Arturo Prado

A Prospective, Randomized, Double-blind, Controlled Clinical Trial Comparing Laser-assisted Lipoplasty with Suction-assisted Lipoplasty

Background: The authors randomized and prospectively analyzed their clinical experience with the use of internal neodymium:yttrium-aluminum-garnet low-level laser-assisted lipoplasty compared with suction-assisted lipoplasty. Methods: Suction-assisted lipoplasty was generated through a SmartLipo machine and delivered into the subcutaneous tissues through 2-mm solid optical probes. Ipsilateral suction-assisted lipoplasty and contralateral laser-assisted lipoplasty were performed on one or more comparable topographic areas of the body in the same patient. Laser-assisted lipoplasty and suction-assisted lipoplasty sides of 25 patients were compared with preoperative and postoperative photographs at 3 to 5 days, 12 to 15 days, and 6 to 11 months. Statistical analysis considered surgeon and patient satisfaction, time used in the procedures, learning curves, lipocrits, operative technique, postoperative pain, edema, ecchymosis, time of recovery, body mass index, DNA proteins, free fatty acids, and cytologic patterns of post–laser-assisted lipoplasty and suction-assisted lipoplasty adipocyte architecture. Photographs were sent to the patients (blinded to the operated sides) and two plastic surgeons unfamiliar with the cases for evaluation of results. Results: All patients completed the preestablished follow-ups. No complications were observed. Less pain, lower lipocrits, higher triglycerides, and DNA cellular membrane traces were detected in the laser-assisted lipoplasty sides. All other considerations studied showed no differences with either technique in the three periods of the follow-up controls. Cytologic studies showed more damage of the adipocytes in the laser-assisted lipoplasty sides. Conclusions: No major clinical differences for suction-assisted lipoplasty versus laser-assisted lipoplasty were found. Higher concentrations of free-fatty acids after laser-assisted lipoplasty must alert us to possible hepatic and renal toxicity.

Composition of Postabdominoplasty Seroma

BackgroundThis study aimed to analyze the composition of postabdominoplasty seroma fluid at different intervals, compare it with blood and lymph, and determine whether it meets the criteria for being considered an exudate.MethodsThe study enrolled 18 female patients with postabdominoplasty seroma diagnosed by clinical and ultrasound evaluation. All the patients had a Matarasso type 4 anterior abdominal wall deformity. None of the patients were overweight, and none had comorbidities. They all underwent a classical abdominoplasty procedure. Fluid samples were taken from the drains between postoperative days 5 and 7, and from needle aspiration between postoperative days 15 and 20. The fluids were assayed in the clinical laboratory at the University of Chile Clinical Hospital for chemical and cellular composition. Blood, lymph, and seroma values were compared by independent group analysis using a Tukey multiple comparison test with an alpha error of 0.05.ResultsThe total protein, lactate dehydrogenase (LDH), and cholesterol levels for the early and late seroma fluids were lower than in the blood, but higher than in the lymph. The total protein seroma-to-plasma ratio was approximately 0.5; the LDH seroma-to-plasma ratio was approximately 0.6; and the cholesterol seroma-to-plasma ratio was 0.32. The platelet level was very low in the late seroma fluid, showing no statistical differences with the lymph level. The leukocyte level was low in the seroma fluid, with a higher percentage of neutrophils than found in the blood or the lymph.ConclusionsThe serous fluid formed under the flap after an abdominoplasty seems to be an exudate. In the early postoperative period, it is an inflammatory exudate that slowly turns into an exudate with some characteristics similar to those of lymph.

Implications of Transaxillary Breast Augmentation: Lifetime Probability of Breast Cancer Development and Sentinel Node Mapping Interference

After the “fifth-generation” breast implants with ultracohesive silicone gel technology are introduced, the Food and Drug Administration (FDA) will sooner or later retire the ban on the use of these devices in the United States. When this happens, the plastic surgery community must be prepared to face a massive demand for reoperations to change saline-filled breast implants because cohesive gel devices have the potential to provide a more natural breast shape, to minimize the risk of postoperative rippling, and to provide a greater degree of safety if the implant loses its integrity. Despite these advantages and extensive use throughout the rest of the world during the ban in the United States, silicone implants also have disadvantages. One drawback is that transaxillary breast augmentation with more “rigid” gel-filled implants may produce trauma to the armpit, may interfere with sentinel node mapping for breast cancer treatment, and may have future medicolegal implications.

Full-face carbon dioxide laser resurfacing: a 10-year follow-up descriptive study.

