Circumareolar dermo-glandular plication: a new concept for correction of breast ptosis.

Circumareolar dermo-glandular plication is the latest advancement of the periareolar dermopexy with a retromammary mastopexy technique I published in 1969. Rather than a technique, the new concept is a procedure which originates new techniques covering multiple indications, i.e. for all conditions combined with ptosis: for mastopexy in ptotic breasts, for hypertrophic or hypoplastic breasts with resection or implant augmentation, respectively; for subcutaneous mastectomy, gynecomastia, asymmetries, and tuberous breasts. It is useful for reoperations to correct secondary ptosis as well as to reduce the length of the scar in vertical techniques. The corresponding techniques are described. The procedure has proved to be safe and reliable in over 200 patients with the following advantages: no full thickness skin incision or excisions are performed; only the epidermis is excised. Except for hypertrophies, the skin is not dissected from the gland, nor the gland from the pectoralis fascia, which increases vascular safety and preserves NAC innervation; the dermoglandular unit of the breast through Cooper's ligaments is stabilized by a single or multiple plications. The scar is only circumareolar, reducing psychological stress and discomfort and achieving an early recovery and patient satisfaction. The inconveniences are puckering and some widening of the periareolar scar, which requires a secondary revision in approximately 50% of the cases, also frequently necessary in conventional techniques. There is a tendency to flattening of the NAC and periareolar bulging with tendency to a "tomato breast appearance." The prevention of the latter is described.

Functional and aesthetic results in hypospadias repair with Hinderer's techniques.

In his editorial to the first issue of Aesthetic Plastic Surgery in 1976, the Managing Editor, Dr. Blair Rogers lays special emphasis on the publication of papers and reports dealing with the increasing role of Aesthetic Plastic Surgery as the final step in the overall rehabilitation of Reconstructive Surgery patients. In genitourinary malformations-hypospadias and epispadias-without any doubt a satisfactory sexual and urinary functional result is essential. However, also a normal aesthetic appearance, resembling a circumcised penis, and with the meatus at the tip of the glans, is becoming increasingly important, notably since the second half of the last century. An abnormal aesthetic appearance affects the patient's body image and has a negative influence on his self-esteem and sexual behaviour. Psychological stress is brought on from genital comparison with school-mates, in adulthood in gym changing rooms and, specifically, in sexual relations. In these days of greater sexual freedom, the knowledge of male genital anatomy and aesthetic appearance has considerably improved. Penile hypoplasia creates a psychological impact perhaps only comparable with that of female mammary hypoplasia. It is therefore unsurprising that not only normal aesthetic appearance after hypospadias surgery is essential, but also the demand for penile lengthening and girth augmentation has progressively increased over these past recent years.

Vertical preperiosteal rejuvenation of the frame of the eyelids and midface.

Aging usually shows first on the eyelids, the periocular frame, and the midface, which is the anterior mobile area of facial expression. The author, therefore, recommends performing a blepharoplasty and rhytidectomy of the upper two-thirds of the face in patients from their mid-30s on. Instead of a subcutaneous approach, correction can be performed at the deep level, with either a lateral or a vertical approach to the midface. The deep lateral approach to the midface was initiated by Skoog in 1974, the vertical subperiosteal approach by Tessier in 1979, and the vertical preperiosteal midface approach by Hinderer in 1985, followed by de la Plaza in 1988. The author's technique is analyzed according to the level of undermining, the transection of the retaining ligaments, the vector of tissue elevation, the stabilization of the superficial musculoaponeurotic system, and the safety of the procedure, mainly regarding the facial nerve. The related anatomy is described. The technique is reliable. No damage to the facial nerve occurred in a consecutive series of 535 patients who were operated on from 1983 through 1998; this was because the author respected the pathway of the nerve, which was determined using cadaver dissections when the technique was first developed. Long-term follow-up, some lasting 15 years, has shown that the results are long-lasting; this is because of the stabilization of the vertically elevated soft tissues, which is done by suturing the temporoparietalis fascia to the temporalis fascia and by using the author's orbicularis suspension technique. A short-scar variation instead of the coronal approach can also be used; the latter is indicated for patients with high foreheads or large forehead ptosis. The author prefers to use the preperiosteal approach, which elevates the soft tissues themselves, after transecting the retaining ligaments, rather than the vertical approach.

