Fritz E. Barton

Anatomy of the subcutaneous tissue of the trunk and lower extremity.

Dissections on 8 fresh and 10 embalmed cadavers were used to determine the anatomy of the subcutaneous adipose tissue in the trunk and extremities. These dissections, along with CT scans, confirmed Grays original description of the subcutaneous tissue consisting of a superficial and deep adipose layer. The superficial adipose layer is contained within organized, compact fascial septa. The deep adipose layer demonstrated regional variations with respect to its fascial framework, but was contained within a relatively loose, less organized, and more widely spaced fascial septa. We observed that the adipose layers are partitioned by a discrete subcutaneous fascia which fuses with the underlying muscle fascia at particular anatomic locations. The deep layer is thus contained by the subcutaneous fascia above and the muscle fascia below to form what we termed the deep adipose compartments. The deep adipose compartments contributed significantly to overall adipose thickness, are bilateral, and are found in the abdomen and paralumbar and gluteal-thigh regions.

Rhytidectomy and the Nasolabial Fold

I describe a technical modification in the Skoog face lift procedure that releases the deep attachments of the SMAS to the muscles of facial expression for maximal mobility of the medial cheek yet elevates the cheek flap as a composite of skin, subcutaneous tissue, and SMAS to enhance skin perfusion. My results with the procedure in 100 patients are analyzed by using functional zones of the nasolabial fold corresponding to underlying musculature and a simple grading system based on preoperative and postoperative photographs. Marked improvement in the nasolabial fold was noted in over 80 percent of patients by 6 and 12 months postoperatively. This effect seemed to last up to 4 years. (Plast. Reconstr. Surg. 90: 601, 1992.)

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

Optimizing breast pocket irrigation: an in vitro study and clinical implications.

Subclinical infections have been implicated in the etiology of capsular contracture. Intraoperatively, breast pocket irrigation with povidone-iodine or other antibiotic solutions has been popularized; however, detrimental effects on wound healing for these agents have been reported and their efficacy against common organisms found around breast implants has not been studied. The purpose of this study was to compare the in vitro efficacy of serial dilutions of povidone-iodine and two double antibiotic solutions DAB-1 (gentamicin/polymyxin B) and DAB-2 (gentamicin/cefazolin), against organisms most commonly found around breast implants. In phase I trials, serial dilutions of povidone-iodine and DAB were combined 1:1 with cultures of five common organisms found around implants. In phase II, povidone-iodine was serially diluted in DAB-1 rather than saline. In phase III, povidone-iodine was serially diluted with DAB-2. Efficacy for all phases was determined by plating the mixture onto agar plates and incubating at 37 degrees C for 48 hours. Povidone-iodine was 100 percent effective at a dilution of 12.5% against Staphylococcus epidermidis and 25% against Staphylococcus aureus but relatively ineffective against Escherichia coli and Pseudomonas, DAB-1 was found to be ineffective against S. epidermidis but effective against S. aureus, Propionibacterium acnes, E. coli, and Pseudomonas. In phase II trials, a concentration of 12.5% povidone-iodine in DAB was effective at killing all experimental bacteria. In phase III trials, 10% povidone-iodine in DAB-2 was effective at killing all bacteria tested. In conclusion, to maximize bacterial control of common breast implant organisms and to minimize the detrimental effects on wound healing, 10% povidone-iodine in gentamycin/cefazolin may be used with excellent results and its use clinically may reduce the incidence of capsular contracture.

The SMAS and the nasolabial fold.

In a series of histologic sections and clinical and cadaver dissections, the superficial musculoaponeurotic system (SMAS) is seen to become the investing fascia of the zygomaticus major and minor muscles in the medial cheek. The pull on the cheek flap during rhytidectomy is diffused by the attachment of the SMAS to these muscles. I believe that this attachment accounts for the minimal change in the nasolabial crease after a Skoog-type sub-SMAS face lift.

Long-term assessment of CO2 facial laser resurfacing: aesthetic results and complications.

Several series have documented the ability of the carbon dioxide laser to smooth facial rhytids; however, follow-up has been limited to several months. Since 1995, more than 600 full or partial facial resurfacings were performed with the pulsed CO2 laser. To assess the long-term efficacy and safety of this procedure, the results of 211 resurfacings were retrospectively reviewed using a custom-designed database. Variables that were input included patient demographics, Fitzpatrick skin type, smoking history, prior and concurrent facial procedures, laser pass data, and postoperative complications. Short and long-term aesthetic results were graded by a blinded panel of plastic surgery reviewers (none of whom performed the laser resurfacing) using a standardized photographic rhytid scale. For each facial region, this scale consisted of eight high-resolution photographs depicting increasingly severe wrinkling. Facial rhytids were almost completely ablated at the 3 and 6 month follow-up. Some relapse was seen at 1 year, but the overall aesthetic result remained very good. Regions with dynamic rhytids (e.g., the perioral region) showed more recurrence. The best and most durable results were seen in the cheeks. Infection and scleral show each occurred in 13 patients (6 percent). Forty-five patients (21 percent) developed postprocedure hyperpigmentation, but the overwhelming majority of this group were treated before our postoperative antipigment regimen. Hypopigmentation was noted in 17 patients (8 percent) in this early follow-up group. Two patients (1 percent) developed postoperative scarring. It is hoped that these data will serve to provide additional information on the long-term results of laserbrasion.

