Bolster Equalization Suture Technique (BEST) Neck: Optimization of Skin Redraping Following Necklift Surgery.

BACKGROUND: Skin laxity of the neck is a primary concern of patients seeking facial rejuvenation. Traditional methods for redraping neck skin have well-described shortcomings. OBJECTIVES: The aim of this study was to optimize skin redraping after necklift surgery while reducing risk, and the Bolster Equalization Suture Technique (BEST). METHODS: At the conclusion of the facelift and necklift, 3 external quilting sutures are placed with protective bolsters. The first suture is placed at the midline, advancing the skin posteriorly toward the hyoid and anchoring the skin to the platysma. The second and third are placed in the cervicomandibular groove over the sternocleidomastoid muscle, advancing the skin posteriorly. Complications such as skin necrosis, skin ischemia, dimpling, hypopigmentation, hyperpigmentation, and scarring were documented. A control group of 20 patients who underwent the same surgery without the BEST was compared to the next 20 patients in which the BEST was applied. Preoperative and postoperative photographs were blindly reviewed by 2 plastic surgeons. The photographs were analyzed for residual central neck skin laxity and cervicomental angle improvement and surveyed according to the pertinent sections of the FACE-Q. RESULTS: In necklift patients who received the BEST, cervicomental angle improvement and decreased central skin laxity were statistically significant. Patient perceived age on a visual analog scale was 2.5 years younger in the BEST group. CONCLUSIONS: The BEST is a safe and efficient method which can be used to improve cervical skin redraping and contour. The BEST creates a more defined cervicomental angle while reducing central skin neck laxity with minimal complications.

Pneumothorax as a Complication of Liposuction.

BACKGROUND: Pneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma. OBJECTIVES: This study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction. METHODS: In a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis. RESULTS: Among the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction. CONCLUSIONS: Possible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area.

Paradoxical adipose hyperplasia after noninvasive radiofrequency treatment: A novel report and review.

The past decade has experienced a surge in the frequency of nonsurgical procedures, including injectables, skin rejuvenation, and nonsurgical fat reduction. Nonsurgical fat reduction methods include cryolipolysis (Coolsculpting), ultrasound (Vaser Shape), laser (Liposonix), and radiofrequency (Vanquish). These methods generally produce good results, with cryolipolysis gaining much popularity over the past few years. Multiple reports of paradoxical adipose hyperplasia have been reported with Coolsculpting, with an incidence of 0.025% to 1%. This entity has never been reported with other methods of nonsurgical fat reduction, including noninvasive radiofrequency (Vanquish). We present a case of paradoxical adipose hyperplasia in a 57-year-old male following treatment with noninvasive radiofrequency (Vanquish) to the abdomen. He was treated with power-assisted liposuction to the abdomen and flanks. This is the first case in the literature of paradoxical adipose hyperplasia in a patient treated with this form of noninvasive fat reduction.

Abdominal Etching: Past and Present.

Since its inception in the 1980s, liposuction has undergone a tremendous paradigm shift from the simple removal of excess subcutaneous fat to a procedure of extreme sophistication and elegance where we as surgeons are able to mold and shape a patient's figure. Plastic surgeons have modified this procedure with the overall goal of improving the aesthetic results while focusing on maximizing safety and minimizing complications. These modifications include advanced liposuction technology and techniques, the increasing use of subdermal superficial liposuction, differential liposuction, the advent and introduction of a wide range of cannulas, and the use of fat grafting simultaneously with liposuction for targeted contour and fat repositioning. In this article, the authors discuss in detail the introduction and progression of abdominal etching, a procedure first introduced by the senior author (H.A.M.) in the early 1990s. The authors also present their experience over the past 4 years. In this procedure, the technique of differential liposuction is employed to enhance the detail of abdominal musculature. The literature on abdominal etching is fairly scarce. Thus, the authors hope that this review will not only give the provider a thorough review and understanding of liposuction and its evolution over the years but will also provide an overview of the indications, patient selection, technique, expectations, and complications of abdominal etching as well.

Safest Practices for Autologous Buttock Augmentation With Fat Grafting Using a Roller Pump Injection Technique.

