David A. Sieber

Clinical evaluation of shaped gel breast implant rotation using high-resolution ultrasound

Background Clinical trials have demonstrated through core and independent studies that anatomical devices are safe and effective with low complication rates. The rotation rate of shaped breast implants in the literature is 0 to 8.2%. Currently there are no studies evaluating the efficacy of in office ultrasound or clinical rotation vs actual rotation rates seen on high-resolution ultrasound (HRUS). Objectives The purpose of the study is to demonstrate the ease and reliability of HRUS for evaluating the rotation rate of 2 different brands of anatomic implants and to correlate this with the presumed clinical rate, as well as independent evaluators assessments. Methods A total of 69 patients were followed up at routine intervals and were evaluated for rotation. Any implant rotated past >30° off of midline (outside 5-7 o’clock) was considered to be rotated. To determine if radiographic rotation was clinically evident, 20 composite patient photos were blindly evaluated. Results A random total of 69 patients underwent bilateral augmentation mammoplasty with form stable anatimic gel implants using 138 implants. Twenty-nine of the 69 (42%) patients and 37 of the 138 (27%) implants were found to be rotated-using HRUS. Eight of the 69 (12%) patients had bilateral rotations. Independent evaluators were able to identify two of 12 (17%) possible rotations, or 2 rotations in 40 (5%) total implants. Conclusions Anatomic form stable gel implants are actually rotated up to 25 times more frequently than previously thought, but these rotations do not translate into clinically significant sequela. High-resolution ultrasound is a simple alternative for breast implant surveillance and is better accepted by patients than magnetic resonance imaging (MRI). The clinical value of HRUS is also discussed and recommendations for FDA implant labeling changes are provided in this article. Level of Evidence 4

Anatomy of the Facial Danger Zones: Maximizing Safety during Soft-Tissue Filler Injections

Summary: With limited downtime and immediate results, facial filler injections are becoming an ever more popular alternative to surgical rejuvenation of the face. The results, and the complications, can be impressive. To maximize safety during injections, the authors have outlined general injection principles followed by pertinent anatomy within six different facial danger zones. Bearing in mind the depth and the location of the vasculature within each zone, practitioners can tailor their injection techniques to prevent vessel injury and avoid cannulation.

What’s Your Micromort? A Patient-Oriented Analysis of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) continues to be a rare and elusive malignancy. Because BIA-ALCL does not behave like traditional lymphomas, additional research needs to be conducted to further delineate the lymphoproliferative nature of BIA-ALCL. An estimated 35 million women worldwide have breast implants and the total reported deaths from BIA-ALCL is 12 to date. The term micromort was introduced in 1979 by Ronald Howard as a persons risk of dying as 1 in a million. Drinking 0.5 L of wine or walking 17 miles all increase your risk of death by 1 micromort. Risk of death from BIA-ALCL is 0.4 micromorts for a woman having bilateral breast implants. This information is important for counseling new patients and those presenting with delayed onset seromas.

Characterization of Adipose Tissue for Autologous Fat Grafting

Fat grafting is a common procedure in aesthetic and reconstructive plastic surgery, but variable graft retention limits its utility. Unpredictable clinical outcomes with fat grafting can be explained in part by the lack of standardized protocols for harvesting, processing, and transplanting adipose tissue (AT). Historically, plastic surgeons have relied on trial and error and their clinical experience to develop fat grafting protocols. Optimization of fat grafting protocols requires systematic assessment of the impact that key variables have on the quality of the AT preparation at each step of the procedure. In this article, we review recent findings regarding the composition and quality of AT prepared for fat grafting and the strengths and limitations of existing AT characterization assays. We discuss the need for an assessment of the viability of intact AT (ie, conventionally harvested AT that has not been disrupted further) by means of an operator-independent, quantitative assay that can be performed in real time and generates reproducible data. Promising assays for the characterization of cell product quality have been developed for other therapeutic applications, such as transplantation of pancreatic islet cells. The development or adaptation of a gold-standard assay to determine the quality of an AT preparation may help to standardize fat grafting protocols and improve clinical outcomes.

MemoryShape: impact of clinical trials, global medical economics, and the future.

Summary: The global breast implant business was invented and configured by American plastic surgeons. In 2012, the first shaped silicone implants were approved in the United States by the Food and Drug Administration. It is the peculiar historical course of implant usage in America that has deprived US plastic surgeons of the opportunity to become experts in the use of this device. Most studies indicate significant safety benefits to using shaped devices, despite the technical challenges involved in their use. Upon approval, adoption of the devices has been slow in the United States, running the risk that American plastic surgery may lose the intellectual and clinical practice hegemony it has enjoyed for over 50 years in this area of the specialty. To continue to maintain leadership in the field of breast surgery, US surgeons should evaluate this new modality and either join the global trend or present data to contradict it.

