Fereydoun Don Parsa

Mycobacterium Cheloneae Infection After Breast Augmentation

Augmentation mammaplasty is one of the most commonly performed plastic surgery procedures. Infection, still one of the most feared complications of the procedure, usually is caused by skin commensal organisms. A wide variety of other organisms also may be responsible for these postoperative infections, including atypical mycobacteria. A case of a prosthetic breast implant infected with Mycobacterium cheloneae is presented, and the presenting signs and symptoms, diagnosis, and treatment options of such an infection are discussed. The importance of promptly isolating the pathogen for potential salvage of the prosthesis also is stressed, as well as the operative intervention necessary when conservative therapy fails.

Polyurethane-Coated Breast Implants Revisited: A 30-Year Follow-Up

Background Polyurethane coating of breast implants has been shown to reduce capsular contracture in short-term follow-up studies. This 30-year study is the longest examination of the use of polyurethane-coated implants and their correlation with capsular contracture. Methods This study evaluates the senior surgeons (F.D.P.) experience with the use of polyurethane-coated implants in aesthetic breast augmentation in 382 patients over 30 years. Follow-up evaluations were conducted for six months after surgery. After the six-month follow-up period, 76 patients returned for reoperation. The gross findings, histology, and associated capsular contracture were noted at the time of explantation. Results No patient during the six-month follow-up period demonstrated capsular contracture. For those who underwent reoperation for capsular contracture, Baker II/III contractures were noted nine to 10 years after surgery and Baker IV contractures were noted 12 to 21 years after surgery. None of the explanted implants had macroscopic evidence of polyurethane, which was only found during the first five years after surgery. The microscopic presence of polyurethane was noted in all capsules up to 30 years after the original operation. Conclusions An inverse correlation was found between the amount of polyurethane coating on the implant and the occurrence of capsular contracture. Increasingly severe capsular contracture was associated with a decreased amount of polyurethane coating on the surface of the implants. No contracture occurred in patients whose implants showed incomplete biodegradation of polyurethane, as indicated by the visible presence of polyurethane coating. We recommend research to find a non-toxic, non-biodegradable synthetic material as an alternative to polyurethane.

Lower Blepharoplasty with Capsulopalpebral Fascia Hernia Repair for Palpebral Bags : A Long-Term Prospective Study

Background: In December of 1998, the authors published a prospective study in Plastic and Reconstructive Surgery (102: 2459, 1998) comparing standard lower blepharoplasty with lipectomy on one side and fat-preserving capsulopalpebral fascia hernia repair on the contralateral side; comparable aesthetic outcomes were demonstrated after 6 months of follow-up. In the present study, the authors report their findings on the original patient cohort with an average follow-up of 11.3 years. Methods: From 1991 to 2007, 26 patients were identified who had previously undergone lower blepharoplasty for palpebral bags, using fat removal on one side and fat preservation on the contralateral side. These patients were evaluated, and the incidence and locations of palpebral bag recurrence, lower lid hollowing, lid malposition, and eyelid dysmobility were documented. Results: The overall recurrence rate of palpebral bags under the eyes following standard fat resection (30.8 percent) was significantly higher than for eyes following capsulopalpebral fascia hernia repair (7.7 percent) (p = 0.043). Recurrences of fat herniation, of generally less significance than the original preoperative status, were not found in any of the lower eyelid compartments in the former group, and only in the lateral compartment in the latter. Conclusions: At long-term follow-up, fat-preserving capsulopalpebral fascia repair for palpebral bags demonstrates superiority to standard blepharoplasty with lipectomy, with significantly lower recurrence of palpebral bags. In a small percentage of patients undergoing capsulopalpebral fascia hernia repair, limited fat resection in selected patients may eliminate hernia recurrence.

The Use of Celecoxib for Reduction of Pain After Subpectoral Breast Augmentation

A study was conducted to determine whether a single 400-mg dose of oral celecoxib administered 30 min before surgery reduces the opioid requirement for patients undergoing aesthetic subpectoral breast augmentation. A total of 695 patients undergoing breast augmentation were randomly selected into either a placebo or a treatment group. The findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly fewer opioid analgesics after the operation than those given a placebo (p < 0.001). It also was found that nonsmokers and multiparous women required significantly fewer opioids than smokers and nulliparous women (p < 0.001). On the basis of this prospective study, the authors recommend a single 400-mg dose of celecoxib administered 30 min before surgery to decrease opioid analgesic requirements after subpectoral breast augmentation.

Surgical correction of the frowning mouth.

Background: The available perioral rejuvenation procedures only partially correct the frowning mouth deformity, which is composed of sagging of the oral commissures and frequently associated with marionette folds. The authors describe their method of surgical correction for this condition and offer a classification for frowning mouth deformity. Methods: Twenty-seven patients underwent correction for frowning mouth deformity from 2000 to 2009. The deformities and the corresponding methods of correction were divided into two types. In type I frowning mouth deformity, correction was performed by lentiform excisions at the vermilion border, and in type II deformity, lentiform excisions also included the marionette folds. Results: Correction of frowning mouth deformities, either as an isolated procedure or concurrent with face lift, was satisfactorily achieved in all 27 patients. All patients were followed for a minimum of 3 months, and 88.9 percent were followed for 1 year; 18.8 percent of the patients showed erythema and scar hypertrophy at the sites of marionette fold excision during the early postoperative period. However, all scars improved over time, with high patient satisfaction. Conclusions: Frowning mouth deformities are correctable by excising lentiform segments of skin through incisions placed at the vermilion border that may be extended to include the marionette folds. Proper patient selection and counseling, particularly regarding temporary or possibly permanent noticeable scar formation, is of utmost importance. When such measures are taken, the outcome is good and patient satisfaction is high.