Background: The purposes of this study were to retrospectively compare the 1-, 5-, and 10-year cosmetic outcomes of full-face carbon dioxide laser resurfacing using the SilkTouch technology, and analyze its advantages, disadvantages, and long-term results. Methods: Photographic results of full-face carbon dioxide laser resurfacing were evaluated after 1, 5, and 10 years. Statistical analysis considered surgeon and patient satisfaction based on a predetermined cosmetic visual analogue scale. Patients and two plastic surgeons unfamiliar with the cases evaluated objective postresurfacing results using Beausang’s grading system and a modified wrinkle assessment scale. Results: One hundred fifty-nine patients were treated and 46 patients completed 1-, 5-, and 10-year follow-up. Combined aesthetic procedures to the full-face carbon dioxide resurfacing were transcutaneous upper lid/lower lid transconjunctival blepharoplasty and endoscopic brow lifts in 15 patients. After 1 year, some relapse occurred, but the overall aesthetic result remained very good. At 5 and 10 years, respectively, 32 and 20 percent of the sample maintained good-quality skin texture; 22 and 19 percent achieved correction of skin pigmentation without scars; and 88 and 98 percent needed correction of recurrent rhytides, jowling, and redundant skin. Permanent hypopigmentation was found in four cases (8.7 percent). Conclusions: The authors’ early experience with the carbon dioxide laser was excellent, but after 1 year, they noticed lines of demarcation between treated and nontreated skin or persistent erythema. After 5 and 10 years, advantages were maintenance of good skin texture, ablation of fine wrinkles, and long-term correction of skin pigmentation. Disadvantages included permanent hypopigmentation of the mandible-neck junction, telangiectasia, and possible accentuation of skin redundancy.

Umbilical Reinsertion in Abdominoplasty: Technique Using Deepithelialized Skin Flaps

One goal of abdominoplasty is to reestablish a natural-appearing umbilicus with hidden scars. The authors present a new technique for navel reinsertion.

Nonresective shrinkage of the septum and fat compartments of the upper and lower eyelids: a comparative study with carbon dioxide laser and Colorado needle.

Background: The purpose of this article is to describe an alternative nonresective treatment of the fat-septum component of the eyelids during blepharoplasty, using shrinkage desiccation with two low-energy modalities: a carbon dioxide laser and a low-range grid of electrocautery with a Colorado microdissection needle. Methods: Thirty-six patients underwent a four-lid blepharoplasty. During surgery, after exposure (not opening) of the septum and assessment of the amount of bulging by gentle globe compression, a grid spray of electrocautery (right eye) and carbon dioxide laser (left eye) was applied over the entire septum until shrinkage and correction of the bulging was achieved. Preoperative, postoperative day 15, and 1-year follow-up photographs were evaluated using an objective grading system by blinded surgeons. For statistical analysis, the Wilcoxon matched-pairs signed-ranks test was used, with p < 0.05 indicating statistical significance. Results: All the patients completed the 15-day evaluation, but only 32 completed the 1-year follow-up. No major eye or eyelids complications were observed. There were no statistical differences in surgical time and postoperative pain on either side. In this study, laser fat-septum shrinkage achieved substandard results compared with electrocautery when analyzed as a continuous variable, but it did not influence the categorical Strasser scale final result in the short- and long-term follow-up. Conclusions: The method described is simple and safe, and provides a subtle but long-lasting, adequate result. No statistical clinical differences were observed between the electrocautery and laser fat-septum shrinkage techniques.

Abdominoplasty: The use of polypropylene mesh to correct myoaponeurotic-layer deformity

The aponeurotic layer is a very important element to consider during abdominoplasty. For most patients, a simple midline plication is enough to obtain good results. However, for in patients with severe aponeurotic laxity, some other maneuvers must be performed. The purpose of this study was to evaluate the use of polypropylene mesh in this group of patients. We analyzed the results for 20 patients in whom three types of mesh anchoring were used on the basis of intraoperative findings. Adequate long-term follow-up results were obtained, with no recurrence of rectus diastases, as shown by ultrasonography.

A new technique of "double-A" bilateral flaps based on perforators for the treatment of sacral defects.

Background: Myocutaneous and fasciocutaneous flaps can provide stable coverage of sacral defects. For neurologically intact patients, sensate innervated gluteal artery perforator flaps are the ideal solution. For patients with spinal cord injury, soft-tissue coverage can be performed with a variety of noninnervated flaps. Methods: Between 1997 and 2004, the authors operated on 30 patients, 21 men and nine women, using bilateral gluteal distal fasciocutaneous and proximal musculocutaneous vertical vector rotation-advancement flaps, based on perforators with V-Y closures. The ages of the patients ranged from 32 to 74 years. Twenty-five patients had spinal cord injuries and all had sacral pressure sores extending to the bone. Three patients had low-grade malignant tumors (sacral chordomas); one had a sacral radiation-induced necrosis and two senile patients with large sacral defects had chronic renal failure and multiple sclerosis. No comorbidities were found in the sample. Results: All the lesions were closed successfully. After follow-up of 1 to 8 years, 27 patients never required repeated surgery after wound complications. Three patients had infection and partial dehiscence of the flaps that healed after reoperation with V-Y readvancement; three died as a result of their primary diseases. Conclusions: This flap design has been used only in selected cases because, after its elevation, use of other gluteal-based flaps for future sacral reconstructions may not be possible. Five neurologically intact patients were found to have good sensitive protection of the flaps and adequate cushion contour after surgery because the authors conserved the gluteal arteries, perforators, and their corresponding sensory nerves.

