Surgical practices of cosmetic breast augmentation by implants among 411 French plastic surgeons.

INTRODUCTION: Breast augmentation is one of the most frequently performed cosmetic surgeries in the world. However, there is no standardized surgical procedure for performing breast augmentation. Many modalities exist for this surgery which may explain why practices vary greatly from one surgeon to another. The aim of this study was to evaluate current practices of breast augmentation by implant in France and changes in practices among French plastic surgeons. MATERIAL AND METHODS: This observational study was conducted between February 2020 and January 2021. An online questionnaire with 62 questions was sent to 729 French plastic surgeons. The questions concerned: the population of surgeons interviewed, pre-operative aspects, surgical technique and post-operative management. RESULTS: 411 plastic surgeons responded, 5.1% of surgeons impose a nicotine screening test on patients. 99.76% and 95.59% reported that they used silicone gel implants and round prostheses. All used smooth or micro-textured shells. The inframammary approach was the most used by 66.2% of plastic surgeons. The implants placed were between 250 and 300 cc on average and were mainly placed in "Dual plane" by 42% of surgeons. In order to reduce bacterial contamination, 26% of surgeons soaked the implants in a povidone-iodine solution and 23% used an insertion sleeve. The most frequent early complication was hematoma, while capsular contracture was a late complication. CONCLUSION: This study provides new data on current surgical practices of breast augmentation in France, allowing more informed choices and opening up perspectives for more standardized practices in the future.

[Upper lip lift]. / Lifting de la lèvre supérieure.

The author revisits an old technique of shortening of the upper lip. He shows the interest of systematically analyzing the length of the upper lip in any consultation of face and especially of rejuvenation. He develops indications based on the visibility of the upper incisors at the half-open mouth rest. He details the technique and shows results.

[Forehead rejuvenation]. / Le rajeunissement du front.

The goal of this article is to provide a systemic approach to forehead rejuvenation. Fillers, botulinic toxin injections, transpalpebral, endoscopic or bicoronal brow lift must be usual techniques for every plastic surgeon in overall facial rejuvenation. Achieving a long lasting and aesthetically pleasing forehead is possible only with surgical techniques when aging is obvious.

[The third dimension of the face aging, improvement of its understanding]. / La troisième dimension du vieillissement facial, une avancée dans la compréhension de la sénescence du visage.

OBJECTIVES: Over the past 30 years, surface imaging has made tremendous progress. Surgical management has also been subject of numerous technical and strategic developments. For a better understanding of the curative strategies of face aging, the authors have put into perspective the three-dimensional data acquired up to date. METHOD: A review of the literature focused on the three-dimensional study of facial aging was carried out. RESULTS: Thanks to the precision of new surface acquisition systems and larger patient cohorts, our understanding of surfaces and volumes is now much more accurate. 3D, particularly highlights the major impact of aging on the perioral area, which was up to now neglected compared to other facial areas. CONCLUSION: A technical discussion is needed to identify the best techniques to correct the defects and provide a natural result for those anatomical areas that are heavily impacted by aging but not corrected in the final.

[Face rejuvenation with tensor threads]. / Quelle est la place des fils tenseurs pour rajeunir le visage.

The last decades has seen new priorities in treatment of a flabby, ageing face towards minimally invasive aesthetic surgery, to be accompanied and followed by the requirements to perform such interventions with the maximally reduced health hazards, with inconsiderable injury, without cuts and, respectively, to be followed by no resulting scars, as well as a short postoperative period. We propose a new reviewing presentation of the tensor threads. After having explained the technology of the threads, we will discuss the good patient indication, the criteria which determine the choice of the threads and methods for each type of patient. There are many techniques, which we will present. Then, we will discuss the results, unsatisfactory outcomes obtained and complications encountered, as well as how to improve the cosmetic outcomes to be obtained. To conclude, we will propose a strategy for the long-term treatment of the neck and the face, preventing surgical management of the aging process.

The vertical midface lift. An improved procedure.

We describe a novel procedure for an anatomically-based face lift to correct vertical vectors in the ageing face. It has the advantage of surgical simplicity, minimal tissue removal and minimal risk. It provides an effective readjustment of cheek volume and correction of periorbital hollowness. Natural facial expression is preserved largely because there is no change in the position of the lateral canthus. The cheek is mobilised subperiosteally through a blepharoplasty incision. A second dissection is made via a short temporal incision, to join the infraorbital dissection. A Hagedorn needle is then inserted through a point inferior to the lateral canthus and in line horizontally with the nasal ala. It is passed to the orbital incision, charged with a loop of suture material, and pulled down again to the cheek incision, from where it is pushed back to the orbit to suspend the cheek. The upper border of orbicularis oculi is fixed firmly to the temporalis aponeurosis at the level of the temporal incision. We now frequently use an Endotine Midface device for fixation. Of the first 150 patients, results were excellent or good in 145. This represents a revival of the subperiosteal mask lift, and abandons the use of endoscopic techniques. In spite of its simplicity, the operation involves subperiosteal dissection as well as delicate eyelid surgery that necessitate plastic surgical skill.

