SPA face lift: SMAS plication-anchoring.

A variation of the superficial musculoaponeurotic system (SMAS) plication called SPA face lift is here described. An axial line and then two medial and lateral parallel lines are penciled on the skin from the lateral canthus to the earlobe to show the future plication area. The undermining zone is delimited 1 cm beyond the medial line. In face- and neck-lifting, such marks extend vertically to the neck. Once the skin is undermined up to the delimiting marks, the three lines are penciled again on the fat layer, and a running lock suture is used for plication, with big superficial bites between the two distal lines. In fatty faces, a strip of fat is removed along the axial line to avoid bulging that can be seen through the skin. Because the undermining is limited, minor swelling occurs, and the postoperative recovery is shorter and faster. The same three lines can be marked in the contralateral side or can differ in cases of asymmetry. This report describes 244 face-lifts without any facial nerve problems. The author managed five hematoma cases in which surgery to the neck was performed. Three patients had to be touched up for insufficient skin tension. The SPA technique is consistent and easy to learn.

Internal lateral nasal osteotomy: double-guarded osteotome and mucosa tearing.

For the internal lateral nasal osteotomy, a 4-mm double-guarded straight osteotome that separates the external periost and mucoperiosteum while the osteotomy is progressing is presented. Before the osteotomy, the external periost and the internal mucoperiosteum are infiltrated with local anesthesia and elevated by tunneling with an elevator. As the sharp part is behind the guards, it is not possible for the osteotome to slip away laterally or medially from the nasal bone. By tunneling just at the base of the nasal bones, arteries, veins, and lymphatics are preserved while the superior part of the external periosteum and the internal mucoperichondrium maintained the bones in a stable position with firm support to both sides. Forty consecutive rhinoplasties were studied with an endoscope. In 35 primary rhinoplasties the mucosa laceration rate was 1.5%, whereas in secondary rhinoplasties it was 80%. The approach to the piriform aperture was intranasal in the first 16 cases and intraoral in the last 24 cases. The intraoral mucosal elevation and osteotomy were easier to carry out than in the intranasal approach. In general, minor lower-lid edema and ecchymosis were observed, possibly related to the fact that the periosteum was elevated, thus preserving the supraperiosteal arteries, veins, and lymphatics. When the mucosa was elevated, the internal irrigation of the mucosa and the lymphatics was also preserved, thus avoiding intraoperative bleeding, intranasal packing, and postoperative bleeding.

Breast enlargement after two reduction mastoplasties: a case report.

In 1989, a bilateral breast reduction was performed for a large-breasted woman. She returned 1 year later with bilateral breast enlargement as severe as in the original case. The operation was repeated but in a more aggressive way. She became pregnant 2 years later, and both her small breasts began to grow again until they became gigantic. Hormonal tests showed results within the standard limits, and no medical treatment was effective. After the delivery, her breasts reduced in size spontaneously.

Transaxillary breast augmentation: two breast cancer patients with successful sentinel lymph node diagnosis.

In recent years, some surgeons have been warned of possible problems with sentinel lymph node diagnosis (SLND) for patients who have undergone transaxillary breast augmentation (TBA), although no scientific studies support this warning. The authors report two additional cases of breast cancer in which the SLND was successfully performed for patients with previous TBA. The surgical anatomy of the axilla, the groups of lymph nodes, and a personal way of performing TBA are described. Five other reports concerning the same issue are thoroughly discussed. Four of these are clinical in vivo reports, and one is a cadaver study. The four in vivo studies and what we are reporting now clearly demonstrate that what was said regarding possible problems in the SLND after TBA was not founded on clinical research and contradicts these five clinical findings.

Periareolar mastopexy and augmentation.

The author performs periareolar mastopexy only in cases requiring correction of moderate ptosis and skin redundancy. The size and shape of the implant to be used and the surgical plan are both decided at consultation. The author prefers high-textured cohesive silicone gel-filled implants placed in the subpectoral position. To facilitate the surgical procedure, the author administers profuse local anesthesia and leaves compresses in the dissected pocket. The use of a cinching running suture helps to obtain a good-quality periareolar scar with minimal wrinkling. These techniques can reduce the incidence of complications and minimize the need for surgical revision.

Circumvertical reduction mastoplasty: new considerations.

The circumvertical technique is a mixture of the periareolar and the vertical techniques in which the skin resection is performed around the areola and is continued in an inverted cone that starts at the infraareolar area and ends 2-4 cm above the submammary crease. Some advantages of this technique are: The glands are removed from the inferior glandular quadrant and from the inferior borders of the lateral and medial quadrants. The areola is moved upward and attached to the gland, preserving the nursing function. There is a harmonious distribution of the pleats around the areola and at the vertical wound. The vertical suture never crosses the submammary crease. The postoperative result is acceptable. Local anesthesia with vasoconstrictor is used minimizing bleeding. Bupivacaine is also included, prolonging the anesthetic effect hours after surgery. This paper describes this simple and rapid surgery and discusses some new, previously unpublished considerations and tricks.

