Evolution of lower lid support following lower lid/midface rejuvenation: the pretarsal orbicularis lateral canthopexy.

An 18-month experience with an endoscopically assisted "closed" technique of modified transblepharoplasty lower lid and midface rejuvenation is presented. In the modified approach, preseptal dissection in the body of the lower lid is eliminated to decrease the incidence of septal scarring and lower lid retraction. The technique also leaves intact the connection between the orbicularis and septum, resulting in tightening of the septum and better support of lid with redraping of the muscle. By providing more secure support of the lower lid and lateral canthus, the need for direct canthal manipulation has been reduced significantly. This experience confirms, however, that an occasional patient with significant exophthalmus occasionally might need additional lower lid support (spacer graft or more direct lateral tendon fixation) to obtain ideal lower lid position. Conversely, an occasional older patient with relative enophthalmus and horizontal lower lid laxity will be best served by canthoplasty with correction of excess laxity. So far, the quality of aesthetic results compared with the "open" approach has not been compromised, and morbidity seems to have been decreased.

The polyurethane-covered mammary prosthesis: facts and fiction (II): a look back and a "peek" ahead.

The senior author believes that there is a niche for polyurethane-covered devices in the new millennium if they in fact become available. During the span of this author's practice, he has never been able to match the number and quality of superior results exemplified by these patients when using other devices. Women seeking reconstruction after mastectomy or aesthetic improvement will be well served if the polyurethane-covered device once again becomes one of the choices of mammary prostheses available to them, in this author's opinion.

Complications in breast augmentation: prevention and correction.

The decision-making process for breast augmentation begins at the initial consultation. Most complications can be avoided with careful planning and decision making. Primary augmentation demands a careful evaluation of the breast morphology and chest wall anatomy. Perioperative techniques such as precise dissection of the pectoralis muscle under direct vision can ensure an adequate pocket, which minimizes the risk for capsular contracture and implant malposition. Secondary breast augmentation for problems such as thinning of the breast skin envelope, long-term pressure atrophy of existing parenchyma, and visibility of the implant can be minimized with appropriate selection of implant type, size, and placement. Patients should understand clearly the immediate and long-term risks associated with breast augmentation and the requirement for future reoperation.

Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Redraping the inferior orbicularis arc.

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.

Measurement of 2,4-toluenediamine in urine and serum samples from women with Même or Replicon breast implants.

The objective of this matched case-control study was to determine whether women with Même or Replicon polyurethane-covered silicone breast implants are exposed to clinically significant levels of free 2,4-TDA from biodegradation of the polyurethane foam. Urine and serum samples were obtained from 61 patients with Même or Replicon breast implants and 61 controls on two separate occasions separated by 10 +/- 3 days. Free TDA was analyzed by gas chromatography combined with negative chemical ionization mass spectrometry with lower limit of quantitation in both urine and serum of 10 pg/ml. The results were correlated with the length of time since implantation. No patients or controls had detectable free 2,4-TDA in their sera. Thirty patients had quantifiable levels of free 2,4-TDA, and 18 had detectable levels in their urine. Controls had no quantifiable levels, but 7 subjects had detectable levels. The biodegradative half-life of the polyurethane foam was estimated to be 2 years. A risk assessment using the cancer potency estimate calculated by the FDA from rat data and the National Academy of Sciences methodology provided a theoretical lifetime risk of approximately one in one million. It was concluded that the polyurethane foam cover on the Même and Replicon breast implants biodegrades. The risk assessment of approximately one in one million derived from this study strengthens earlier conclusions by the Health Protection Branch (Canada) that there is no significant risk of cancer from exposure to the 2,4-TDA formed from this biodegradation.

TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients.

