Marlene Rankin

National Plastic Surgery Survey: Face Lift Techniques and Complications

The purpose of this study was to assess trends in technique and philosophy of face lifting, associated procedures, and the incidence and management of complications. Surveys were sent to 3800 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS); 570 surveys (15 percent) were returned. Numerous very specific technique and philosophy questions were asked. Details of demographics, techniques, incidence of complications, management of complications, and basic philosophy are presented. Three basic conclusions can be gleaned from this study: (1) Surgeons perform more tried and true methods of aesthetic surgery, rather than the many new methods that seem to get the most attention in the media and at the meetings. (2) It seems that less-experienced surgeons tend to be generally more conservative in their approach to aesthetic surgery. (3) Complication rates reported by the plastic surgery community at large coincide with previous complication rates, as outlined in other nonsurvey studies. The authors expect to report additional data from the survey—on brow surgery (part II) and facility and ancillary procedures (part III)—in forthcoming publications. (Plast. Reconstr. Surg. 106: 1185, 2000.)

Quality-of-life outcomes after cosmetic surgery.

Cosmetic surgery is an increasingly common medical procedure whose benefits to patients have not been quantified objectively. The purpose of this study was to prospectively examine long-term quality-of-life outcomes for patients undergoing elective cosmetic surgery. In this prospective, correlational study of 105 consecutive patients undergoing elective cosmetic surgery, the parameters of quality-of-life index, depression, social support, and coping were determined preoperatively and at 1- and 6-month intervals postoperatively. The data from the four study instruments were analyzed using Pearson correlation and repeated measures of multivariate analysis of variance for differences in each variable over time. The multivariate analysis of variance quality-of-life index scores for patients improved from baseline preoperative mean levels of 3.24 to a mean of 2.56 at 1 month, and then to 2.11 (f = 518.5, p = < 0.0001) at 6 months postsurgery. Mean scores for depression [determined by using the Center for Epidemiologic Studies Depression Scale (CESD)], improved from 11.2 preoperatively to 6.5 at 1 month, and to 6.3 (f= 79.3, p = < .0001) at 6 months after surgery. Surgical intervention produced no significant differences between preoperative and postoperative ways of coping and social support scores. Cosmetic surgery produces positive psychological benefits by significantly improving quality-of-life outcomes that persist long term, without adversely affecting social support and ways of coping.

Perceived functional impact of abnormal facial appearance.

Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with “normal” and “abnormal” congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.

Reevaluating the need for routine drainage in reduction mammaplasty.

&NA; The incidence of complications after reduction mammaplasty without drains was reviewed by analysis of 50 bilateral reduction mammaplasty procedures. Patients ranged in age from 14 to 65 years; the average combined volume removed was 953 g. Eighty‐four percent of the patients underwent a Pitanguy technique, and the remaining patients underwent an inferior pedicle or amputative technique with free nipple grafts. Three patients had six complications; one of these patients had three of the complications. Complications included two cases of fat necrosis and one case of wound disruption. One patient had a hematoma with wound disruption and partial nipple loss. There were no cases of infection. The purpose of this study was to determine the rate of complications in reduction mammaplasty performed without drains. Incidentally, statistical analysis using the chi‐squared test revealed that this series without drains compared favorably with previously published data for reduction mammaplasty using drains. It is concluded that routine closed suction drainage after reduction mammaplasty is unnecessary and should be reconsidered. (Plast. Reconstr. Surg. 102: 1917, 1998.)

Lidocaine is not necessary in liposuction.

Lidocaine is an integral part of most wetting solutions used in liposuction. Although the Physicians Desk Reference states that the permissible dose of lidocaine is 7 mg/kg, doses as high as 75 mg/kg have been used in liposuction. Lidocaine is used in the wetting solution even when the procedure is performed under epidural or general anesthesia. The justification for this is a reduction in postoperative pain. This study compared the pain between paired, mirrored sides of 10 patients when lidocaine was used on only one side. There was no statistically significant difference between the postoperative pain at 5, 30, 60, and 120 minutes and on the first postoperative day. Because there was no difference in pain whether or not lidocaine was used, and because lidocaine is potentially toxic and lethal, this study concludes that lidocaine is not necessary in liposuction.

anxiety Disorders in Plastic Surgery

Surgery is a stressful event, with the potential for profound disturbance to the patients psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patients reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patients psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.

Appearance is a function of the face.

Background: Increasingly, third-party insurers deny coverage to patients with posttraumatic and congenital facial deformities because these are not seen as “functional.” Recent facial transplants have demonstrated that severely deformed patients are willing to undergo potentially life-threatening surgery in search of a normal physiognomy. Scant quantitative research exists that objectively documents appearance as a primary “function” of the face. This study was designed to establish a population-based definition of the functions of the human face, rank importance of the face among various anatomical areas, and determine the risk value the average person places on a normal appearance. Methods: Voluntary adult subjects (n = 210) in three states aged 18 to 75 years were recruited using a quota sampling technique. Subjects completed study questionnaires of demography and bias using the Gamble Chance of Death Questionnaire and the Rosenberg Self-Esteem Scale. Results: The face ranked as the most important anatomical area for functional reconstruction. Appearance was the fifth most important function of the face, after breathing, sight, speech, and eating. Normal facial appearance was rated as very important for one to be a functioning member of American society (p = 0.01) by 49 percent. One in seven subjects (13 percent) would accept a 30 to 45 percent risk of death to obtain a “normal” face. Conclusions: Normal appearance is a primary function of the face, based on a large, culturally diverse population sample across the lifespan. Normal appearance ranks above smell and expression as a function. Restoration of facial appearance is ranked the most important anatomical area for repair. Normal facial appearance is very important for one to be a functional member of American society.

