Joe M. Gryskiewicz

Waste not, want not: the use of AlloDerm in secondary rhinoplasty.

Background: This article describes the authors successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in secondary rhinoplasty. AlloDerm is a cadaver dermal filler graft, an off-the-shelf product that is readily available, pliable, and affordable. It is particularly suited for secondary rhinoplasty patients who are graft-depleted. The maximum dorsal augmentation is less than or equal to 3 mm; it is not a support graft. The major indication in this study was dorsal augmentation in the overresected secondary rhinoplasty patient to create a soft, smooth bridge and pleasing dorsal aesthetic lines. Methods: Twenty-five secondary rhinoplasty patients underwent multiple nasal corrections and were followed for 2 to 8 years. Results: Analysis demonstrated no contour changes between year 1 and year 2, showing the dermal grafts to be stable after 1 year. Long-term follow-up for 2 years or longer showed good results, although partial graft resorption (defined to be ≤ 50 percent) occurred in 45 percent of patients. Resorption was most common over the bony dorsum, with approximately 20 to 30 percent of the graft absorbing; over the tip, approximately 10 to 15 percent of the graft absorbed. Conclusion: Absorption did not seem to relate to the number of layers used. AlloDerm does not shift. Overall, the experience for nasal augmentation in secondary rhinoplasty was en-couraging. Partial absorption, especially over the bony dorsum in a thin-skinned patient, is a definite disadvantage. Complete absorption was not seen in this study. The author has discovered that it is imperative to overcorrect the defect intraoperatively. Regrafting is possible and sometimes necessary.

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates.

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker’s preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.

Visible scars from percutaneous osteotomies.

Background: One of the criticisms of the percutaneous lateral nasal osteotomy technique is the potential for unfavorable, visible scarring. No clinical study has compared the external percutaneous approach with an internal approach to evaluate scarring in the same patient. This prospective, randomized, blinded study was designed to test the hypothesis that percutaneous perforating osteotomies cause perceptible scars when compared with the transnasal internal lateral osteotomy methods. Methods: Fifty consecutive rhinoplasty patients requiring bilateral osteotomies (100 total lateral osteotomies) were prospectively randomized (institutional review board no. 1341-1M) so that each patient received an external skin puncture perforating osteotomy on one side and an internal lateral osteotomy on the control side. The percutaneous skin puncture was made with the flat edge of the sharpened 2-mm unguarded osteotome. The puncture site was approximated with Steri-Strips as part of the postoperative nasal splint. All patients were evaluated for scarring on the left versus the right side of the face at 1, 3, and 6 weeks; 6 months; 1 year; and when possible up to 2 years after the operation. The median follow-up in this series is over 1 year. Results: The external percutaneous ap-proach caused a visible scar in three patients (6 percent) as noted by three blinded examiners. One of these patients (2 percent) required a scar revision. Care must be taken to cleanse the chisel before percutaneous entry. This practice should avoid a traumatic tattoo. Conclusion: Percutaneous osteotomies generally produce an imperceptible scar (94 percent) but may cause a visible scar in a small percentage of patients.

Current clinical practices of the Rhinoplasty Society members.

IntroductionAs rhinoplasty remains among the most challenging and controversial operations in plastic surgery, we sought to elucidate present-day practice characteristics. Members of The Rhinoplasty Society were polled in preparation for the national meeting held in Boston, Mass, on May 2011. The goal was to provide information regarding surgical approaches used as well as technique and practice patterns used. MethodsTwo electronic surveys were distributed to members of The Rhinoplasty Society in preparation for the annual meeting. All 76 members received the surveys as well as instructions for completion. The initial survey included 10 questions discussing the preferred approach for rhinoplasty and practice details. The second survey dealt with specific techniques used during rhinoplasty. Data were collected and reviewed. ResultsThe primary survey yielded a 61.8% response rate, whereas the secondary survey 48.7%. Of all surgeons, 72% reported doing the open approach for primary rhinoplasty more than 50% of the time, whereas the remaining 28% use the closed approach. For secondary rhinoplasty, 76% reported using the open approach in more than half of cases for which they were not the primary surgeons. In contrast, 53% used the closed approach in more than half the cases of secondary surgery if they were the initial surgeons. Revision rates for primary and secondary rhinoplasties were 9.1% and 7.8%, respectively. The difference was not statistically significant. On average, members performed 101 nasal surgeries per year. Previous patient recommendation was the most common reason for referral. Of the members, 54% reported using spreader grafts in more than half of the cases of aesthetic rhinoplasty and 75.7% when pertaining to functional rhinoplasty. Finally, 37.8% of responding members reported using tip grafts more than half the time when performing aesthetic rhinoplasty. ConclusionsOf the responding members of The Rhinoplasty Society, the open approach is the preferred choice for both primary and other surgeons’ revision rhinoplasties. Spreader grafts are commonplace in both functional and aesthetic rhinoplasties.