Aging of the upper lip: a new treatment technique.

The signs of aging of the upper lip, the pathogeny, and different treatments proposed up to now are discussed. A personal technique used since 1992 is presented. It is based on an earlier personal technique, described in 1970, which consisted of dissecting the skin from the orbicularis muscle and inserting a temporary (three weeks) silicone sheet. The present technique consists of a skin excision at the nasolabial junction, based on that described by Cardoso and Sperli in 1971. However, I dissect the skin of the vermilion border and insert a trapezoidal graft of the pretemporal areolar tissue, taken during rhytidectomy. The graft is fixed with Vicryl sutures at the level of the nasolabial folds. In a few patients this has been combined with a peel. The technique corrects both the superficial and the deep wrinkles caused by the retraction of the fibers that join dermis and orbicularis muscle. It achieves an eversion of the vermilion, enhancing its convexity and producing a fuller look, and shortens the lip, which adopts a concave, youthful appearance because of the improvement of the philtrum and of Cupid's arch. Our technique has been used in 15 patients who were satisfied with the results.

Correction of weakness of the lower eyelid and lateral canthus. Personal techniques.

The author describes the approach to weakness of the lower eyelid and lateral canthus due to a decreased tension of the orbicularis muscle and canthal ligament. He describes several techniques such as blepharocanthoplasty, muscular suspension blepharoplasty, submusculoaponeurotic system rhytidectomy of the upper two thirds of the face, and a temporal fascia sling procedure indicated for major elevation of the lower eyelid and rim.

Development of reconstructive blepharoplasty: the temporofacial rotation flap. Was it first conceived on the Spree, on the Seine, or on the Manzanares?

The development of reconstructive blepharoplasty in the 19th century is analyzed and the techniques classified according to their principles. Besides the main contributions of French, German, and Italian plastic surgeons, those made by two Spanish surgeons are summarized. Argumosa, who published an article on the tempororotation flap two years before Dieffenbach, and Hysern, who developed the first musculocutaneous transposition flaps for eyelid reconstruction, are usually omitted in the literature. After Dieffenbach's publication, German and French surgeons argued about who contributed to the development of plastic surgery in general and to blepharoplasty in particular, while in Spain controversies arose about the importance of Hysern's and Argumosa's contributions. The background and causes of these disputes are analyzed and compared with the present day dissemination and publication of new techniques.

Erich Lexer's mammaplasty.

A summary of Hans May's biography of Erich Lexer is reproduced, followed by a translation of Lexer's first publication, in Spain in 1921, on the correction of pendular breasts. Lexer's fundamental contributions to mammaplasty are analyzed. This author was the first in the history of mammaplasty to perform breast reduction with an "open" nipple-areola complex transposition, with preservation of the continuity of the skin to the remaining gland. This feature was far ahead of its time, as the techniques based on this concept did not become popular until after 1955. Lexer also was the first to propose subcutaneous mastectomy for treatment of fibrocystic disease, to perform breast augmentation in the ptotic hypoplastic breast with fat flaps, and to use free fat grafts taken from the abdomen or hips for augmentation mammaplasty.

Nasal base, maxillary, and infraorbital implants--alloplastic.