[Approach to augmentation mammaplasty]. / Les voies d'abord et les plans de l'augmentation mammaire par prothèse.

The anatomy give a description of the fixation of breast ligaments, on submammary fold, on the vascularisation of the areola-nipple complex and the surgical consequence on sensibility. The innervation areola-nipple complex comes from the 4th lateral cutaneous branch. The sensitive troubles are frequent but compensed by the sensual gratification of the breast. Skin incisions have been analyticly study. Periareolar incision is less pratice than submammary or axillary incision. The concept of adequation parenchyma-implant is fondamental however the pocket is pre- or retropectoral.

[Endoscopic axillary breast augmentation]. / Augmentation mammaire endoscopique par voie axillaire.

Endoscopic axillary breast augmentation combine advantages against few inconvenients. The authors discribe the surgical endoscopic technique and the medical patient management. A study on 48 patients shows the efficiency on quick professional activity (3 days) thanks to the control of inflamatory syndrom with a quick procedure and perioperatoire treatment.

[Cutaneous incision in facelift. Oblique cervicomalar SMAS flap and malar facelift. Technical notes]. / Incision cutanée dans le lifting lambeau de SMAS cervico-malaire oblique et lifting malaire. Notes techniques.

The objectives of these incisions are: in the temporal region to preserve hair capital and to elevate the temporo-canthal region while keeping side burns in place--this "Z" type incision is particularly useful for mak life surgery--in the mastoïde region, to minimize common "step" in hairline and to have a good lift effect even in the back part of this short incision. The oblique SMAS flap begins 2 cm under the canthal region and finishes in the neck at the posterior border of the plastysma muscle. The posterior border of the flap is thus close and parallel to the medial folds of the face. The suture of this border after ascension of the flap ensures good results on these ageing folds. The subsmas dissection of the malar region allows lifting of the sliding malar fat pad. The submalar crease disappears and the nasolabial fold is improved.

[Subperiosteal face lift or "mask-lift"]. / Le lifting sous-périosté ou "Mask-lift".

The subperiosteal facelift is, as its name indicates, a deep technique essentially adapted to the upper two-thirds of the face. It is performed via a bicoronal incision, often associated with a vestibular incision, which allows frontal, maxillary, malar, zygomatic and orbital dissection. Section of the superficial leaflet of the temporal aponeurosis reveals the DMAS (Deep Musculo Aponeurotic System) which can be used to raise all of the soft tissues of the face while protecting the frontal branch of the facial nerve. Elevation of the tissues of the face is essentially vertical and acts on the forehead, temporal region, gaze and cheekbones. Current incisions allow maximal preservation of hair and avoid ascension of the sideburns. This technique is particularly indicated in relatively young subjects.

The subperiosteal lift.

The subperiosteal lift developed by Tessier is a technique for rejuvenating the face and emphasizing beauty. It is performed using two approaches: intraoral and bicoronal or precapillary. It entails a total subperiosteal undermining of the face beginning 2 cm over the orbits and continuing on the orbital rims, the zygomatic arches, and the malar bones. This allows total lifting of the soft tissues of the face (DMAS, deep musculo aponeurotic system). The lateral and vertical traction allows elevation of the superior two thirds of the face, eyebrows, and cheeks. Lifting pulls up from the forehead to the mandibular line. The fixation of the superficial layer of the temporal aponeurosis in traction to the upper part also has an effect on tissue elevation. The best candidates for this procedure are women in their late 30s or early 40s but can be used on those from 30 to 50 and more. It is highly specialized operation which requires substantial surgical experience both in selecting the patient and in execution.

[Orbicular myorraphy for correction of bags and wrinkles of the lower eyelids]. / Myorraphie de l'orbiculaire pour la correction des poches et des rides des paupières inférieures.

The lower eyelid consists of four planes. The deepest plane is the orbital fat, followed by the septum, orbicularis muscle and the skin. Pouches are classically treated by resection of the fat, i.e. reduction of the orbital contents De La Plazza proposed a new method by tightening the septum which retains the orbital fat posteriorly. This idea of preservation of the orbital fat led me to consider the third plane: the orbicularis muscle. By comparing orbicularis myorraphy with median myorraphy of abdominal plasties. I propose reinforcement of the orbicularis muscle to retain the orbital fat and to reduce the pouches without resection of the fat. The fourth plane, the skin, is classically draped over the muscular layer, but as the height of the muscle plane is reduced by this myorraphy, this skin will be less involved in smiling, which improves the wrinkles. As the skin is traditionally detached from the muscle, autoplication of the orbicularis muscle is performed, taking care not to modify the position of the free edge in order not to create muscular ectropion. This suture is composed of inverted 6/0 Dexon sutures. The advantages are preservation of the orbicularis fat which prevents loss of this fat and the risk of senile enophthalmia in the long-term. The indications are of three orders: a) pouches when they are not excessive; b) static wrinkles; c) dynamic wrinkles of smiling. A muscular roll must be avoided by a very careful suture technique. Orbicularis myorraphy appears to be a new contribution to the various therapeutic procedures proposed for aesthetic blepharoplasty and may improve some of the results.