BACKGROUND: Autologous buttock augmentation with fat grafting has emerged as one of the preeminent modalities for body contouring employed by plastic surgeons today. Since 2009, we have used the roller pump injection technique. OBJECTIVES: This procedure can be performed safely without specialized equipment and eliminates the tasks of manual graft preparation and injection. We describe our technique and standard safety measures. The anatomy of and complications associated with liposuction and fat grafting were recorded and reviewed. METHODS: Retrospective chart review of 916 patients who underwent autologous buttock augmentation by this method from February 2009 to November 2016 was performed. All procedures were performed under general anesthesia at the same surgical center. Liposuction was performed and using a roller pump, the fat layer was propelled through an open-ended cannula into the recipient site. RESULTS: Mean volume of fat removed and fat grafted in each patient was 3156 mL and 1807 mL per patient, respectively. There were complications in 13 patients for a rate of 1.4% with 10 (1.1%) related to fat grafting. Fourteen patients (1.5%) had subsequent procedures for volume and four patients (0.44%) for asymmetry. There were no venous thrombolic events, fat embolic events, or deaths. CONCLUSIONS: The roller pump injection technique for buttock augmentation with fat grafting is safe and efficient. This technique minimizes preparatory effort and does not require additional equipment. We were unable to identify variables associated with complication risk due to the power of this study and the low percentage of complications.

Safety and Efficacy of Novel Oral Anticoagulants vs Low Molecular Weight Heparin for Thromboprophylaxis in Large-Volume Liposuction and Body Contouring Procedures.

BACKGROUND: Preventing venous thromboembolism (VTE) remains an important topic in the plastic surgery community. However, there is little consensus regarding appropriate VTE prophylaxis for patients undergoing common body contouring procedures. OBJECTIVES: This study compared the use of two novel oral anticoagulants (Rivaroxaban and Apixiban) vs low molecular weight heparin (LMWH) for postoperative chemical prophylaxis in body contouring plastic surgery procedures. METHODS: A single center retrospective chart review of 1572 patients who underwent body contouring plastic surgery procedures from January 2012 to February 2015 was performed. Major complications associated with chemical prophylaxis were reviewed including hematomas requiring surgical evacuation, acute blood loss anemia requiring transfusions, and thrombotic or hemorrhagic events. RESULTS: Drug-related adverse events occurred in 1.27% (n = 20) of patients. The complications encountered by the 454 patients on LMWH consisted of 0.88% (n = 4) with hematomas requiring surgical evacuation, 0.44% (n = 2) with decreased hemoglobin requiring transfusions, and 0.22% (n = 1) with a deep vein thrombosis (DVT). The complications encountered by 703 patients on with Rivaroxaban consisted of 1.3% (n = 9) with hematomas requiring surgical evacuation, 0.43% (n = 3) with decreased hemoglobin requiring transfusions, and 0.1% (n = 1) with a DVT and pulmonary embolism. The complications encountered by 415 patients on with Apixaban consisted of 0.48% (n = 2) with a DVT. CONCLUSIONS: Novel oral anticoagulants (Rivaroxaban and Apixiban) are comparable to LMWH for chemical prophylaxis after body contouring procedures with similar rates of drug-related complications. Further investigation is warranted with more clinical cases in order to recommend the use of this medication for routine postoperative chemical prophylaxis after body contouring procedures. LEVEL OF EVIDENCE: 3 Therapeutic.

The Delay Fill Technique: A Safer Approach to Combination Augmentation Mastopexy.

Combining breast augmentation with mastopexy is a challenging procedure that has a relatively high revision rate in the literature. Some surgeons prefer a two-stage procedure to avoid the potential for skin flap or nipple-areolar complex necrosis that can occur with a one-stage procedure. The authors compared 101 patients who had subpectoral breast augmentation with immediate implant fill and mastopexy with 203 patients who had subpectoral breast augmentation with delayed (10-14 days) implant fill and mastopexy. They found the revision rate for immediate implant fill was 24%; in the delayed implant fill group, the revision rate was 10.3%. Patients had soft tissue-related complications in 16% of the immediate fill group and in 2% of the delayed fill group. Delaying implant fill in combined breast augmentation mastopexy significantly reduces the risk of soft tissue-related complications and revision procedures; the delay flap phenomenon is responsible for fewer wound-healing complications when implant fill is delayed during a combined augmentation mastopexy procedure.