This study examines the vascular anatomy of the TRAM flap and evaluates risk factors associated with complications among 556 women who had TRAM flap breast reconstruction. Fifty-nine patients (10.6 percent) developed fat necrosis involving 10 percent or more of their breast. Risk factors associated with fat necrosis were a history of chest-wall irradiation (p = 0.001), significant abdominal scar (p < 0.01), and obesity (p < 0.02). Among unipedicle reconstructions, patients with multiple risk factors had three times the incidence of fat necrosis (24.7 versus 8.3 percent) compared with patients with one or no risk factors (p < 0.002). Patients with multiple risk factors who had bipedicled TRAM flap reconstruction had no associated increased incidence of fat necrosis (p > 0.18). Forty-nine patients (8.8 percent) developed abdominal hernias. Risk factors associated with hernia formation included smoking at the time of surgery (p = 0.00001) and abdominal-wall repair with interposed mesh (p < 0.00001). The overall complication rate for this series was 23.7 percent (132 of 556). Risk factors associated with any complication included smoking (p < 0.002), history of chest-wall irradiation (p < 0.002), significant abdominal scar (p < 0.005), and obesity (p < 0.02). Patient selection is a fundamental determinant of successful TRAM flap breast reconstruction. Among patients with multiple risk factors, the risk of tissue loss in the reconstructed breast may be diminished by use of a bipedicled TRAM flap.

MR detection of leakage from silicone breast implants: value of a silicone-selective pulse sequence.

OBJECTIVE: The purpose of this study was to determine the value of MR imaging with a silicone-selective pulse sequence for detecting leakage from silicone breast implants. SUBJECTS AND METHODS: Women with silicone breast implants were referred for this study on the basis of clinical or imaging findings suggestive of implant rupture. Twenty-eight patients with 38 implants were examined with silicone-selective MR imaging and also underwent surgical removal of the studied implant. All but four also had mammography before MR imaging. Results of silicone-selective MR imaging for the detection of silicone leakage were compared with mammographic and surgical findings. Surgical proof was considered the gold standard. RESULTS: Silicone-selective MR imaging showed an apparently intact implant in 21 cases; 20 of these were found to be intact at surgery. Silicone-selective MR imaging showed evidence of leakage in 17 implants, all of which showed leakage at surgery. The sensitivity for detection of leakage was 94%; the specificity was 100%. The findings of silicone-selective MR imaging and mammography were in agreement in 30 of 34 cases in which both studies were performed. In the four cases of disagreement, surgical findings agreed with MR findings in three and with mammographic findings in one. When the findings of mammography and silicone-selective MR imaging were combined, the correct status (leakage or no leakage) of all implants examined was determinable. CONCLUSION: Silicone-selective MR imaging is highly effective for detecting leakage from silicone breast implants. Accuracy is improved when mammographic and MR findings are considered together.

The "split" gluteus maximus musculocutaneous flap.

The "split" gluteus musculocutaneous flap is a useful flap for perineal and ischial reconstruction. The flap uses the superficial 1 to 2 cm of the gluteus muscle, supplied by proximal parasacral perforators. It can be raised simply, quickly, and with minimal blood loss. Importantly, the deep muscle is left in place and remains innervated and well-vascularized. Deep structures are protected, and other flap options are preserved. Anatomic findings based on 16 cadaver dissections (8 cadavers with bilateral dissections) are presented. Representative case reports and our experience with 18 consecutive cases in 17 patients are presented.

Sternal resection and reconstruction.

Twenty-one patients underwent sternal resection and reconstruction. Surgical indications included sternal infection in 9 patients, recurrent breast cancer in 6, metastatic carcinoma from an unknown primary in 2, pectus excavatum in 2, and osteogenic sarcoma and eosinophilic granuloma in 1 each. Management included partial sternectomy in 10 patients (group 1) and complete sternectomy in 11 (group 2). Chest wall reconstruction was by various flaps and mesh repairs. Blood transfusions averaged 2 units in group 1 versus 5.5 units in group 2 (p = 0.02). Average number of days until extubation was 2.6 in group 1 versus 7.3 in group 2 (p = 0.04). Average number of intensive care unit days was 4.4 for group 1 versus 9.4 for group 2 (p = 0.03). The number of days until discharge was 14 days for group 1 versus 20 days for group 2. Complications occurred in 40% of group 1 and 82% of group 2 patients. Overall mortality was 9.5%. Sternal resection and reconstruction, particularly complete sternal resections, are a major undertaking with substantial morbidity. Using a multidisciplinary approach (cardiothoracic, plastic and reconstructive, critical care medicine, and infectious disease) and aggressive pulmonary support, acceptable cosmetic and functional results are possible.