Secondary abdominal contour surgery: a review of early and late reoperative surgery.

A retrospective chart review of 400 abdominal contour operations produced a series of 24 patients who underwent both their primary and then their secondary abdominal contour surgeries with the senior author (Matarasso). The majority of patients were classified and treated according to the abdominoplasty classification system previously described; however, a subgroup could not be categorized according to this system. In this study, the authors identified the secondary abdominal contour surgical experience of one surgeon. A comparison was made between two groups of patients treated for both primary and secondary operations: group I, considered early, less than 18 months after the previous operation; and group II, considered late, 18 or more months after the previous operation. There was a significant difference between groups I and II (&khgr;2 = 4.12, p = 0.05); most patients had their surgical procedures before 18 months. For patients who underwent either a miniabdominoplasty or a full primary abdominoplasty, there was a statistically significant difference between the number of patients treated in group I and the number in group II (Fisher’s exact test, D = 0, p = 0.05). Next, the nature of the secondary procedure was determined to be either a revisional procedure or a completely new reoperative procedure. The majority of patients underwent revision or “touch-ups,” accomplished with either liposuction alone or in combination with scar revision. There was no significant difference between types of primary and secondary procedures performed in group I or group II. Secondary abdominal contour surgery accounted for 6 percent (24 of 400) of all abdominal contour procedures performed by one surgeon. Complete secondary surgery, performing an additional open procedure, occurred in 21 percent of cases (five of 24). Revision surgery (scar revision or removal of dog-ears) was performed in 29 percent of all cases (seven of 24). There was a 4 percent (one of 24) complication rate requiring operative intervention. This rate is consistent with that reported in the literature for primary abdominal contour surgery. With the overall acceptance of aesthetic surgery increasing, the number of patients undergoing abdominoplasty increasing, an aging population, and the safety of secondary abdominal contour surgery suggested from this review, it is likely that plastic surgeons will see more patients requesting secondary abdominal contour surgery in the future.

Age-based Comparisons of Patients Undergoing Secondary Rhytidectomy

BACKGROUND Statistics published by The American Society for Aesthetic Plastic Surgery report a 48% increase in cosmetic procedures for 2000-2001 and a 14% increase for rhytidectomies alone. Patients aged 35 to 50 account for 30.2% of all rhytidectomies performed. Many of these patients undergo secondary rhytidectomy. OBJECTIVE We investigated differences between patients undergoing secondary rhytidectomy and those undergoing a primary rhytidectomy, and between older (more than 60 years) and younger (60 years or less) patients undergoing secondary rhytidectomy. METHODS A retrospective descriptive research design with the computer cross-filing system of the senior author (A.M.) was reviewed for patients undergoing secondary or more (ie, tertiary, quaternary, etc) rhytidectomy. A total of 113 consecutive patients were identified; charts from 98 female patients and 3 male patients, were available for review. Ages at the time of surgery ranged from 40 to 81 years, with an average of 60. RESULTS Among patients older than 60 undergoing secondary face lift, 41 of 53 patients (77%) had combined procedures with their most recent face lift; 39 of 53 (74%) of these patients had at least one comorbid medical condition. Among patients aged 60 or younger undergoing secondary face lift, 37 of 48 patients (77%) underwent multiple procedures along with their most recent face lift, and 16 of 48 patients (33%) had at least one comorbid medical condition. The overall complication rate was 2/101 (2%). CONCLUSIONS There is a statistically significant increase in the number of comorbid medical conditions in older patients. The overall complication rate in patients undergoing secondary rhytidectomy compares favorably to that traditionally quoted for patients undergoing primary rhytidectomy, who on average are younger at the time of surgery. This suggests that in properly screened patients, even in older patients with combined ancillary procedures, secondary face lifting is both common and safe. (Aesthetic Surg J 2002;22:526-530.).

Resumption of sexual activity after plastic surgery: Current practice and recommendations

Background: Information on sexual counseling and practice guidelines after plastic surgery is quite limited and poorly documented as part of clinical care after surgery. The aim of this study was to assess board-certified plastic surgeons’ current practices and to make clinical recommendations for resumption of sexual activity in the postoperative period. Methods: A descriptive mailed survey of randomly chosen American Society of Plastic Surgeons’ members was designed to evaluate plastic surgeons’ methods of screening for sexual concerns, the frequency of postoperative discussions with patients, and clinical recommendations for safe sexual positions. Results: There were 281 respondents, for a response rate of 40 percent. A minority of plastic surgeons (32.9 percent) felt it was the surgeon’s role to provide postoperative sexual counseling regarding restrictions and guidelines; the majority of plastic surgeons (63 percent) felt that their nurse should provide this service. Patients never (46.6 percent) or rarely (23.8 percent) asked about sexual activity restrictions after surgery. Some surgeons (27.8 percent) proactively discussed postoperative sexual activity, but 57.3 percent said they rarely or never gave specific advice. There were gender differences; male plastic surgeons discussed specific sexual techniques and positions significantly more frequently than female plastic surgeons (p = 0.001), and patients ask male plastic surgeons significantly more frequently about sexual activity restrictions than they do female plastic surgeons (p = 0.001). Conclusions: Many plastic surgeons gave little or no advice to patients regarding resumption of sexual activity after surgery, and the majority of patients do not initiate the discussion. Most surgeons expect their nursing staff to provide sexual counseling.