Henrique N. Radwanski

Surgical treatment of hemangiomas of the nose.

The approach to a rapidly growing vascular tumor is determined by a number of objective and subjective factors. As a rule, treatment of a hemangioma in an infant is usually delayed, in the expectation that involution will be complete. While most hemangiomas are harmless vascular marks, some may grow to become large, infiltrating masses. Local factors that influence treatment decision making include volume, ulceration, secondary infection, and bleeding of the tumor. Hemangiomas situated on the nose are distinguished from other locations by a few but important aspects and may demand a more aggressive position from the surgeon. An important consideration is the potential for aplasia of the delicate nasal cartilages that are undergoing development, due to the mass effect of the tumor. Nasal tip hemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that invariably remains even after total involution. More importantly, hemangiomas of the nasal region are particularly prone to causing great social distress to the parents, who will request prompt treatment for such a visible, deforming lesion. A definite solution that ensures removal of affected tissue and preservation of anatomy seems to be the best treatment for these tumors. In this article, the experience of the senior author (IP) in treating hemangiomas located on the nose is reviewed. The elliptical midline incision over the nasal dorsum described in the text was developed to address three important aspects: an expedient procedure to treat a highly disfiguring disease; an open access to allow for complete resection and, at the same time, allow for the correction of underlying cartilaginous disruption; and placement of a scar in an anatomic location proven to be very satisfactory aesthetically, permitting access for secondary procedures for better definition of nasal contour. Careful patient selection for this surgical procedure is emphasized.

Numerical modeling of facial aging.

Facial aging is a biological phenomenon. Skin properties change with time, and gravity and facial expressions exert mechanical deformation. Knowledge of these alterations may suggest ways to reverse them by identifying the corresponding distortional forces. The aim of this study was to determine a pattern of change for parameters of the face during the aging process, based on the numerical fitting of measures from a sample of patients. The first aspect of this study was to define adequate facial parameters and means of measuring them. Subsequently, each parameter was defined individually, and these data were analyzed as a set. The sample for the research was restricted to a group of 40 white female patients with a history of limited exposure to the sun, with ages ranging from 25 to 65. The reason for choosing this sample was the availability of frontal pattern photographs at different ages. The parameters for each patient were measured at two different ages. A strong correlation was found between age and behavior of the parameters. This aging model can be verified qualitatively by comparing photographs of a patient with manipulated photographs simulating aging. The quantitative verification of the model was done through the comparison of the measured and the predicted parameters.

The surgical importance of the dermocartilaginous ligament of the nose.

The dermocartilaginous ligament of the nose, as first described by the senior author, has been shown to influence the equilibrium of the dorsum-tip relationship. In some noses, this is manifested by a residual convexity after routine rhinoplastic management of the osteocartilaginous structures. The anatomic findings are reported, and surgical considerations are analyzed. A system of classification based on the thickness of the ligament has been shown to be helpful in the intraoperative evaluation of this structure.

Ethical Issues in Plastic and Reconstructive Surgery

Plastic, reconstructive, and cosmetic surgery refers to a variety of operations performed in order to repair or restore body parts to look normal or to enhance a certain structure or anatomy that is already normal. Several ethical considerations such as a patient’s right for autonomy, informed consent, beneficence, and nonmalfeasance need to be given careful consideration. The principal objective of the medical profession is to render services to humanity with full respect for human dignity. Plastic surgeons should merit the confidence of patients entrusted to their care, rendering to each a full measure of service and devotion. They require an extensive amount of education and training. The increases in demand for aesthetic plastic surgery and the advocacy of practice in the media have raised concerns about the circumstances under which cosmetic surgery is ethical and permissible. Innovative research, and new technologies derived from such research, almost always raises ethical and policy concerns. Medical ethics regulate what is, and what is not, correct in promoting plastic surgery to the public. It is essential to create an educated and informed public about the ethical issues in the plastic and reconstructive surgery field. Plastic surgeons need to carefully evaluate the degree of deformity, physical and emotional maturity, and desired outcome of patients who request plastic surgery procedures. Science is a powerful force for change in modern society and plastic surgeons have a responsibility to shepherd that change with thoughtful advocacy and careful ethical scrutiny of their own behavior.

Relative Implant Volume and Sensibility Alterations After Breast Augmentation

BackgroundRecent studies have provided diverging results regarding the factors that may affect sensibility after primary breast augmentation. Implant volume is believed to be an important factor, but the relation of implant size to breast volume has not been adequately addressed. In addition, the literature shows that a conflict exists when the periareolar and inframammary approaches are compared. This study aimed to refine the volumetric analysis comparing the implant and final breast size as well as the intrinsic association of these two factors with postoperative sensory alteration of the breast.MethodsA prospective study investigated patients who underwent aesthetic breast augmentation between June 2004 and October 2005 (i.e., a 16-month period) at the Ivo Pitanguy Institute. The sensibility in nine regions of the breast was tested before and after surgery using Semmes-Weinstein monofilaments. Breast sizers were used to compare the pre- and postoperative breast volumes. Statistical analysis of the data took into consideration the relative volume of the implant, the surgical approach, the presence of minor complications, the breast-feeding history, and the subjective evaluation of sensory changes in the patients.ResultsA total of 37 patients who underwent breast augmentation were examined preoperatively. The relative volume of the implant was found to be associated with sensibility alterations. No difference was found between the periareolar and inframammary incision approaches. Other factors such as previous breast-feeding, minor complications, and subjective alterations were not associated with sensory alterations.ConclusionsThe study findings suggest that larger implants and smaller breasts show an increased association with postoperative sensory alterations of the breast. Plastic surgeons and their patients should be aware of this possibility. Implant volume should be considered together with breast size to avoid sensory complications, and this is summarized in the concept of relative volume.

