Howard A. Tobin

The Extended Subperiosteal Coronal Lift

The extended subperiosteal coronal lift is a new technique of facial rejuvenation. It appears to offer improved correction of sagging of the mid and upper face. Combined with traditional lower lifting, it affords a more balanced rejuvenation. The author describes his technique and discusses results, advantages, and complications based on an experience of over 100 patients who underwent extended coronal lifts, either alone or in combination with traditional lower facelift surgery.

Augmentation Mammaplasty with Saline-Filled Textured Implants: Review of 9 Years' Experience and Results of Patient Survey

Introduction: In June of 2000 the FDA approved saline-filled breast implants as safe prosthetic devices based on results of clinical testing presented by the manufacturers. The corresponding author has been using saline-filled implants since 1992. It was decided to review his experience and assess the incidence of postoperative complications as reported by the patients and to identify factors related to their satisfaction. Materials and Methods: A survey was mailed out to a cohort of 460 patients. The survey included questions pertaining to possible postoperative complications and the patients overall satisfaction. Overall, 207 surveys were returned after 2 mailings. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software. Results: The patients age at the time of surgery ranged from 18 to 62 years, with a mean of 33.8 years. Follow-up time ranged from 6 months to 102 months postoperatively, with a mean of 37.2 months. Forty-two out of 193 patients were smokers. Implant volumes ranged from 180 to 800 mL, with an average of 380 mL. Implant types used were McGhan (55.5%), Mentor (40.5%), and Microcell (4%). All implants had surface texturing. Most of the implants (90.7%) were placed in a submuscular position. Sixty-five percent of the patients preferred a transaxillary approach, whereas 35% preferred the periareolar approach. Discussion: Capsular contracture remains one of the main factors affecting patient satisfaction. Implant volume and position had no significant effect on the risk of developing capsular contracture. Furthermore, the volume of an implant did not have a significant impact on the risk of developing pain, loss of nipple sensation, or wrinkling. In this study, a significant number of patients reported wrinkling (44.4%) and alteration of nipple sensation (40.6%), which reflects the fact that this is a subjective patient-reported result. Overall satisfaction rate reported was 96.6%.

Cosmetic Blepharoplasty: A Comparison of CO2 Laser and Electrosurgical Technique

A study of blepharoplasty results was performed comparing a conventional electrosurgical technique to the CO2 laser. Patients were recruited for the study, in which a direct comparison of the techniques was made on each patient using the electrosurgical technique on one eye and the CO2 laser on the other. Both the physician and the patient evaluated the results independently throughout the postoperative period with follow-up to 3 months. Results demonstrated greater operative time with the CO2 laser. No significant difference between techniques was found with regard to pain, bleeding, and itching during the postoperative period or the final postoperative appearance at 3 months. Swelling and discomfort were significantly greater with electrosurgery on day 4 with the trend extending through the third postoperative week. Bruising was significantly greater in the laser-operated eye more often, but the amount relative to the electrosurgical eye for each patient was not significant in the opinion of the surgeon. Both techniques were determined to be safe with acceptable results.

Prevention of Venous Thromboembolism in Abdominoplasty

Introduction: Venous thromboembolism is an important and life-threatening complication associated with abdominoplasty, a common cosmetic procedure. Materials and Methods: A retrospective study of 100 consecutive patients who underwent abdominoplasty in an outpatient setting. Results: The complication rate was 35%. The most common complication was wound separation. No patient developed deep vein thrombosis, although 2 patients developed postoperative abdominal hematoma due to Lovenox prophylaxis. Conclusions: Abdominoplasty was found to be a safe and predictable outpatient procedure in our patient population.

Breast Capsulorrhaphy Revisited: A Simple Technique Utilizing a Gore-Tex Mesh

Introduction: Mammary prosthetic migration is a complication seen not infrequently after breast surgeries. Many factors can contribute to the displacement. When migration occurs, the patient is often left with a sense of disfigurement; and the surgeon faces a challenging repair. We present a case series describing 10 patients who have experienced implant migration and have had successful outcomes after capsulorrhaphies using Gore-Tex (expanded polytetrafluoroethylene). Materials and Methods: A retrospective review was performed of the charts of patients who underwent capsulorrhaphies at the Facial Plastic and Cosmetic Surgery Center between 1993 and 2010. We describe the surgical repair of implant migration using a Gore-Tex reinforced capsulorrhaphy. Results: Retrospective information was gathered for the period 1993 to 2010, during which time a total of 10 patients underwent revisional surgeries for implant migration. Notably, most patients had had multiple procedures before the onset of migration; 6 patients (60%) had had more than one prior breast procedure. Inferior displacement of the implant was the most common type of migration, occurring in 8 patients (80%). Two patients (20%) experienced relapse, and the remaining 8 patients (80%) demonstrated excellent results. Conclusions: Capsulorrhaphies have become a standard method in the repair of mammary prosthetic migration. Although the technique is generally effective, in some cases, additional stability is warranted. The adjunctive use of a Gore-Tex synthetic mesh can provide the necessary additional reinforcement. Gore-Tex used as an adjunctive procedure with capsulorrhaphies has resulted in long-lasting and cosmetically desirable outcomes.