The aesthetic surgery of the facial skeletal contour requires either the performance of ostectomies of excessively prominent segments or the augmentation of retruded segments with organic or synthetic material, in order to achieve balanced tridimensional relations of each segment with regard to the total facial unit. Craniomaxillofacial surgeries are necessary in major malformations or in those combined with malocclusion. In the nasal dorsum or tip, the author prefers the use of cartilage, because synthetic materials need adequate soft-tissue bulk for cover to be inserted without tension and absence of passive mobility of the reception site. For malar augmentation, first proposed by the author and independently by Spadafora in 1971, for chin augmentation up to 8 mm, and for augmentation of the mandibular angle, the author prefers silicone implants because they do not change in shape or volume, may be premanufactured or custom-made, have a similar consistency to that of bone, and do not support bacterial growth. On the other hand, autologous bone grafts adapt less to curved bony surfaces, have an erratic rate of resorption, and need an additional surgical step for removal with the corresponding morbidity and scar. Subperiosteal insertion is preferred because it confers greater stability and the cavity is easier to dissect without soft-tissue damage. Although bone erosion may occur, with over 1200 implants clinically no major change in the soft-tissue contour has been observed, nor has the author been consulted for late complication. In the malar region this may be due to the large surface of the implant and absence of muscular pressure. In the chin, an insertion over the site of the dental roots is avoided. For midface augmentation the following implants are used: (1) The premaxillary lower nasal base implant, proposed in 1971, is indicated to correct a concave midfacial profile, frequent in Asian, black, and Mestizo patients from Latin America and in Caucasian patients with maxillonasal dysplasia or Binder's syndrome, after trauma, with excessive septum and nasal spine resections, and in nasal-maxillary sequels in cleft patients. In case of dental malocclusion, orthognathic surgery is the technique of choice. A prototype implant is available in two sizes, to be inserted through a lateral incision at the base of the columella. In 108 patients two implants have been partially removed. After the first month the patient is usually well adapted to the foreign body.(ABSTRACT TRUNCATED AT 400 WORDS)

Dermal and subdermal tissue filling with fetal connective tissue and cartilage, collagen, and silicone: experimental study in the pig compared with clinical results. A new technique of dermis mini-autograft injections.

The early reaction to the injection of silicone, collagen, and lyophilized heterologous fetal connective and cartilage tissues into the limiting zone deep dermis-superficial subcutaneous tissue was histologically examined in the pig and compared with clinical results. The inflammatory reaction to lyophilized heterologous fetal tissue is considerably more intense than that to collagen and silicone and lasts for several weeks. Therefore, it is not recommended for soft tissue filling in the face. Admitting an inferior antigenicity of fetal tissues, the authors suggest that enzymatically denaturalized collagen should be manufactured from heterologous fetal connective tissue, to be then further tested. The reaction of tissue to silicone and collagen is minimal. Silicone is preferred for dermal injections since in clinical experience it remains in the site of injection much longer. For subdermal injections, however, collagen is preferred. Based on experience with over 600 patients since 1958, the first author continues using liquid silicone. The lack of complications is probably a result of the fact that only small amounts (milliliters) of silicone were used in wrinkles or small depressions in the dermal layer and that from the beginning injection into the subcutaneous tissue was avoided. Since 1988 a new technique for the treatment of wrinkles and skin depressions with injections of dermal miniautografts has been used with satisfactory results.

Reconstruction of the external genitalia in the adrenogenital syndrome by means of a personal one-stage procedure.

The techniques for correction of the external genitalia in the adrenogenital syndrome, as far as known by the author, are reviewed. The goals of repair and timing of surgery are discussed. The author's one-stage technique, first published in 1974, is described with intraoperative illustrations, and the results obtained in nine patients are discussed. The advantages of the technique are preservation of a clitoral glans with erogenous sensation based exclusively on the deep dorsal neurovascular bundle. The glans of the megaloclitoris is obliquely reduced in size at its base toward the ventral surface and by resection of up to two-thirds of the ventral segment. It is relocated at its anatomic female position. The labia minora and the introitus vaginae are reconstructed at the same stage with the skin of the megaloclitoris displaced in posterior direction after a cutback incision. Dispareunia is prevented by total excision of the corpora cavernosa, including the crura.

The blepharo-periorbitoplasty: anatomical basis.

A new combined subperiosteal-subcutaneous musculo-aponeurotic system and suborbicularis technique is described: the "blepharo-periorbitoplasty." This technique achieves complete mobilization of the forehead and brow, the lower eyelid, the raphe and lateral canthal area, the upper palpebral region, and of the suprazygomatic and infrazygomatic soft tissues, including the cheeks. These soft tissues are displaced upward and moderately backward. If a major lateral upward slant of the palpebral fissure is desired, Hinderer's lateral canthoplasty must be added. The blepharo-periorbitoplasty technique can be combined with a facial-cervical rhytidectomy. The technique is also useful for senile preectropion and postoperative "round eye" conditions with scleral show. The safety has been proven both clinically and in anatomical dissections.