Repeated expansion in burn sequela.

This paper presents a retrospective study of the use of 346 expanders in 132 patients operated at the Ivo Pitanguy Clinic, between the period of 1985 and 2000. The expanders were used in the treatment of burn sequela. In the majority of cases, more than one expander was used at the same time. In 42 patients, repeated tissue expansion was done. The re-expanded flaps demonstrated good distension and viability. With the increase in area at each new expansion, larger volume expanders were employed, achieving an adequate advancement of the flaps to remove the injured tissue. The great advantage of using tissue re-expansion in the burned patient is the reconstruction of extensive areas with the same color and texture of neighboring tissues, without the addition of new scars.

Contour surgery in the patient with great weight loss.

Abstract. Obesity can be defined as a chronic disease in which there is excess of body adiposity, leading to severe secondary health problems. This metabolic pathology shortens life-span and is a main cause of diabetes, atherosclerosis, systemic arterial hypertension, and reduction of pulmonary function, among others. The plastic surgeon is involved with the obese patient under two circumstances: either the patient is currently overweight and requests reduction of excess adipose tissue, or has suffered a great weight loss and desires correction of one, or more, contour deformities. In either case, planning demands a close preoperative analysis and careful preparation of the patient, execution of a meticulous surgical routine, and close postoperative follow-up. In this article, various body contour deformities will be addressed, showing the senior authors strategy in treating the obese patient that has achieved the loss of considerable weight.

Treatment of the Aging Face Using the “Round-lifting” Technique

Abstract Background: Characteristics of the aging face include not only senescence and flaccidity of the skin, but also sagging of deeper tissues, especially in the fascial and fatty layers. Objective: This study was undertaken to evaluate the different surgical approaches to the aging face, specifically the techniques available for correction of the prominent nasolabial fold, which is a significant sign of facial aging. Methods: Through a total of 7446 cases in more than 40 years of experience in the surgical correction of the aging face, the senior author has emphasized the importance of the repositioning of the skin and the facial soft tissues. After appropriate treatment of the superficial musculoaponeurotic system (SMAS) and the malar fat pad has been completed, adequate placement of the skin flaps is done by rotation, as described in the round-lifting technique, rather than by direct traction. The anatomic basis of this correction is discussed. Results: Traction of the SMAS was found to soften the appearance of the nasolabial fold to varying degrees, but other complementary procedures such as collagen injection or fat grafting often were necessary to achieve a more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varied with each individual and his or her unique aging process. Simple traction of the SMAS did not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results. Again, long-term correction by this technique is related to the aging process, and the final result was deemed superior to treatment of the SMAS alone. Direct excision of the nasolabial fold was performed in patients ranging from 35 to 60 years of age who had extremely prominent folds. In these very select cases, the results were considered satisfactory to both the surgeon and patient, with correction of the fold and acceptable scars. Conclusions: There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely.

On skin expansion

This article discusses skin expansion without considering cellular growth of the skin. An in vivo analysis was carried out that involved expansion at three different sites on one patient, allowing for the observation of the relaxation process. Those measurements were used to characterize the human skin of the thorax during the surgical process of skin expansion. A comparison between the in vivo results and the numerical finite elements model of the expansion was used to identify the material elastic parameters of the skin of the thorax of that patient. Delfinos constitutive equation was chosen to model the in vivo results. The skin is considered to be an isotropic, homogeneous, hyperelastic, and incompressible membrane. When the skin is extended, such as with expanders, the collagen fibers are also extended and cause stiffening in the skin, which results in increasing resistance to expansion or further stretching. We observed this phenomenon as an increase in the parameters as subsequent expansions continued. The number and shape of the skin expanders used in expansions were also studied, both mathematically and experimentally. The choice of the site where the expansion should be performed is discussed to enlighten problems that can lead to frustrated skin expansions. These results are very encouraging and provide insight into our understanding of the behavior of stretched skin by expansion. To our knowledge, this study has provided results that considerably improve our understanding of the behavior of human skin under expansion.

Long-Term Ultrasonographic Evaluation of Midline Aponeurotic Plication During Abdominoplasty

Background: The purpose of this study was to evaluate the efficiency of the plication of the anterior rectus sheath during abdominoplasty and the anatomical characteristics of patients with recurrence. Methods: Thirty-eight patients were selected. Patients had undergone abdominoplasty between 1 and 5 years previously. Patients were divided into two groups: group A, 18 patients who had undergone surgery 5 years previously; and group B, 20 patients who had undergone surgery 1 year before. All patients were submitted to a complete physical examination by the plastic surgeon to evaluate the abdominal wall. In addition, an ultrasound examination was performed by the same radiologist in all patients to evaluate rectus diastasis recurrence at two levels: in the supraumbilical region and in the infraumbilical region. The insertion of the recti muscles in the costal margin was also assessed. Groups were compared using Fisher’s exact test and the t test. Groups were similar regarding age, body mass index, number of smokers, physical activity, and number of pregnancies. Results: There was no recurrence of diastasis in any cases of the group with a follow-up of more than 5 years, whereas in the 1-year follow-up group there were two cases of recurrence of the diastasis. Only one of the patients who had recurrence of rectus diastasis had a clinical complaint. Conclusions: Recurrence of rectus diastasis is not directly related to the length of the follow-up. It may occur within the first year after abdominoplasty. Recurrence of diastasis diagnosed by ultrasound is not related to a clinical complaint. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.