Recent developments in the ability to predict and modify breast cancer risk

The identification of women at higher risk for breast cancer is a matter of public health and anyone who participates in any treatment modality of this condition (this includes the plastic surgeon) should be aware of the tools and predictive models of breast cancer. Screening for breast cancer in the community, and probably during the daily plastic surgery consultation, until recently, was limited to decisions about when to initiate a mammography study. New developments that predict and modify breast cancer risk must be clearly understood by our specialty through identification of women at higher risk for breast cancer and be familiar with the current issues related to screening and risk-reduction measures. In this review, we discuss current knowledge regarding the recent data of breast cancer risk, screening strategies for high-risk women and medical and surgical approaches to reduce breast cancer risk. Patients with breast cancer belong to one of three groups: a. Sporadic breast cancer (75%)--patients without family history or those who have a breast biopsy with proliferative changes. b. Genetic mutation breast cancer (5%)--women who have a genetic predisposition, and most of these are attributable to mutations in the breast cancer susceptibility gene 1 (BRCA1) and breast cancer susceptibility gene 2 (BRCA2). c. Cluster family breast cancer (20%)--seen in women with a relevant history of breast cancer in the family and breast biopsy with proliferative breast changes with no association with mutations.Those at high risk for breast cancer should investigate the family history with genetic testing consideration, clinical history, including prior breast biopsies and evaluation of mammographic density. Tools for breast cancer risk assessment include the Gail and Claus model, genetic screening,BRCAPRO and others that are evaluated in this review.

Creativity in Plastic Surgery

Creativity in plastic surgery has been a hot topic of the past decade. This is explained by the nature of plastic surgery, with its intense pressure for innovation and maintenance of a competitive edge. Creativity is the ability to make or bring into existence something new, whether a new solution to a problem or a new method, technique, or device, or simply the act of making something new. Creativity also may be seen as a mental process involving the generation of new ideas or concepts or the process of making new associations between existing ideas or concepts [1]. The creative thought is original, and innovation applies such creative ideas in some specific context. For example, ‘‘invention,’’ is a term usually understood as referring to new devices, instruments, and machines, but this is a narrowing of its original meaning, ‘‘to come on something, to fabricate in the mind.’’ For this reason, it is equally proper to speak of an invention of an idea [2]. How do we define creativity in plastic surgery? Plastic surgeons are seen by other specialties as imaginative, original, inventive, and ingenious people. What the others do not see is that innovations in our specialty appear after the complete picture of principles is grasped, as shown in the Principalization of Plastic Surgery by Millard [3]. Attendance at several courses, meetings, and symposia enables us to recognize creative individuals when they communicate something partly or wholly new, invest an existing object with new properties or characteristics, imagine new possibilities not conceived previously, or perform something in a manner different from what was thought possible or normal previously. It is easy to distinguish these individuals from other less creative peers because they have a rich body of domain-relevant knowledge and well-developed skills. They are intrinsically motivated by their work; tend to be independent, unconventional, and more risk taking; have a wide interest and greater openness to new experiences; and have skill in recognizing differences and similarities and in making connections. These creative individuals have a true appreciation of and ability for writing and drawing, flexibility to change, and willingness to question norms and assumptions. They tend to have a discovery orientation and ask novel questions. In work contexts, creative plastic surgeons tend to take the initiative, to work in teams, and to have extensive networks. The presence of stimulating coworkers promotes more creativity by adding excitement, energy, and synergy. Competitive pressure leads to enhanced individual and group creativity. The affective context also is important because it influences creative problem solving. An important aspect of being in the University is the ability to teach, investigate, promote extension, communicate, publish, and finally, with free will, create. Observation of how things work and develop is transcendental. For this purpose, the creative individual must have time, imagination, and an open mind. The Greeks developed leisure so they could observe because this was the first step to innovation. It is said that the University gives its academics a sabbatical year to ‘‘think and have time to create.’’ But this utopia in our globilized world requires each one of us to ‘‘kill our own pig’’ to survive and ‘‘feed the family.’’ Creative minds in plastic surgery have imagination that sparks ‘‘brainstorming of ideas,’’ the same as a schizophrenic A. Prado (&) P. Andrades Plastic Surgery Division, Department of Surgery, School of Medicine, Jose Joaquin Aguirre Clinical Hospital, University of Chile, Santiago, Chile e-mail: pradoplast@yahoo.com