Neck Rejuvenation through the Lateral Platysma Window: A Key Component of Face-Lift Surgery

Summary: Rejuvenating an aged face relies on maintaining facial harmony to provide optimal aesthetic results. Restoration of more youthful facial contours is dependent on blending the aesthetic facial topographic units. Many authors continue to debate the best approach for neck rejuvenation through a medial approach, a lateral approach, or a combination of the two. The authors present their approach to neck rejuvenation through medial platysma plication, inferior release, and lateral platysma window.

Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections.

Summary: Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

Are We Killing Our Fat Cells before Grafting Them

1 David A. Sieber, MD Allen L. Van Beek, MD Division of Plastic and Reconstructive Surgery University of Minnesota Minneapolis, Minn. Sir: S its inception by Neuber in 1893, there have been numerous modifications in fat grafting techniques, all attempting to maximize posttransplant adipocyte survival. Despite ongoing research, there remains wide variations in viability after autologous fat grafting, with reported loss ranging from 40% to 60%.1 Research studying various methods of harvesting, force and time of centrifugation, effects of local anesthetic, cannula size, hand versus machine aspiration, and location of donor sites are discussed.2,3 However, the question remains: why are so many adipocytes being resorbed after transfer? There is suggestion in the literature that high negative pressures may contribute to cellular rupture before injection.4 Our study was able to identify that high negative pressures are generated through hand aspiration with minimal amounts of distraction. The maximum negative pressure generated exceeds 600 mm Hg, which is likely enough negative pressure to cause cellular rupture and also creates excess pressure with distractions greater than 3 mL. To date, there has been a lack of convincing research to define a range of negative pressures that cause direct cellular rupture of living adipocytes. A single study suggests that cells begin to rupture at negative pressures over 20 mm Hg, but the scientific literature has never addressed this issue directly.4 Coleman5 recommends displacing the plunger by 1–2 mL in a 10-mL syringe. This distraction amount generates negative pressures in the range of 50–115 mm Hg (Fig. 1). The pressure at which cell rupture occurs has yet to be determined; however, some studies do suggest higher cell viability with low pressure harvesting of aggregates of cells. The current literature evaluates cells under negative 760mm Hg and negative 380mm Hg of pressure but is lacking in comparing high negative pressures of 760 mm Hg with low negative pressures of <150 mm Hg. Persistent issues in the literature are the lack of a standardized protocol for lipoaspiration and a need for a quantitative method of evaluating adipocyte viability. Without standard methods, available studies have multiple variables that potentially confound the data and provide conflicting results. This may be the reason that so many of the currently published studies have not been able to show significance between experimental and control groups. Many authors have attempted to determine cell viability by preserving cells in fixative. This merely suspends the cell in time, providing a snapshot of healthy cellular architecture, but it does not provide an accurate picture of eventual cell death due to programmed apoptosis or induced cell death. Newer assays measuring cytoplasmic enzymes such as 3-phosphate dehydrogenase do a better of job of determining viable cells from those that are programmed to die, but it still does not provide a quantitative evaluation of living cells ability to survive. Clinical fat grafting is an evolving process where the end result is variable, and the factors creating that variability have yet to be adequately studied. It seems likely that high negative pressure and other technical factors during aspiration and grafting contribute to premature cellular death. However, more stringent standardized protocols and quantitative measurements of cell viability need to be developed before that question can be answered.

IL-13 is produced by tumor cells in breast implant–associated anaplastic large cell lymphoma: implications for pathogenesis

More than 500 women worldwide have developed a CD30+ T-cell lymphoma around breast implants, strongly suggesting a cause-and-effect relationship, and designated as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The mechanism of lymphomagenesis is unknown. Recently, a bacterial biofilm containing gram-negative bacilli was discovered on the surface of breast implants associated with ALCL. We and others have described overexpression of the proto-oncogene JUNB and mutations of JAK1/2, TP53 and STAT3 in BIA-ALCL. Here we report that BIA-ALCL cell lines and anaplastic lymphoma cells in clinical specimens produce IL-13, the signature cytokine of allergic inflammation. Supporting the link of BIA-ALCL to allergic inflammation, lymphoma cells were often surrounded by eosinophils and mast cells, features typically absent in systemic ALCL. Because of the link of IL-13 to allergy, we looked for IgE and found it decorating the surface of mast cells and antigen-presenting follicular dendritic cells in capsules and lymph nodes infiltrated by anaplastic lymphoma cells, but not uninvolved capsules. Plasma cells within capsules and regional lymph nodes were identified as a possible source of IgE. Together, these findings suggest the hypothesis that an amplified immune response with features of a chronic allergic reaction in a susceptible patient underlies the pathogenesis of BIA-ALCL.

Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty

Summary: Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point. Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts, and suturing techniques such as alar flaring sutures. The authors present their technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft. Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique to optimize tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.