Muscle-Sparing Blepharoplasty: A Prospective Left-Right Comparative Study

Background Standard upper blepharoplasty involves removal of both the skin and a portion of the underlying orbicularis oculi muscle. The senior author had observed sluggishness of eyelid closure, lagophthalmos as well as varying degrees of eye irritation in certain patients during the early postoperative period. He postulated that these findings could be due to orbicularis muscle excision. He therefore undertook a prospective study 27 years ago comparing standard blepharoplasty on one eyelid to skin-only excision on the fellow eyelid. Methods A randomized, prospective, single-blinded study was designed using the fellow eye as an internal control. 22 patients undergoing upper blepharoplasty procedure requiring greater than 5 mm of skin resection and with no history of ophthalmologic disease, dry eye, or previous eyelid surgery were selected. Upper blepharoplasty was performed with skin-only removal on one side, and combined skin-muscle removal on the other side. Patients were evaluated until six months after surgery except for two patients who were lost to follow-up after three months. Sluggish eyelid closure, lagophthalmos, dry eye and aesthetic result were outcome measures scored by patient survey, the operating surgeon, and a blinded expert panel. Results There were comparable aesthetic outcomes in both eyelids. The incidence of sluggish eyelid closure, lagophthalmos and dry eye syndrome were significantly higher in eyelids where wide segments of muscle had been resected. Conclusions Muscle-sparing upper blepharoplasty produces similar aesthetic outcomes as conventional blepharoplasty, while significantly reducing the complications of sluggish eyelid closure, lagophthalmos and dry eye disease. The authors therefore recommend muscle-sparing upper blepharoplasty.

Late extrusion of saline prostheses after aesthetic breast augmentation.

Close to 220,000 women underwent aesthetic breast augmentation in the United States in 2002.1 This procedure has been increasing in popularity since May 10, 2000, when the Food and Drug Administration approved saline implants as safe and effective.2,3 The Food and Drug Administration’s list of complications after breast augmentation includes capsular contracture, deflation, rupture, pain, infection, hematoma/seroma, and extrusion.4 Implant extrusion is a well-documented complication in patients undergoing breast reconstruction with mammary prostheses.5–23 However, extrusion is virtually unreported in young, healthy patients undergoing aesthetic breast augmentation, with late extrusion occurring upward of 10 years not documented. We present a case of this late extrusion in a healthy 26-year-old woman who had undergone subpectoral breast augmentation with textured saline mammary implants.

Case of late hematoma after breast augmentation

We present a case report of a patient who experienced a late, spontaneous breast hematoma 26 years after primary breast augmentation. Late hematomas are a rare complication of breast augmentation with uncertain etiology. In this case, there was no trauma, calcifications, or implant rupture. We believe the patient’s hematoma was secondary to erosion of a capsular vessel due to capsular contracture.

The Importance of Umbilical Blood Supply and Umbilical Delay in Secondary Abdominoplasty: A Case Report

Level of Evidence 5

Prevention of Acute Hematoma After Face-Lifts

The authors should be commended for studying the postoperative medical regimen in their effort to reduce hematoma after face-lift. They showed that the prophylactic use of medications such as analgesics, antihypertensives, antiemetics, and sedatives during the perioperative phase is superior to making drugs available to patients on request and can decrease the occurrence of acute hematoma in face-lift patients. Their prophylactic treatment consists of 1 g perfalgan (for pain control), 150 lg clonidine (for blood pressure stabilization and prevention of agitation), and 4 mg ondansetron (for prevention of nausea and vomiting). The authors obtained a 0% hematoma rate when the operation was performed in the ‘‘private facility’’ of a public hospital where the prophylactic regimen was provided compared with a rate of 7% when the same procedures were performed at a ‘‘private’’ clinic with ‘‘comparable’’ nursing care and the use of medications on a request basis. They attribute the main cause of hematoma formation to an increase in the blood pressure when prophylactic measures were not taken. Although the level of care at the two facilities is reported to be ‘‘comparable,’’ it would have been of value if the authors had reported on the adequacy of the timing used for medication administered on demand. It is a common observation that a certain time elapses between when a patient makes a request for a medication such as an analgesic and when it actually is administered. This interval (i.e., waiting period) may be considered as a possible cause for hematoma formation in the reported group of patients. All potential causes of postoperative blood pressure elevation are currently well defined and have been well studied for the past several decades. These causes include pain, anxiety, urinary retention, and hypoventilation, among others. The authors confirm these findings in their study, and we commend them for that. Use of fibrin glue, drains, adrenaline infiltration, and the Harmonic scalpel, although encouraging in some studies, require further study. Although the benefits of clonidine used prophylactically in plastic surgery are relatively well established [1], caution must be observed with its use for the elderly and patients receiving beta blockers. The authors quote Saray et al. [2], who state that ‘‘modern medical practice dictates the generous use of analgesic agents.’’ The preoperative prophylactic use of nonopioid medications such as the combination of celecoxib and gabapentin is becoming the current trend in the management of postoperative pain because such medications not only diminish postoperative pain significantly but also prevent the nausea and vomiting that result from the intake of opioids [3]. Finally, the type of anesthesia used (general vs intravenous use of propofol and ketamine) is shown to be an important factor in significantly reducing postoperative complications in aesthetic procedures [4].