Optimizing breast-pocket irrigation: The post-Betadine era

The practice of breast-pocket irrigation with various antibiotic solutions is supported by good literature and extensive clinical practice among most plastic surgeons. Unfortunately, recent restrictions on the use of Betadine (povidone-iodine) for breast-pocket irrigation have left many plastic surg

Fat extrusion and septal reset in patients with the tear trough triad: A critical appraisal

Arcus marginalis release, fat extrusion, and septal reset were applied to 71 selected patients with a constellation of orbital deformities the authors term a “tear trough triad.” Of the initial 71 patients, 59 had complete follow-up records. Evaluated by means of a proportional topographic scale, 95 percent of patients achieved significant improvement. Equally important, no incidence of middle lamella contracture occurred in the entire series. The authors conclude that the procedure is safe and effective in selected patients.

Anatomy of the nasolabial fold

An anatomical evaluation involving the nasolabial fold was performed on three fresh cadavers. Both gross and histologic analyses were made. The mimetic muscles were noted to have dermal extensions to the skin overlying the nasolabial fold. The dynamics of these mimetic muscles were evaluated subsequently in the clinical setting. Marked dimples and contour irregularities could be elicited by selectively contracting these muscles. Our findings suggest that it may be possible to improve the contour over the nasolabial fold during rhytidectomy procedures by severing the dermal extensions of the mimetic muscles along the nasolabial fold. This may allow better gliding of the skin and subcutaneous tissue over the nasolabial fold, thereby resulting in a smoother crease.

Effect of 4% topical lidocaine applied to the face on the serum levels of lidocaine and its metabolite, monoethylglycinexylidide.

BACKGROUND Topical lidocaine is a common form of anesthesia for a wealth of procedures across a large number of disciplines, including laser treatments. Preparations can be purchased over the counter with no prescription necessary. It is considered a safer and more acceptable form of anesthetic than hypodermic injections; however, there have been reports of fatalities following its application. Above certain serum lidocaine concentrations, patients may experience effects of toxicity such as lightheadedness and paraesthesia; these effects can progress to seizures and cardiorespiratory depression, which can ultimately lead to death. The active metabolite of lidocaine, monoethylglycinexylidide (MEGX), can be almost as potent as lidocaine in terms of toxicity. OBJECTIVES The authors examine the levels of both lidocaine and MEGX in blood serum after application of topical lidocaine. METHODS Twenty-five healthy volunteers were assigned to one of four groups (A, B, C, D). Group A had 2.5 g of 4% lidocaine topical anesthetic cream applied to the face for one hour without occlusion, Group B had 5 g applied to the face for one half-hour without occlusion, Group C had 5 g applied to the face for one hour without occlusion, and Group D had 5 g applied to the face for one hour with occlusion. To evaluate serum concentrations, blood was drawn every 30 minutes for four hours. RESULTS Group D showed the highest serum levels of lidocaine and MEGX, a three-fold increase compared with group C, which received the same dose (5g topical 4% lidocaine) but without occlusion. In group D, peak serum levels occurred at 90 minutes for serum lidocaine, which was also the fastest of the four groups. Serum MEGX levels peaked much later than serum lidocaine levels, at 210 minutes. Individual serum levels did not exceed 0.6 µg/mL. Across the groups, there was significant interindividual variation in both lidocaine and MEGX serum levels (P = .061). Applications of 5 g of 4% lidocaine resulted in higher serum concentration of both lidocaine and MEGX. When comparing group A to group C, doubling the dose of 4% lidocaine from 2.5 g to 5 g resulted in double the serum levels of MEGX and a 50% increase in the serum lidocaine levels (P = .021). When comparing groups C and D, the addition of an occlusive dressing resulted in a tripling of the serum lidocaine levels and a doubling of the serum MEGX levels, both of which were statistically significant (P < .001). When comparing all four groups, there were significant differences between the combined serum concentrations of lidocaine and MEGX (P < .001). CONCLUSIONS Topical lidocaine preparations are increasingly being employed to provide a patient-friendly form of noninvasive analgesia for a multitude of procedures. Some preparations are available over the counter for unsupervised patient application. Our study has demonstrated significant interindividual variability for a given dose, especially when occlusion is applied. There have been fatalities resulting from topical lidocaine application, and our study suggests that this is the result of the unpredictability of lidocaine metabolism between individuals. Therefore, we recommend that caution be exercised with topical lidocaine preparations, in particular when applied in conjunction with occlusive dressings.