Jeffrey C. Popp

Fat hypertrophy after autologous fat transfer.

Purpose To describe fat graft hypertrophy after autologous fat transfer. Methods Case report. Results Noticeable hypertrophy of autologous fat grafts at approximately 10-year follow-up. Conclusions This case report demonstrates the unpredictable nature of autologous fat grafting. Clinicians should be aware of this potential complication of fat hypertrophy after autologous fat grafting.

Sentinel lymph node biopsy for conjunctival melanoma.

Objective To investigate the feasibility and safety of preoperative lymphoscintigraphy and sentinel lymph node (SLN) biopsy for conjunctival melanoma. Methods A 49-year-old man with a biopsy-proven malignant melanoma of the conjunctiva (caruncle) underwent preoperative lymphoscintigraphy and SLN biopsy using a technique in which both isosulfan blue dye and technetium Tc 99 m sulfur colloid were injected in the subconjunctival space around the primary lesion. The conjunctival melanoma was excised just before identification and removal of the SLNs. The SLNs were excised along with concomitant dissection of their associated lymph node basins. The SLNs were evaluated histologically using serial sectioning and immunohistochemical staining with antisera against the S-100 protein and the melanoma antigen HMB-45. Results Three SLNs were identified in the left submandibular and the left upper and middle jugular lymph node basins during the preoperative lymphoscintigraphy. The same three SLNs were successfully identified in the operating room. The SLNs were histologically negative, and the immunohistochemical staining against S-100 and HMB-45 was also negative. We did not observe any immediate adverse effects on the globe or the periocular structures from lymphatic mapping and SLN biopsy. By 24 hours after injection of blue dye, only a faint trace of blue was visible on the ocular surface. Conclusions Preoperative lymphoscintigraphy and SLN biopsy can be performed safely in patients with conjunctival melanoma. A larger study is planned to determine the sensitivity of this technique for the detection of occult regional nodal disease in patients with conjunctival melanoma.

Lateral Wall Advancement in Orbital Decompression

Treatment of dysthyroid orbitopathy can be enhanced with a modified craniofacial approach using a lateral wall osteotomy, and anterolateral advancement and osteosynthesis in conjunction with medial and inferior wall orbital decompression. The technique of lateral wall advancement is described, and the results are discussed. While the authors advocate orbital decompression for dysthyroid optic neuropathy, advancement of the lateral orbital wall can easily be performed as an adjunct to the two- or three-wall decompression procedure. Advancement appears to increase the overall decompressive effect by providing a potential space where lateral expansion can occur and by enlarging the bony orbital volume. It also appears to lessen lid retraction and facilitates (and in some cases, obviates) the need for further lid retraction surgery.

Refinements of the Tarsal Strip Procedure

We present several refinements in technique that simplify the tarsal strip procedure and enhance its results. Among these refinements are: electrosurgical deepithelialization of conjunctiva and lid margin, use of a V-shaped needle, direct needle passage about the lateral orbital tubercle, and the parallel placement of a buried absorbable suture to unite the upper and lower lid margins and to maintain a long-lasting sharp canthal angle. We have used these maneuvers in 45 patients with few complications; patient acceptance has been high. Also, we have found that using these maneuvers is helpful in teaching the procedure to residents.

Simultaneous lateral, anterior, and posterior (SLAP) lower-lid blepharoplasty.

We report a hybrid of procedures for correcting the aging lower eyelid--transconjunctival blepharoplasty, skin blepharoplasty, and skin-muscle blepharoplasty--that maximizes the strengths of these procedures while minimizing their shortcomings. Our procedure, a simultaneous lateral, anterior, and posterior blepharoplasty, simultaneously attacks the lateral canthal angle, the anterior lamella, and the posterior lamella of the eyelid.

Reinforced Swan-Neck, Flexible Shaft, Beveled Liposuction Cannulas

Introduction: Traditional liposuction cannulas and ultrasonic liposuction cannulas have had the feature of relative rigidity in common. Herein we introduce a new design that allows a patients entrance wound to act as a fulcrum, enabling the surgeons guiding hand to redirect cannulas with long, flexible shafts and highly reinforced swan necks. The nonultrasonic version of this cannula system includes a highly beveled tip adjacent to a triport (Accellerator III) set of openings. The new cannulas easily penetrate fibrous fat, reach fat deposits distant from the entrance wounds, and curve within the subcutaneous tissue below the dermal envelope, thereby reducing the need to move a patients body position intraoperatively. A novel Teflon entrance wound insert that resembles the shape of a calla lily aids in the use of the system, thereby reducing cannula friction inside the insert and maximizing friction via projections on the outside of the insert. This friction outside of the insert maintains the inserts position in the wound during cannula backstroke. Materials and Methods: Reinforced swan-neck, flexible shaft, triport bevel cannulas (RSFSTBCs) have been used successfully in hundreds of liposuctions performed by one of us (P.J.W.). P.J.W. has also used the Capistrano cannula tip with success. Capistrano cannulas and RSFSTBCs of 2.5 mm and 3.5 mm diameter were compared in 12 patients (eight female and four male) on contralateral but otherwise identical fat deposits. Results: No adverse effects were noted with either system; no indentations, inordinate bruising, seromas, or infections occurred. The reinforced swan-neck cannulas penetrated tissue with greater ease, and the flexible shafts allowed the operator to arc the cannulas to greater distances within the body. Thus the operator could reach more areas with fewer entrance wounds and less movement of patients on the operating table. Novel cannula motions occurred as a result of using the patients entrance wound as a fulcrum and redirecting the distal shaft and tip of the cannula with an opposing hand. Discussion: The long, flexible shafts of the RSFSTBC system allow for a reduction in the need for cannula entrance wounds. The beveled tip provides for ease of penetration, even in fibrous tissues. The reinforced swan neck, in combination with the flexible shaft, enables the use of both mildly and highly arced cannula paths via several mechanisms.