Transaxillary Nonendoscopic Subpectoral Augmentation Mammaplasty: A 10-Year Experience With Gel vs Saline in 2000 Patients—With Long-Term Patient Satisfaction Measured by the BREAST-Q

BACKGROUND Transaxillary augmentation mammaplasty (TAM) is an option for patients who wish to avoid a visible breast incision from breast augmentation (BA). OBJECTIVES The authors compared TAM outcome data for gel and saline implants and evaluated patient satisfaction using the BREAST-Q patient-reported outcome measure (BQ). METHODS In this 10-year retrospective, comparative, and cross-sectional study, the authors reviewed results of saline implants placed with TAM in a surgeons practice during the final 5 years of the moratorium of the US Food and Drug Administration (phase 1) and compared them with results for gel and saline implants placed with TAM during the 5 years after the moratorium (phase 2). Outcomes were assessed for the entire BA study population (n = 2430 for primary BA; 4860 implants); 670 patients completed and returned the BQ, from which postoperative satisfaction was evaluated. RESULTS BQ responses demonstrated a high rate of patient satisfaction, with outcomes comparable to those of other studies. The differences between the median BQ-assessed breast satisfaction and outcome satisfaction scores in the axillary and nonaxillary surgical groups were statistically significant, favoring axillary over nonaxillary. The difference in mean satisfaction scores was marginally significant between the 2 types of implants, favoring silicone gel. The incidence of surgical revision was 7.5% for the entire BA study population and 6.8% for the patients who underwent TAM. CONCLUSIONS TAM produces long-term patient satisfaction as measured by the BQ. Complication rates are similar to those of other studies. In the present study, patients who underwent TAM and thus had hidden incisions were more satisfied than patients whose incisions were visible. LEVEL OF EVIDENCE 3.

What doctors aren't being told: Using the freedom of information act

An enormous amount of information on adverse events for medications and medical devices is out there. Unfortunately, obtaining this information sometimes reminds me of an interrogation process. I have had to cite the Freedom of Information Act to gain access to information physicians are not always being told. Take my experience with using the asthma medications Accolate (AstraZeneca, Wilmington, Del.) and Singulair (Merck & Co. Inc., Whitehouse Station, N.J.) to treat capsular contracture after breast augmentation. On the basis of clinical observation, several plastic surgeons postulated that these asthma medications would help prevent and treat breast implant capsules.1,2 After reading these assumptions, I contacted five of my patients who had breast implant capsules. I started all five on Accolate. Subsequently, I reviewed the Physicians’ Desk Reference description of Accolate and read that “if liver dysfunction is suspected based on clinical signs and symptoms, Accolate should be discontinued.”3 In most cases, discontinuing Accolate completely reversed hepatocellular dysfunction, the Physicians’ Desk Reference description continued. But, I read, in rare cases patients progressed to liver failure. Because I had not been advised of any significant side effects to Accolate, my discomfort level increased after reading these statements. I thought of something I had once heard: “I do not mind bad news, but I hate surprises.” So I contacted the manufacturer, AstraZeneca, and spoke with the Pharm.D. I kept detailed notes of my conversation. I was told normal doses of Accolate caused liver failure in eight reported patients—mostly women who presented with anorexia, right upper quadrant pain, pruritus, and jaundice. Two patients ended up having orthotopic liver transplants. The onset of hepatocellular dysfunction ranged from 2 to 18 months. Feeling really uneasy, I logged on to WebMD.com. This is not an authoritative Web site for medical information, but at the same time, it does present historical and factual data. WebMD reported that data associated Accolate with liver damage as far back as December 20, 2000. The Micromedex.com Web site contained an article stating that since April of 1997, the manufacturer recommended discontinuing Accolate use “if liver dysfunction is suspected based upon clinical signs or symptoms.” The WebMD article said AstraZeneca had been working with the Food and Drug Administration since these reports surfaced. In discussions with the Food and Drug Administration, the manufacturer was asked to possibly reissue an official warning, but instead it sent out a notice, which I believe was part of what I quoted earlier. If symptoms were to worsen, liver function tests should be performed; if results were elevated, Accolate should be stopped immediately, the WebMD information stated. I reviewed the notes from my call to AstraZeneca and contacted another Pharm.D. there because I was puzzled about the term “reported.” “Reported” meant eight published cases of patients with hepatocellular dysfunction, two of whom progressed to hepatic failure. So I asked about the word “published.” This meant cases found in the medical literature, the Pharm.D. said. Having written papers myself, I realize the effort and time it takes to publish in a peer-