Use of abdominal field block injections with liposomal bupivicaine to control postoperative pain after abdominoplasty.

BACKGROUND: It is well known that improving postoperative pain control in plastic surgery procedures leads to earlier mobilization, shortened hospital stay, reduced hospital costs, and increased patient satisfaction. OBJECTIVE: The authors evaluate the use of abdominal field block injections with liposomal bupivicaine (Exparel; Pacira Pharmaceuticals, Inc, San Diego, California) in postoperative pain management in patients undergoing abdominoplasty with rectus plication. METHODS: Case records from 64 female patients who underwent abdominoplasty with rectus plication were reviewed. We performed a total of 118 abdominoplasties with rectus plication, alone or in combination with other surgical procedures, from August 2012 to December 2012, but 54 patients were excluded from the series due to inadequate follow-up. Patients received liposomal bupivicaine injections in an abdominal field block fashion. Patient age, height, weight, and smoking status were recorded. Delivery of standardized postoperative intramuscular or intravenous injections and oral pain pills was recorded. Postoperative data and questionnaires were used to evaluate clinical efficacy. RESULTS: The average number of procedures (including abdominoplasty with rectus plication) per patient was 7. Average patient body mass index was 27 kg/m(2). Average pain scores were 3.5 (postoperative visit 1) and 2.8 (visit 2). The average number of oral pain pills required was 14 at the first postoperative visit and 11.5 at the second postoperative visit. Patients were able to resume normal activity at an average of 6.4 days. CONCLUSIONS: Our experience with liposomal bupivicaine injections for regional blocks in abdominoplasty with rectus plication indicates that patients experienced reduced postoperative pain, required less postoperative narcotic medication, and resumed both earlier ambulation and normal activity. Further investigation is warranted with more clinical cases to recommend the use of this medication for routine pain management after an abdominoplasty.

Thromboembolism in high-risk aesthetic surgery: experience with 17 patients in a review of 3871 consecutive cases.

BACKGROUND: Pulmonary embolism (PE) represents the third most frequent cause of postoperative death in the United States. In recent years, there has been an increasing demand among plastic surgeons for patient safety guidelines that specifically address the complications of deep venous thrombosis (DVT) and PE in relation to aesthetic surgery. OBJECTIVE: In this study, we review 3871 consecutive major body contouring procedures performed over the last 8 years in our surgery center in an attempt to identify common factors that could have contributed to the onset of DVT/PE in 17 of these patients. METHODS: We conducted a retrospective chart review to identify common factors associated with the occurrence of DVT/PE in high risk patients who undergo aesthetic surgery. RESULTS: Among these patients, we calculated the following incidence rates: 0.46% for DVT and 0.08% for PE. We discovered that a culmination of factors working synergistically play a significant role in the development of DVT/PE. CONCLUSIONS: We conclude that a carefully planned, comprehensive, appropriately enforced protocol is necessary to reduce the rate of thromboembolic events. Practical safety measures and technical recommendations are presented that strongly encourage the use of thromboprophylaxis during the pre-, intra-, and postoperative phases of aesthetic surgical procedures. We feel that DVT and PE prevention should involve a partnership between patient and surgeon.

Correction of gynecomastia through a single puncture incision.

In men, the development of feminized breasts may cause significant emotional distress and embarrassment, particularly in young men and adolescents. Unfortunately, gynecomastia responds poorly to diet and exercise, and conventional corrective surgery may produce large stigmatizing areolar or chest scars and a flattened or concave chest. In 2004, board-certified plastic surgeons performed 16,275 corrective procedures, and in 2005 there was a 17% increase, according to The American Society of Plastic Surgeons (ASPS) procedural statistics. This report describes a surgical approach for removal of both glandular and adipose tissue using a small 3-mm areolar stab wound incision and a piecemeal glandular resection to correct gynecomastia with minimal and imperceptible external scarring. Pectoral etching of the chest and suction lipectomy are performed simultaneously to enhance and define the thoracic musculature and further virilize the upper thorax. Excellent results have been obtained with minimal complications. The authors present their experience with more than 200 consecutive cases over the past 4 years. They are very optimistic with these results because they have obtained a high degree of patient satisfaction.