Otoplasty for prominent ears.

A technique for correction of prominent ears is described. It combines the advantages of simplicity and accuracy and provides satisfactory results. Essential points of the technique are perichondrial cartilage scratching at the superior crus and antihelical fold according to Stenström, mattress sutures applied to the perichondrium and soft tissues at the medial surface, and to these we add the trimming of the tail of the helix, thinning of the antitragus, and a double-spindle skin excision at the medial auricular surface. In patients with insufficient curling of the helical rim ("shell-ear" deformity) the base of the helical arch is scratched at its medial surface.

Otoplasty for lop ears.

The classification of malformations of the auricle is reviewed. Hinderer's technique is described. It is based on long oblique skin and cartilage flaps of the upper pole of the ear, taken in opposite directions for expansion of the helical arch, thus preventing a later visible notching at the helical rim. The remaining scapha is straightened and the superior crus and antihelical fold are formed by scratching and sandpaper abrasion of the lateral surface. A deep concha is treated by a cartilage strip expansion from the posterior conchal wall.

Macrotia.

Techniques for treatment of severe and moderate macrotia and for hypertrophy of the earlobe are described. For macrotia, the excision of cartilage at the scapha, helical arch, and skin are performed at different levels to prevent a notching, mainly at the helix. For hypertrophies of the earlobe, through-and-through excisions of two triangular pieces are used with reinsertion of the remaining earlobe at the base.

[Neural risk zones in rhytidectomy]. / Nerven-Risikozonen bei der Rhytidektomie.

During the last decades the treatment of the ageing face has evolved from a mere action at the skin level, towards an additional correction of the ptosis of the underlying soft tissues, and procedures involving the bony-cartilaginous framework. Any new rhytidectomy technique with deep undermining should be examined with regard to high risk areas. The areas of risk relate to the branches of the facial nerve and to sensory innervation. These are described on the basis of the current literature, clinical observations and cadaver dissections. The expected improvement in results by the use of techniques with deep dissection compensate for the longer surgery and the increased stress to the patient whenever the risk areas are respected.

A simple method for enhancing X-ray details.

The authors describe a simple and low-cost process to achieve a bas-relief effect with normal X-rays, allowing observation of fine detail. No additional apparatus is needed and patient exposure is not increased.

An unusual case of gigantomasty.

The authors report an unusual case of gigantomasty, of such proportions that it is believed to be the most striking published case, when the ratio of breast weight/body weight is taken into account (24%). The outstanding breast volume and the aggressive and pronounced growth potential of the breast tissue presented unusual problems which required special solutions. The case is presented from its beginning, when the patient was 12 years old up to the completion of treatment with the patient at adult age.

[Indications and significance of esthetic plastic surgery]. / Indikation und Bedeutung der ästhetisch-plastischen Chirurgie.

The motivations of aesthetic operations for achievement of a more harmonious appearance or for treatment of the external signs of aging are, besides purely aesthetic reasons, the desire to increase professional opportunities, to better adapt to the social environment or to improve affective relations. Aesthetic surgery has therefore a mainly psychic indication: the aim is to improve the self-esteem, which, on the other hand facilitates the social integration. A responsible execution of aesthetic surgery requires, besides a basic knowledge of psychology and sensitivity for aesthetics, a complete training in general surgery and in reconstructive plastic surgery as well as a continuing education in the aesthetic field. It is therefore not advisable to divide the specialty of plastic surgery. The advancements in both fields have a mutual positive influence and both have to consider function as well as appearance, although with different emphasis. The adequate treatment of eventual complications also requires a basic knowledge in both fields. The intensive advertising made by commercial, so-called "cosmetic clinics" is in contrast to the plastic surgeon's possibilities of public relations, restricted for ethical considerations. Undoubtedly it is not sufficient, at least on a medium-term basis, to achieve better results--in benefit of the patient--unless this is also made known to the public. The necessary information of the public should therefore be taken over or be directed by the National Societies of Plastic Surgery, on an anonymous basis.