Achieving Quicker Recovery After Breast Augmentation

What surgeon would allow a breast augmentation (BA) patient to return to normal activity on the first day after surgery? In this article, the author reviews his BA population with respect to postoperative recovery. The goal was to determine whether certain adopted practices would predictably return BA patients to full normal activities within 24 hours of surgery, thus sparing them a slow, painful recovery. The quicker-recovery principles and practices described in this article have been used for 2871 cosmetic BA patients since 2002 and are based on 3 time points (Table 1). These preoperative, intraoperative, and postoperative methods were thoroughly discussed with each patient during the initial preoperative consultation. View this table: Table 1. Protocol to Minimize Pain and Suffering After Breast Augmentation Patient expectations were carefully managed. We reviewed our outcomes data with patients preoperatively so they could be confident about returning to normal daily activities by the morning after surgery. We shared our book of testimonials in which our previous patients described how quickly they recovered; these testimonials included detailed descriptions of household and social activities pursued on the actual evening of the surgery. We also maintain a voluntary referral list of former patients (which includes first name and telephone number) so that new patients can contact them to discuss how quickly their recovery progressed. Multiple techniques described previously, as well as additional practices of the author, …

Book-Review: Mastering Rhinoplasty

Rollin K. Daniel, MD Mastering Rhinoplasty. 2nd ed. New York, NY: Springer, 2010. ISBN: 978-3-642-01401-7 I still remember, as a young surgeon, nervously paging through Sheen’s texts, trying to find a patient who vaguely resembled my rhinoplasty patient scheduled for the next morning.1-2 Dr. Rollin Daniel’s text, Mastering Rhinoplasty , would have been a perfect reference, had it been available at the time. Thanks to its logical organization—down to the molecular level—the reader will instantly find his or her target case, supported by photos and a DVD menu detailing the adjacent intraoperative maneuvers. In all, this text offers 259 color figures and intraoperative photos, in 1408 parts within 12 chapters. It should be noted that Mastering Rhinoplasty is a second edition in name only. Ninety percent of the text and case studies are new; only the basic anatomy and aesthetic drawings remain the same from the previous edition. According to Dr. Daniel, this text is an attempt to relay the fundamentals of a standardized rhinoplasty operation, while allowing for the human face’s endless anatomical variants and their requisite interventions. Even though the text is aimed at the average, well-trained nasal surgeon, the budding resident surgeon and the sage nasal surgeon alike will also greatly benefit from the lessons therein. To this end, the cases are divided into three levels, from easiest to more difficult. Fundamental operations are presented in a step-by-step fashion, with progressive adaptations for the three levels of deformity. The commentary in the text is insightful and enlightening, and there is a candid question-and-answer section. The questions are similar to …