial deformities in Parry-Romberg disease since 1983. The authors also report the classification they use to plan the most appropriate surgical procedure for these patients. METHODS: For this study, 95 patients (67 females and 28 males) with different types of facial tissue depression were classified according to the depth of the defect so adequate treatment could be planned. The cases were classified into four types. For types 1 and 2, only fat grafts were used, whereas for types 3 and 4, a combined procedure was used according to the case using cartilage and bone grafts, free dermis-fat grafts, and galeal flaps. RESULTS: The results were successful, with few or no complications. Objective examinations showed excellent aesthetic improvement, with obvious deformity alleviated and the emotional status of the patients improved. CONCLUSIONS: The authors' practice frequently sees cases of Parry-Romberg disease, which has allowed them to gain significant experience in this field. For depression types 1 and 2, they recommend only fat infiltration, and for types 3 and 4, they favor combined treatment with lipoinjection, galeal flaps, free dermis-fat grafts, and bone and cartilage grafts. Occasionally, in areas of soft tissue with fibrosis, the authors infiltrated around 4 ml of fragmented fascia grafts instead of fat grafts.

Multifragmented cartilage wrapped with fascia in augmentation rhinoplasty.

BACKGROUND: Dorsal nasal contour can be improved by using fragmented or crushed cartilage grafts wrapped with fascia in patients with dorsal nasal deformities. METHODS: The authors obtain cartilage from the ear concha that is fragmented or crushed. Fascia is harvested from the temporal region. Multifragmented cartilage is wrapped with deep temporal fascia, making a roll. After creating a cavity in the nasal dorsum, the bone is rasped and the combined roll graft is introduced, and appropriate modeling of the graft is mandatory. The authors have operated on 115 patients with this procedure, 68 primary operations and 47 secondary operations, over a 13-year period. RESULTS: In the great majority of cases, results were excellent. To avoid deviation of the roll graft, it is important to prepare a straight cavity. Especially in secondary cases, seroma is manifested by swelling and reddish skin color, which is removed with a 2-mm incision made with a no. 15 knife and constant pressure over the nose for some minutes. The authors have observed only five primary cases with seroma and 13 secondary cases. CONCLUSIONS: This procedure in the authors' hands has given magnificent aesthetic long-lasting results and a "natural appearing" outcome.

The universal serial bus endoscope: design and initial clinical experience.

Endoscopic forehead lift is a well-established procedure in aesthetic plastic surgery. Many agree that currently available video-endoscopic equipment is bulky, multipieced and sometimes cumbersome in the operating theater. A novel system, the Universal Serial Bus Endoscope (USBE) was designed to simplify and reduce the number of necessary equipment pieces in the endoscopic setup. The USBE is attached by a single cable to a Universal Serial Bus (USB) port of a laptop computer. A built-in miniaturized cold light source provides illumination. A built-in digital camera chip enables procedure recording. The real-time images and movies obtained with USBE are displayed on the computer's screen and recorded on the laptop's hard disk drive. In this study, 25 patients underwent endoscopic browlift using the USBE system to test its clinical usefulness, all with good results and without complications or need for revision. The USBE was found to be reliable and easier to use than current video-endoscope equipment. The operative time needed to complete the procedure by the authors was reduced approximately 50%. The design and main technical characteristics of the USBE are presented.

Brachioplasty.

The author presents his preferred brachioplasty procedure, describing how he varies treatment according to the patient's degree of upper arm flaccidity. In patients with mild flaccidity, short incisions are used, but patients with excessive flaccidity with adiposity are treated with lipoplasty and tissue removal involving a long incision to produce the best aesthetic contour.

Aesthetic facial contour augmentation with microlipofilling.

BACKGROUND: We have found that the use of microfat grafts can improve the contour of the face. OBJECTIVE: We describe our technique for facial contour augmentation using microlipofilling and present the results of 32 cases treated between 1995 and 2002. METHODS: We conducted a preoperative evaluation, including photographic and radiologic studies, to determine for which patients the procedure was appropriate and to identify the need for additional procedures. Fat was harvested with the use of 10-mL syringes with 14-gauge needles. Only 5 mL of fat was harvested in each syringe. After the donated fat was washed and fragmented, it was infiltrated by means of a percutaneous approach with 18- or 20-gauge needles to reduce trauma and avoid scarring. Thin (2-mm-wide) rolls of fat grafts were placed in well-vascularized tissues to prevent absorption. The amount of fat infiltrated depended on the flatness of the area. RESULTS: All patients had satisfactory outcomes after follow-up ranging from 1 to 5 years. Complications were rare. CONCLUSIONS: With appropriate placement, facial contour augmentation with microlipofilling is a safe, simple, inexpensive aesthetic procedure that provides consistent, long-term aesthetic improvement.