Jacob Haiavy

A Review of General Cosmetic Surgery Training in Fellowship Programs Offered by the American Academy of Cosmetic Surgery

PURPOSEnWe sought, first, to evaluate the operative experience of surgeons who have completed postresidency fellowships offered by the American Academy of Cosmetic Surgery (AACS), and second, to compare this cosmetic surgery training to other surgical residency and fellowship programs in the United States. Finally, we suggest how new and existing oral and maxillofacial surgeons can use these programs.nnnMATERIALS AND METHODSnWe reviewed the completed case logs from AACS-accredited fellowships. The logs were data mined for 7 of the most common cosmetic operations, including the median total number of operations. We then compared the cosmetic case requirements from the different residencies and fellowships.nnnRESULTSnThirty-nine case logs were reviewed from the 1-year general cosmetic surgery fellowships offered by the AACS from 2007 to 2012. The fellows completed a median of 687 total procedures. The median number of the most common cosmetic procedures performed was 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations, and 189 liposuctions. The data obtained were compared with the minimum cosmetic surgical requirements in residency and fellowship programs. The minimum residency requirements were as follows: no minimum listed for plastic surgery, 35 for otolaryngology, 20 for oral and maxillofacial surgery, 28 for ophthalmology, 0 for obstetrics and gynecology, and 20 for dermatology. The minimum fellowship requirements were as follows: 300 for the AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and 0 for Mohs dermatology.nnnCONCLUSIONnDedicating ones practice exclusively to cosmetic surgery requires additional postresidency training owing to the breadth of the field. The AACS created comprehensive fellowship programs to fill an essential part in the continuum of cosmetic surgeons education, training, and experience. This builds on the foundation of their primary board residency program. The AACS fellowships are a valuable option for additional training for qualified surgeons seeking proficiency and competency in cosmetic surgery.

Survey of Transumbilical Breast Augmentation (TUBA)

Transumbilical breast augmentation (TUBA) has been used for at least the past 17 years as an alternative to other approaches for augmentation. There are essentially few articles that have included the possible risks and complications and their rate. This study, using a form, was done to collect as many cases as possible to determine the type of TUBA procedure used and the rate of some of the possible complications. A total of 5073 cases were reported and the statistics evaluated.

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%.

Injectable Fillers in the Upper Face

Facial fillers are valuable in volumetric rejuvenation of the upper face, alone, or as an adjunct to cosmetic surgical facial procedures and neurotoxins. The injector must evaluate the need of the patient and select the appropriate filler for specific anatomic area. HA fillers are considered the workhorse of volumetric facial enhancement owing to simplicity of use, limited adverse effects, and reversibility. Autologous fat grafting is gaining more popularity with long-term predictable results. Choice of facial filler is a shared decision between the patient and the surgeon. It is important for the facial surgeon to familiarize himself or herself with different types of existing facial fillers to choose the right material for the right anatomic area.

2012 American Academy of Cosmetic Surgery Review of Anesthesia Safety for the Cosmetic Surgeon

Safety guidelines from many different medical specialties have been developed and are frequently used to establish a standard of care. The American Academy of Cosmetic Surgery appointed a committee to produce a review of anesthesia safety for cosmetic surgeons. This document is not intended to represent a standard of care, but reflects what the committee considers to be key elements of practice that benefit patient safety when anesthesia is being used as part of the practice of cosmetic surgery.

Correction of Implant Malposition with Capsulorrhaphy: A Retrospective Review and Implementation of Patient Survey

Introduction: Aesthetic breast surgery is rapidly evolving and is now the most commonly performed cosmetic surgery; more than 311 000 breast augmentations were performed in 2009. Over the years, the average implant size has increased. It is to be expected that with the increasing number of breast augmentation procedures performed, the rate of implant malposition has increased as well. This problem can be addressed in a systematic way to restore symmetry to the breasts through a surgical procedure consisting of a capsulorrhaphy. Materials and Methods: A retrospective chart review was done from August 2004 through May 2009. All patients who had undergone revisional breast surgery involving capsulorrhaphy were included in the study. Patients were asked to complete a 2-page survey. Intraoperatively, correction of implant malposition involved medial, lateral, and/or inferior capsulorrhaphy. The technique of capsule modification will be described in detail. Results: During the period from August 2004 through May 2009, 30 patients underwent capsulorrhaphy breast surgery for implant malposition. A 2-page survey was completed by 22 of the 30 patients (73%). Average implant size for patients needing capsulorrhaphy surgery was 502.5 mL and 60% were silicone implants. The time from original breast augmentation to revisional surgery was 53.2 months (36.4 months, excluding 2 patient outliers who were >20 years out from their original breast augmentation). The most common problem was inferior or inferolateral implant malposition, which occurred 79% of the time. Bilateral malposition occurred 21% of the time. In all, 91% of patients needed narcotic pain medicine for less than a week, and 59% discontinued narcotic pain medication within 3 days. Patients were taped on average 3.14 weeks. A total of 82% of patients said they had improvement or marked improvement with their current results, and 36% stated that they currently were very symmetric. Follow-up ranged from 3 months to 62 months; mean time from capsulorrhaphy surgery to completion of the patient survey was 22.2 months. In all, 82% of patients stated that if given a choice, they would undergo revisional surgery again. Finally, when asked about overall satisfaction with their experience and results, 86% of patients stated that they were satisfied, 45% were very satisfied, and 14% of patients were unsatisfied. Conclusions: Information collected by the patient survey following our surgical technique shows that the problem of implant malposition following breast augmentation can be addressed and treated by capsulorrhaphy surgery with good aesthetic outcomes and high patient satisfaction. In addition, a recovery with little postoperative discomfort and a decreased need for narcotic pain medicine can be expected. Little information has been published on implant malposition after breast augmentation. More research needs to be dedicated to this common problem.

