Jacob G. Unger

3D analysis of breast augmentation defines operative changes and their relationship to implant dimensions.

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7–58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant.

An Innovative Three-dimensional Approach to Defining the Anatomical Changes Occurring after Short Scar-medial Pedicle Reduction Mammaplasty

Background: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. Methods: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. Results: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 ± 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 ± 0.2 postoperatively compared with 8.1 ± 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 ± 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 ± 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 ± 2 percent above the inframammary fold preoperatively versus 76 ± 2 percent postoperatively; p < 0.01). Conclusions: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures.

Three-Dimensional Imaging Provides Valuable Clinical Data to Aid in Unilateral Tissue Expander-Implant Breast Reconstruction

Abstract:  The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual‐estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three‐dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)‐implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre‐ and postoperative office visits. The 3D breast‐volume calculations served as a guide for surgical management. Twelve patients have completed 3D‐assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm3. The mean baseline breast asymmetry in this group was 12.0 ± 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 ± 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE‐implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome.

Mammometrics: The standardization of aesthetic and reconstructive breast surgery

The goal of cosmetic and reconstructive breast surgery is to create symmetric and aesthetically pleasing results in a reproducible manner. Although continued progress is dependent on the ability of plastic surgeons to accurately assess surgical outcomes, available methods to objectively evaluate aesthetic and reconstructive breast surgery are limited. This is quite different from other areas of plastic surgery, such as craniomaxillofacial surgery, that often use precise skeletal measurements to provide a platform for preoperative and postoperative analysis. In comparison, systematic evaluation of breast surgery has yet to be standardized. With the advent of three-dimensional photography, objective soft-tissue analysis of the breast is now possible. Recent work from our group and others has validated the use of three-dimensional breast photography in various clinical arenas, including autologous breast reconstruction, prosthetic breast reconstruction, reduction mammaplasty, and augmentation mammaplasty.1–7 Enthusiasm toward three-dimensional imaging technology has stemmed from the ability to not only obtain well-established breast measurements in an accurate manner, but also to generate measurements that were not previously possible with conventional tools, such as total breast volume, volumetric distribution, and breast projection. This article provides an overview of three-dimensional breast photography, with particular emphasis on its potential role to establish a standardized system for breast analysis. We introduce a new concept termed “mammometrics,” in which three-dimensional–based breast measurements can be used to help guide operative planning, objectively analyze surgical results, and document postoperative changes that occur over time.

Lift-and-fill face lift: Integrating the fat compartments

Background: Recent discovery of the numerous fat compartments of the face has improved our ability to more precisely restore facial volume while rejuvenating it through differential superficial musculoaponeurotic system treatment. Incorporation of selective fat compartment volume restoration along with superficial musculoaponeurotic system manipulation allows for improved control in recontouring while addressing one of the key problems in facial aging, namely, volume deflation. This theory was evaluated by assessing the contour changes from simultaneous face “lifting” and “filling” through fat compartment–guided facial fat transfer. Methods: A review of 100 face-lift patients was performed. All patients had an individualized component face lift with fat grafting to the nasolabial fold, deep malar, and high/lateral malar fat compartment locations. Photographic analysis using a computer program was conducted on oblique facial views preoperatively and postoperatively, to obtain the most projected malar contour point. Two independent observers visually evaluated the malar prominence and nasolabial fold improvements based on standardized photographs. Results: Nasolabial fold improved by at least one grade in 81 percent and by over one grade in 11 percent. Malar prominence average projection increase was 13.47 percent and the average amount of lift was 12.24 percent. The malar prominence score improved by at least one grade in 62 percent of the patients postoperatively, and 9 percent had a greater than one grade improvement. Twenty-eight percent of the patients had a convex malar prominence postoperatively compared with 6 percent preoperatively. Malar prominence improved by at least one grade in 63 percent and by over one grade in 10 percent. Conclusions: The lift-and-fill face lift merges two key concepts in facial rejuvenation: (1) effective tissue manipulation by means of lifting and tightening in differential vectors according to original facial asymmetry and shape; and (2) selective fat compartment filling of deep malar and high malar locations and nasolabial fold fat grafting to precisely control facial contouring. This was shown with objective numerical grading and through observer assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Re-defining pseudoptosis from a 3D perspective after short scar-medial pedicle reduction mammaplasty

BACKGROUND Bottoming out is a well-known phenomenon described with reduction mammaplasty (RM). To date, the evaluation of post-operative bottoming out remains an imprecise science. The following study reports the application of three-dimensional (3D) photography to objectively investigate changes in breast morphology. METHODS Patients undergoing medial pedicle RM had 3D photographs (Konica Minolta V910) taken during the early and late post-operative period (early=60-120 days; late=400-500 days). 3D images were compared and bottoming out was assessed with 3D parameters and vectors including total breast volume, volumetric tissue distribution above and below the Central (C) plane, distance of the C-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall. RESULTS Post-operative images from 15 consecutive RM patients showed an average volume of 556+/-144 cm3 (early) and 441+/-183 cm3 (late). The percent of tissue in the upper pole of the breast changed from the early to late post-operative period (76% vs. 69%, respectively; p<0.01). The distance from a fixed C-plane to the inferior pole significantly increased (42+/-15 mm early vs. 51+/-18 mm late; p<0.01). AP projection decreased by an average of 6.23 mm (p<0.01). The lateral border of the IMF significantly dropped by 6.27 mm. CONCLUSIONS This study objectively describes both the occurrence of bottoming out and the quantitative amount in terms of changes in volumetric distribution, surface topography and breast projection. With 3D photography, plastic surgeons can perform objective evaluation of breast transformation over time, which ultimately will aid in planning to allow for better surgical outcomes.