Use of stacked polyurethane-covered mammary implants in aesthetic and reconstructive breast surgery.

The use of stacked polyurethane-covered mammary implants has proven useful in improving results in the correction of deficiencies of mammary form and projection that can occur in certain cases of congenital and acquired breast deformity. The method has been used in 57 patients (102 breasts). The rate of significant complications, including seroma, rash, infection, hematoma, and capsular contracture, has been low (1 to 6 percent). Polyurethane-covered implants will maintain their position when used in a stacked system because of their unique biophysical characteristics, which include tissue bonding and a high friction coefficient between the implant surfaces.

Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps.

Our experience treating perineal wounds secondary to abdominoperineal resection, either for inflammatory bowel disease or cancer, is presented. A total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection. All wounds were closed using the inferior gluteal myocutaneous flap. Fifteen of 16 patients have achieved healing, eight of whom had no complications. Only minor revisions or local wound care were required in the remaining patients, with only one patient failing to heal. Our results compare favorably with previous reports of treatment of this difficult problem.

Jejunal free autograft: analysis of complications and their resolution.

Review of 101 patients who underwent 111 free jejunal autografts has demonstrated an absolute procedural failure rate of 13.5 percent. Salvage reconstruction with a second jejunum was successful in six of nine patients and one third-time jejunum was successful, giving an overall salvage rate of 70 percent. There were 33 patients experiencing pharyngocutaneous fistulas, 20 of whom had been previously irradiated. Of these patients, 15 experienced spontaneous closure and 9 others had successful surgical correction. The mortality rate was 5 percent. Eighty-three percent of patients were restored to adequate per oral alimentation. The jejunum, despite its relatively high complication rate, is an excellent method for pharyngoesophageal reconstruction, expeditiously providing return to function for patients with late-stage disease.

Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases.

Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.

Abdominoplasty combined with other major surgical procedures: safe or sorry?

The clinical records of 563 patients undergoing either abdominoplasty alone or in combination with other major surgical procedures were reviewed in order to determine the relative safety of combined procedures. One-hundred-seventeen patients had abdominoplasty alone; 230 had abdominoplasty with either an intraabdominal or major pelvic procedure with or without an additional major aesthetic procedure; 216 had abdominoplasty with one or more major aesthetic procedures (without intraabdominal or pelvic procedures). The rates of occurrence of major complications, including death, pulmonary embolus, and infection, among the three groups were examined. Also examined were morbidity factors such as length of hospital stay and the need for blood transfusion. In this study, the only risk factor identified in predicting major morbidity, specifically the occurrence of pulmonary embolus, was obesity, not the complexity of the surgical procedure.

A 5-year experience with polyurethane-covered mammary prostheses for treatment of capsular contracture, primary augmentation mammoplasty, and breast reconstruction.

This paper reviews a 5-year experience using polyurethane-covered mammary prostheses in the treatment of capsular contracture following placement of smooth-walled devices, primary augmentation mammoplasty, and breast reconstruction after mastectomy. The rate of occurrence of clinically significant capsular contracture has been reduced in all patient groups. Results in terms of aesthetic and functional improvement have been excellent. Major complications have been rare.

Central breast pedicle and "free-hand" technique for alteration of volume and skin envelope of the breast.

We have found the central pedicle, free-hand technique applicable across the spectrum of surgical endeavors that seek to alter breast volume and revise the skin envelope for aesthetic and functional improvement. The rate of occurrence of significant complications has been low. The primary advantages of this approach are that (1) excellent pedicle vascularity has virtually eliminated the need for free nipple-areolar grafting in major reductions and correction of severe ptosis, and (2) in addition to its application in a wide variety of standard breast pathology, the technique allows individualization of volume change and skin brassiere alteration, which has significantly improved aesthetic results in more difficult cases such as the severe asymmetries presented.