A retrospective study on the use of a low-molecular-weight heparin for thromboembolism prophylaxis in large-volume liposuction and body contouring procedures.

This retrospective study was designed to evaluate the efficacy of low-molecular-weight heparin (enoxeparin) as a prophylaxis for venous thromboembolism and deep venous thrombosis (DVT) in the management of large-volume liposuction, added body-contouring procedures, or both. The author present an 18-month experience with the use of this therapy for 291 consecutive patients. All the patients fell into the categories of high risk and highest risk for the development of deep vein thrombosis, embolism, or both. Three patients experienced transient DVT-like symptoms and underwent a thorough workup by an independent highly specialized critical care medical team. The results were found ultimately to be inconclusive for DVT and pulmonary embolism. However, all the patients experienced a complete recovery. The results show a 0% incidence of DVT and pulmonary embolism among patients who received enoxeparin as prophylaxis. The medication did not precipitate major bleeding when administered 1 h after surgery. This study offers the first report that describes the use of enoxeparin in aesthetic surgery for high-risk patients. The authors feel the need to inform their colleagues of the benefits obtained over the past 18 months by incorporating this therapy in large-volume liposuction and extensive body-contouring procedures performed during the same operative session. This study was conducted by a highly experienced surgical team in a fully accredited outpatient facility with established protocols for handling these types of procedures on a daily basis. The authors are optimistic about the results, and the use of enoxeparin is now part of their postoperative regimen in high-risk aesthetic surgery cases.

Facelift: measurement of superficial muscular aponeurotic system advancement with and without zygomaticus major muscle release.

Multiple authors have sought ways to improve nasolabial folds, jowls, and jaw lines with face-lifting procedures. The retaining ligaments of the face support facial soft tissue in the normal anatomic position. However, with age, gravitational changes occur, and fat descends into the plane between the superficial and deep facial fascia. Face-lift procedures are designed to lift these sagging tissues. To date, the authors have not found a study that quantifies the amount of vertical advancement gain when a face-lift operation is performed with elevation of the superficial muscular aponeurotic system (SMAS). The movement was studied in 22 rhytidectomy SMAS flaps, and measurements of the vertical advancement were compared using two different SMAS patterns. Elevation and fixation of the SMAS was accomplished under the same conditions, and by the same surgeon. A high SMAS elevation was performed after skin and retaining ligaments were released. Precise measurements were obtained at the medial and lateral edges of the SMAS and before and after a backcut release from the zygomaticus major muscle. The results demonstrated an average improvement in medial flap shift gain of 14.04 mm after the release. There were no complications from these measurements during a 16-month follow-up period. The authors believe this is a particularly interesting finding because it demonstrates and quantifies an increased medial SMAS advancement shift with this maneuver, and therefore improves the cosmetic appearance of the jowls and the midface. Excellent aesthetic results were obtained with a high level of patient satisfaction.

Use of a regional infusion pump to control postoperative pain after an abdominoplasty.

This study presents the clinical results for 20 patients who underwent abdominoplasty. A subset of these patients were given a pain relief system that provides continuous infusion of a nonnarcotic medication directly into the surgical wound to reduce postoperative pain. Whereas patients received a pain pump in addition to standard oral/intramuscular pain medication, 10 patients received only the standard oral and intramuscular postoperative pain medications. All 20 patients then were asked to complete an evaluation of their postoperative discomfort and pain. The findings show a significant reduction in postoperative pain with the use of the ambulatory pain pump. The simplicity of installing and running the pump and the benefits obtained, including early ambulation and less pain as well as reduced need and strength of narcotic medications lead the authors to believe that the implementation of this pain control technology soon will become widespread in their specialty. The study indicates that patients require less sedation and get out of bed sooner with this device, thereby reducing the incidence of deep venous thrombosis, pulmonary emboli, and narcotic-dependency.