Circumvertical reduction mammaplasty.

The main indication of the circumvertical technique is the removal of 400-1000 mg of breast tissue. It is also an intermediate method and an alternative between the periareolar and the vertical techniques. The advantages of the circumvertical technique is that it is simple and fast to accomplish, only the inferior half of the gland is operated, there is no transection of the lactiferous ducts, at the end of the surgery there is an harmonious redistribution of the pleats, the vertical scar never crosses the submammary fold, and at the end of the surgery an acceptable result is almost always observed. The posterior skin retraction will improve this initial result even more. The Marcaine infiltration allows some hours of postoperative pain relief. In brief, this technique is ideal for young women because it neither distorts the remnant anatomy nor alters the future lactation, being a good alternative to moderate and large hypertrophies.

Face lift postoperative recovery.

The purpose of this paper is to describe what I have studied and experienced, mainly regarding the control and prediction of the postoperative edema; how to achieve an agreeable recovery and give positive support to the patient, who in turn will receive pleasant sensations that neutralize the negative consequences of the surgery.After the skin is lifted, the drainage flow to the flaps is reversed abruptly toward the medial part of the face, where the flap bases are located. The thickness and extension of the flap determines the magnitude of the post-op edema, which is also augmented by medial surgeries (blepharo, rhino) whose trauma obstruct their natural drainage, increasing the congestion and edema. To study the lymphatic drainage, the day before an extended face lift (FL) a woman was infiltrated in the cheek skin with lynfofast (solution of tecmesio) and the absorption was observed by gamma camera. Seven days after the FL she underwent the same study; we observed no absorption by the lymphatic, concluding that a week after surgery, the lymphatic network was still damaged. To study the venous return during surgery, a fine catheter was introduced into the external jugular vein up to the mandibular border to measure the peripheral pressure. Following platysma plication the pressure rose, and again after a simple bandage, but with an elastic bandage it increased even further, diminishing considerably when it was released. Hence, platysma plication and the elastic bandage on the neck augment the venous congestion of the face. There are diseases that produce and can prolong the surgical edema: cardiac, hepatic, and renal insufficiencies, hypothyroidism, malnutrition, etc. According to these factors, the post-op edema can be predicted, the surgeon can choose between a wide dissection or a medial surgery, depending on the social or employment compromises the patient has, or the patient must accept a prolonged recovery if a complex surgery is necessary. Operative measures which prevent extensive edemas are: avoiding transection of the temporal pedicle, or to realizing platysma plication too tight by using strong aspirative drainage instead of elastic bandages. In the post-op, the manual lymphatic drainage is initiated on the third or fifth day, but must be done by a trained professional, in a method contrary to that specified in the books for non-operated individuals. An aesthetician washes the hair and applies decongestive cold tea on the face the second day, and on the fifth, moisturizes the skin and cosmetically conceals any signs of bruising. The psychological support provided by the staff keeps the patient calm and relaxed. Five years experience with this protocol has enabled us to minimize post-op pain. The edema can be predicted with certain consistency (in which surgery there will be more or less edema) and the proper technique can be selected, permitting the patient to choose the best moment for a FL while the surgeon can avoid intra and postoperative measures that increase the edema. After surgery, the patient receives the daily assistance of the staff, which rapidly and efficiently improves this condition. We can predict and control the post-op recovery and the patient feels fine, unlike the past when recovery was abandoned to its natural evolution. If the patient perceived an intensive, positive support on behalf of the entire staff that kept him or her content, then we have succeeded in doing an excellent marketing. This may encourage others to undergo aesthetic surgery, especially those who are convinced that after surgery they might have to endure considerable suffering.

Chin augmentation with nasal osteocartilaginous graft.

The use of the nasal hump removed during rhinoplasty was described by Aufricht in 1934 and 1958. In the past 10 years, the author has been using a similar technique but with significant variations. Before beginning the rhinoplasty surgery, the author dissects, through a submental incision, a subperiosteal mental pocket. Then, the osteocartilaginous nasal hump is removed; once the mucoperiosteum/mucoperichondrium is meticulously dissected, the nasal hump is tailored to achieve a mental form and the removed alar cartilage, nasal spine, or septal cartilage is used to fill or supplement the concavities of the hump. This report includes a total of 36 cases, 10 of which were controlled after 3 to 8 years of implantation by tridimensional computed tomography, from which the author observed an osteointegration with the mandibular bone and no reabsorption of the grafts or alteration of the structure of this bone. The patients revealed a high degree of satisfaction, and during the clinical examination, the author could not observe or palpate any distortion of the shape or projection of the chin. None of the grafts needed review or removal. This simple, fast procedure is a very good alternative for patients with some form of microgenia or when patients and surgeons are not likely to use alloplastic implants.