Improving Fat Transfer Viability: The Role of Aging, Body Mass Index, and Harvest Site

Background: Fat grafting remains unpredictable in the clinical setting, and variables that influence adipocyte survival, such as age, body mass index, and specific donor sites, are still not well understood. Methods: Twenty-four female subjects were enrolled in this research after institutional review board approval and signed consent to participate was obtained. Subjects were separated into groups according to (1) age (younger, ⩽45 years; and older, ≥46 years) and (2) body mass index (normal weight, body mass index <25; and overweight, body mass index ≥25). All fat samples were obtained through dry liposuction of three donor sites: lower abdomen, inner thigh, and flank. They were processed identically for dissociation of adipose tissue and isolation of adipocytes. Adipocyte viability was measured using the Nexcelom Cellometer Auto T4. Results: In younger patients, adipocyte viability was greater in the lower abdomen than in the flank; in older patients, this difference was not seen. When lower abdominal fat from younger was compared with that from older patients, the viability was higher in younger patients. However, adipocytes from the flank depot had higher viability in the older group compared with the younger group. Inner thigh fat viability was not significantly different across the two age groups. The authors also found no significant differences in fat viability for any given donor site between the normal weight and overweight body mass index groups. Conclusions: The optimal choice site for fat harvest should take patient age into consideration. In younger patients, both lower abdomen and inner thigh appear to be good options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty.

Background: Dorsal hump reduction can lead to significant aesthetic and functional deformities if one does not preserve and subsequently restore proper position of the upper lateral cartilages. The senior author (R.J.R.) previously described the component dorsal hump reduction to preserve the integrity of the upper lateral cartilages, thereby avoiding routine use of spreader grafts. In this study, the authors introduce their algorithm for reconstitution of the nasal dorsum. Methods: The charts of 100 consecutive primary rhinoplasty patients from the senior author’s practice were reviewed. The technique used for dorsal reconstitution, complications, and revisions were analyzed. Preoperative and postoperative images of the dorsal aesthetic lines were examined for symmetry and contour. Results: Mean follow-up was 19 months. A dorsal hump reduction of 5 mm or more was performed in 39 patients (39 percent). No patients received spreader grafts. The technique used for dorsum reconstitution was upper lateral cartilage tension spanning suture (type 1) in 65 percent, reapproximation (type 2) in 25 percent, and spreader flaps (type 3) in 10 percent. There were no significant complications and 4 percent required revision. Dorsal aesthetic lines were symmetric in 69 patients (69 percent) preoperatively and in 94 patients (94 percent) postoperatively. The authors found 65 dorsal aesthetic lines (32.5 percent) without contour irregularities preoperatively compared with 194 (97 percent) postoperatively. Conclusion: Reconstituting the nasal dorsum with repositioning of the upper lateral cartilages that is based on the individual anatomy of the rhinoplasty patient can provide durable cosmetic and functional results without the need for routine use of spreader grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reversal of skin aging with topical retinoids

Topical skin care and its place in plastic surgery today are often overlooked by clinicians formulating a plan for facial rejuvenation. Not only is it important to consider topical skin care as part of comprehensive care, but clinicians should also be educated with the data available in todays literature. This review aims to familiarize the reader with the biological processes of skin aging and evidence-based clinical outcomes afforded by various topical therapies. Furthermore, this review will focus on solar damage, the value of retinoids, and how they can be used in conjunction with forms of treatment such as chemical peel, dermabrasion, and lasers. Finally, guidelines will be provided to help the physician administer appropriate skin care based on the data presented.

A multivariate analysis of nasal tip deprojection.

Background: Projection of the nasal tip is a complex problem that often mandates attention during rhinoplasty. Occasionally, the goal is to decrease tip projection. Most published solutions to this problem involve division or manipulation of the lower lateral cartilages, although objective data on the efficacy of these techniques are limited. This study reviews a series of rhinoplasties and determines which maneuvers had the greatest effect on tip projection. Methods: One hundred twenty-five consecutive rhinoplasties performed by a single surgeon in a university setting were reviewed. Charts were analyzed for surgical indications and technical steps performed in the operating room. Preoperative and postoperative photographs underwent multivariate analysis to determine changes in nasal projection and which factors contribute to affecting tip projection. Results: Overall revision rate was 3.8 percent. Cartilage-splitting techniques were used in only 2.4 percent of cases. Multivariate dummy variable analysis revealed that only dorsal component reduction and caudal trim were associated with significant decreases in tip projection. Alar base resection did not change absolute tip position but did have a marked effect on the position of the alar-cheek junction and thus the overall balance of the nose with regard to length-to-projection ratios and projection proportions. Conclusions: Cartilage-dividing techniques are rarely necessary to reduce projection. Release of the soft-tissue attachments of the lower lateral cartilages and modification of the anterior septum are frequently sufficient to achieve a satisfactory aesthetic endpoint. Alar base resection has a complex interaction with nasal aesthetics with regard to tip projection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.