The Use of Mesh Reinforcement during Abdominoplasty: A Case Report and Literature Review:

Introduction: Abdominoplasty is a well-established procedure that consistently ranks in the top 5 most common cosmetic surgical procedures performed in the United States per year. In cases of severe myoaponeurotic laxity some surgeons choose to supplement their procedure with the placement of mesh to reinforce their plication. Some surgeons place mesh on a more routine basis. There is limited data in the literature to substantiate the use of synthetic mesh. This is a case report and review of the literature for the use of mesh reinforcement during abdominoplasty. Materials and Methods: A case report is presented, detailing the infectious complications suffered by 1 patient subsequent to abdominoplasty with mesh reinforcement. A thorough review of the literature was performed. Literature was evaluated with respect to the number of patients, age range, type of mesh, method of fixation, follow-up interval, complications, and cosmetic results. Results: Four studies were found assessing the use of mesh reinforcement during abdominoplasty. Number of patients was limited, ranging from 18 to 52. Types of mesh included Polypropylene, Prolene, and Vicryl. No infection, dehiscence, or extrusion of mesh were reported. Authors report stable repair with follow-up ranging from 6 months to 54 months in cases involving severe myoaponeurotic laxity only. Conclusions: Following review of the literature, it is clear that the evidence to support routine placement of mesh during abdominoplasty is lacking. As demonstrated by the case report described, placement of mesh in any procedure puts the patient at risk for undue sequelae. Our recommendations are as follows: Do not use mesh reinforcement during routine abdominoplasty. In only the worst cases of myoaponeurotic laxity, consider placing mesh using an onlay technique or in a submuscular layer (if experienced with this procedure), recognizing the limitations of the current literature on this subject. In either case, the surgeon should be aware of the significant risks of complications involved with these procedures, including seroma, umbilical and flap necrosis, as well as infection. If mesh is placed at the time of surgery, make certain that the patient is aware of the fact. In cases of wound infection where mesh was placed, have a high suspicion for mesh infection and a low threshold for reoperation.

Reoperative Face and Neck Lifts

The complexity of the reoperative facelift or neck lift is directly related to the way the primary procedure was performed. Regardless of the primary technique used, the secondary procedure should be directed to the specific problems that the patient exhibits, such as scars, earlobe deformity, hair pattern changes, laxity in the upper face or neck, jowling, or deepening of the nasolabial folds. Contour should be restored within the deep layer support via the elevation of the superficial musculoaponeurotic system and platysma rather than rotating skin flaps in an exaggerated manner in a cephalad direction, producing a tight unnatural look.

Facial Rejuvenation with Barbed Sutures: A Retrospective Analysis of Technique and Results

Introduction: In the last thirty years, various techniques of face-lifting have been developed. Many of these operations require a long recovery. With the increased public awareness of cosmetic surgery, the demand for effective procedures with minimal downtime and quicker recovery is on the rise. We set out to examine a technique of facial rejuvenation with barbed sutures, originally described by Dr M.A. Sulamanidze, and its effectiveness. Materials and Methods: Twenty-seven patients were treated with the APTOS sutures for facial ptosis from May 2002 to October 2003. The patients were followed for 3 to 28 months. The areas treated were the brows, cheeks, jowls and neck. Digital images were taken at each preoperative and postoperative visit. Almost all of the cases (25 of 27) were performed under local anesthesia. The results were evaluated at each postoperative visit by the patients and the surgeons. Results: Two hundred and eighty-two sutures were placed in the 27 patients. The malar area was the most commonly treated (88.9% of patients) section of the face. The brows and jowls were the second most common area of treatment (40.7%). The neck was the least common area of treatment (29.6%). The patients mean age was 50.9 years. The average follow-up time was 18.6 months. The results were evaluated by the patients and the surgeons based on a subjective rating of improvement when compared to the preoperation pictures in the specific area of treatment. Overall patient improvement rating was highest in the malar region, at 55%, compared to a doctor improvement rating of 40%. Pearson correlation analysis showed that the patients perceived degree of improvement was directly correlated (P < 0.01) with the patients overall satisfaction. The most common reason for dissatisfaction was patient disappointment with longevity of results. Complications encountered during the study were suture extrusion, bruising, pain, asymmetry, dimpling of skin, and visible suture tracts. Conclusions: Placement of barbed sutures into the soft tissues of the face for facial lifting is a developing technique. The APTOS lift, as advocated by Dr Sulamanidze, is a limited procedure that is indicated primarily in patients with mild to moderate ptosis who are seeking a subtle improvement in their appearance that is temporary and requires minimal downtime. It is not a replacement for a facelift. When patients are properly informed and educated about the benefits and limitations of this procedure, the chances that they will be satisfied is much higher.

Capsular Contracture in Breast Augmentation: Medical Management and Indications for Capsulectomy

This article reviews the literature on the etiology and management of capsular contracture, focusing on indications for capsulectomy along with explantation of breast implants. This article outlines the clinical factors which should be considered when managing capsular contracture. This article offers the most comprehensive review to date of surgical and nonsurgical management of capsular contracture. The goal of treatment is to prevent recurrence of capsular contracture, minimize risk to the patient, and obtain esthetic results. Capsulectomy is indicated in the majority of cases when breast implants are being removed or replaced in the setting of contracture. However, the surgeon must consider the risks and benefits of capsulectomy.