Monopolar Cautery for Graft Cartilage Sculpting in Reconstructive Eyelid Surgery

We describe a technique for using the monopolar cautery to sculpt ear cartilage to prepare it for use as a graft to reconstruct or support the posterior lamella of the eyelid in oculoplastic procedures. We have used this simple, rapid, and predictable technique in 16 patients with excellent results.

Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction.

Any reader of this book might conclude that the professionals practicing anesthesiology are emulating the classic “Three Stooges,” Larry, Moe and Curly—instead of the appropriately esteemed Barash, Stoelting, and Miller. Some readers may go one step further and find it to be a derogatory discourse that tarnishes our specialty by portraying the anesthesia profession in an extremely negative light. The basis of Klein’s arguments seems to be made up of old references, anecdotal reports, self-made statistics based on selfobservation, and archaic cross-specialty citations. In presenting challenges to the safety of modern anesthesia, Klein refers to poor clinical judgment, human error, and carelessness on the part of anesthesiologists. This casts an ominous and false shadow on the extraordinary progress we have made during the last two decades. For example, he asserts that the dangers of patient monitoring may outweigh the benefits and suggests that prudent and appropriate handling of a monitor alarms by anesthesiologists is more an exception than a rule. While alluding to our implied ineptitude, Klein strings together a variety of causes for anesthesiarelated catastrophes. Further along in the book, using contorted reasoning, he remarks that there is a dose-response relationship between general anesthesia and pulmonary embolism. Based on his conclusion, a reader may believe that Virchow’s triad should be updated, perhaps supplanting stasis with general anesthesia. Klein tackles the issue of anesthesia-related mortality in a very curious and highly unorthodox fashion, implying that the risk may be as high as one (1) death for every one thousand (1000) general anesthetics. Perhaps unintentionally, some of Klein’s preposterous prose may serve to needlessly misinform and frighten. It distorts the realities of modern anesthesia care, where more patients than ever before receive exemplary care provided by intelligent, skilled, wellintentioned physician anesthesiologists using the latest technology. Surgeons do not escape Klein’s criticism. He equates the personality traits of surgeons with minimally effective care. In addition, he states that systemic anesthesia tends to release surgeons from common-sense restraints—and the lack of knowledge about his suggested safe dose of lidocaine results in the use of more general anesthesia. I am certain that most surgeons would disagree with his reasoning and conclusions. However, Dr. Klein’s book is not without merit. His discussions concerning the pharmacokinetics and pharmacodynamics of local anesthetics are very instructive. The sections that review the potentiation and inhibition of the cytochrome P450 system, and the effect on local anesthesia metabolism, are very complete. Every anesthesiologist would benefit from reviewing the list of medications that affect cytochrome P450 function and local anesthesia metabolism. In addition, he does an excellent job reviewing the procedural aspects of surgical liposuction and some of the nuances to consider, especially impressive considering the fact that he has not completed a residency in surgery. Every office-based anesthesiologist recalls the very first time he/ she provided anesthesia care for a tumescent liposuction patient. The routine inquiry about the dose of lidocaine the patient was anticipated to receive was probably answered with 35, 40, or 50 or more mg/kg. Thinking that this must be a mistake, and the dose was probably 5 mg per kg, a long discussion probably ensued with the surgeon or dermatologist. At this point, the surgeon or dermatologist probably evoked Dr. Klein’s name and rationale, the same way a discussion of home runs would, of course, involve Babe Ruth or Barry Bonds. Dr. Klein’s suggested maximum dose of lidocaine (50 mg/kg) and the exact way in which it must be administered— with epinephrine and into the subcutaneous fat—is based partly on personal observation, a strong dose of deductive reasoning, anecdotal reports, toxicity experienced by patients at higher doses, and to a lesser extent, basic scientific study. Nevertheless, Dr. Klein deserves much credit for bravely outlining his rationale for using such high doses of anesthesia, and explaining why it is safe in his opinion. His large-dose lidocaine anesthesia tumescent technique is becoming, or has become, a standard in the liposuction community. Therefore, despite his derisive and pejorative insinuations about our professional value and skill, familiarity with this book has some merit. Although he is unlikely to be invited to an anesthesia department lectern or to your home for dinner, Dr. Klein does has something interesting to say and many ambulatory and office-based anesthesiologists might therefore consider reading Tumescent Technique.