B Mastopexy: Versatility and 5-Year Experience

Introduction: Many women are searching for restoration of a younger outward physical appearance. Mastopexy with or without augmentation may help improve or restore a womans breast shape at the price of scars on the breast. We describe our experience with the versatility and improved aesthetic result using the B mastopexy technique, which provides a natural-appearing breast contour with less scarring. Materials and Methods: A retrospective review was performed on 40 patients who underwent B-type mastopexy from June 2000 through August 2005. Our technique is described in detail including our approach when simultaneous augmentation is performed. Patients undergoing simultaneous augmentation to give additional fill to the breast typically received an implant size ranging from 240 mL to 300 mL. Results: B mastopexy was performed on 40 patients with simultaneous augmentation performed in 27 patients. There were no complications, and only 1 patient underwent scar revision. All patients were satisfied with final outcome. Conclusion: B mastopexy provides an approach to restoring a naturally appearing breast contour and a more youthful look when augmentation is performed simultaneously. The versatility and limited scar makes this our procedure of choice.

Endoscopic CO2 Laser-Assisted Capsulotomy—A New Therapeutic Method for Correcting Capsular Contracture

Introduction: Capsular contracture presents as a common and frustrating complication of breast augmentation surgery. Various strategies have been recommended for resolving this problem, including both closed and open techniques. However, morbidity associated with previously described procedures has left the clinician without a fully satisfactory solution. In this retrospective study, we report our experience with the endoscopic laser-assisted capsulotomy and suggest that it provides a safe, effective method of treating capsular contracture while minimizing morbidity. Materials and Methods: The endoscopic, laser-assisted capsulotomy is a technique that has been utilized for 10 years by the senior author and is presented here with our experience in 28 consecutive affected breasts treated over a 5- year period. The operation consists of a small periareolar access incision into the capsule space, followed by capsular release utilizing a CO2 Ultrapulse laser visualized with a 4-mm endoscope and specialized sleeve developed by the senior author. In this retrospective study, each patient was assessed by the senior author both pre- and postoperatively. Capsular contracture was graded according to Bakers classification method. Postoperative complications and their respective frequencies were also noted. Results: Of the 11 patients that initially presented with a Baker score of IV, 9 patients (82%) achieved an acceptable result after laser-assisted endoscopic capsulotomy. One patient (9%) had a final Baker score of III, but was pleased with the result and did not seek further treatment. One patient saw no change in Baker score and underwent a second endoscopic capsulotomy. A final Baker score of I was then achieved. Of the 16 patients that began with a Baker score of III, 15 (94%) achieved an acceptable result. One patient (6%) saw no change in Baker score but elected to forego further treatment. One patient that presented with an objectionable Baker grade II contracture achieved a Baker score of I following treatment. Complications noted included: intraoperative bleeding requiring drain placement in 3 patients, scar hypopigmentation in 1 patient, superficial skin infection in 1 patient that responded to oral antibiotics, and asymmetry between the operated and unoperated breast in 2 patients that did not require correction. Late-term complications included: 4 patients presented with recurrent capsule formation. All underwent a second capsulotomy procedure with acceptable results. Conclusion: To our knowledge, this is the first report of use of the CO2 Ultrapulse laser for this purpose. The capsuloscope sleeve used was developed by the senior author. The technique was effective in correcting capsular contracture, while minimizing complications, scarring, and patient morbidity.

Current Practice Standards in Liposuction

Liposuction: Practitioner Profile This paper is the result of the organized efforts of the American Academy of Cosmetic Surgerys Liposuction Practices Task Force, the primary organization providing information, research and training in liposuction. The task force commissioned the worlds largest professional services firm, Arthur Andersen, to conduct an independent survey ofAACS membership during the summer of 1998. The surveys focus includes liposuction practitioners, their training, practice standards, and complications. Collaborative preparation, writing and review of this paper was conducted by task force chairs Richard L. Dolsky, MD and Robert F. Jackson, MD, and task force members Robert w: Alexander, MD, DMD, Guillermo D. Castillo, MD, Claude H. Crockett, Jr., MD, Richard G. Glogau, MD, C. William Hanke, MD, Jeffrey A . Klein, MD, Edward B. Lack, MD, Marc S. Leventhal, MD, Steven E. Nathanson, MD, and Howard A. Tobin, MD. responded. The industry standard for a survey of this type is normally about 10 percent. Twenty-five surveys were received after the agencys deadline and were not included in the totals. Of the remaining 272 responses, 84.9 percent (231) of respondents report they currently perform liposuction.

The Use of GoreTex in Reconstruction of the Inframammary Fold

Inferior displacement of breast implants is a relatively common complication of breast augmentation. The authors describe the use of GoreTex® in the repair of a case that failed after a previous attempt at correction. Possible mechanisms that might lead to this complication are reviewed along with a discussion of the anatomy of the region of the inframammary fold

Tumescent Liposuction under General Anesthesia

Tumescent liposuction has been recently established as a technique of infiltration of dilute concentrations of lidocaine and adrenalin, which appears to drastically limit the amount of blood loss during liposuction surgery. Previous reports focused on its use under local anesthesia. I have found that it is equally applicable to patients undergoing liposuction surgery under general anesthesia and have also found that the concentration of adrenalin can be reduced from 1: 1,000,000 to 1: 4,000,000 without compromising the hemostatic effects. The technique allows relatively large amounts of fat to be aspirated safely without autologous transfusion.