Nabil Fanous

Absence of capsular contracture in 319 consecutive augmentation mammaplasties: Dependent drains as a possible factor

Capsular contracture is one of the major complications of augmentation mammaplasty. A review of 638 augmented breasts in 319 consecutive patients who underwent primary augmentation, with an average follow-up of 17.2 months and without a single case of capsular contracture of any degree to date, is presented, along with a discussion of the surgical technique and complications, and an analysis of measures used to prevent capsular contraction. Each patient received a pair of smooth saline-filled implants (Mentor, USA) placed in the submuscular space through an inframammary incision. In all operated breasts, many of the known measures commonly used for capsular contracture prevention were implemented. As well, a dependent drain was used as the final hemostatic step to prevent blood accumulation in the pocket. Leaving a dependent drain in the dissected pocket overnight, as one of the sequence of measures aimed at eliminating blood accumulation, is believed to be a contributing factor in capsular contracture prevention.

Premaxillary augmentation : Adjunct to rhinoplasty

Recession of the premaxillary area is a relatively common deformity. Typically, it presents as a mild weakness of the central maxilla, but in certain instances, such as in the Black and Asian communities, it may be moderate to severe. This condition can be compounded by a narrow nasolabial angle, recessed alar bases, and sunken cheeks. To resolve this deficiency, a new design for premaxillary augmentation is suggested. A bat-shaped premaxillary implant is used for correction. The implant is introduced by means of an intranasal or intraoral approach, while the patient is under either local or general anesthesia. Thirty-three patients have been managed for premaxillary recession and have been corrected by premaxillary augmentation. Satisfactory cosmetic results have been achieved, with only a few minor complications.

A New Patient Classification for Laser Resurfacing and Peels: Predicting Responses, Risks, and Results

Abstract. Traditional classifications for skin treatment modalities are based on skin characteristics, the most important being skin color. Other factors are considered as well, such as oiliness, thickness, pathology, and sensitivity. While useful, these classifications are occasionally inadequate in predicting and explaining the outcome of some peels, dermabrasions, or laser resurfacing procedures. Why, for example, would a Korean patient with a light white skin inadvertently develop more hyperpigmentation than his darker skinned French counterpart? The new classification introduced here is based on the racial and genetic origins of patients. It suggests that racial genetic predisposition is the determining factor in human response to skin injury, including skin treatments. This classification takes into account both skin and features, rather than skin alone. It offers a new approach in evaluating patients scheduled for skin peels or laser resurfacing, in the hope of helping physicians to better predict reactions, select the appropriate type and intensity of the skin treatment and, ultimately, better control the outcome. Six categories (sub-races) are described: Nordics, Europeans, Mediterraneans, Indo-Pakistanis, Africans, and Asians. The reaction of each sub-race to peels, laser resurfacing, or dermabrasion is analyzed. The risks associated with each group are noted. This new classification provides physicians with a practical way to evaluate patients prior to treatment, with a view to determining each patients suitability, postoperative reaction, the likelihood of complications, and likely result.

Laser Resurfacing of the Neck: A Review of 48 Cases

Abstract. With the advent of the new sophisticated carbon dioxide (CO2) laser, effective treatment of facial rhytides and pigmented lesions of the photodamaged skin has been gaining popularity. Partial and full facial skin resurfacings have been reported. However, resurfacing of the neck has been ignored or discouraged. The objective of this study is to assess the feasibility, benefits, and risks of laser resurfacing of the neck, combined with the additional resurfacing of the whole face. A total of 48 patients underwent the procedure with a high-power and short-exposure time CO2 laser (ultrapulse). Patients were evaluated and classified preoperatively. The great majority of patients had local anesthesia (topical and infiltrative) with minimal sedation. A computer pattern generator was used in all cases but one. In this paper, preoperative preparation, postoperative care, laser resurfacing techniques, and depth guidelines are discussed. Incorporating the neck with the facial resurfacing has given very satisfactory results, with minimal drawbacks.

Correction of thin lips: a 17-year follow-up of the original technique.

The demand for lip augmentation in the older population and, occasionally, the younger one remains high. During the natural course of the aging process, the progressive loss of soft-tissue bulk and the flattening of the lip contour create an appearance of thin lips and their associated stigmata of old age. In general, methods for lip augmentation fall into two categories: (1) local oral mucosal flaps and (2) autologous grafts, alloplastic implants, or injections.1 Numerous techniques have been described to address the senile lip,2–9 including V-Y plasty, lip-lifting buffalo horn excision, frenulum plasty, fat or dermal-fat grafting, use of polyacrylamide hydrogel, use of polytetrafluoroethylene tube, and silicone microgel injection, among others. In 1984, the lip lift technique10 was published as a procedure for correcting thin lips. Since its original publication, several modifications have been introduced. Outlined below are the revised evaluation of the lip complex and the modifications to the original lip lift technique, as experienced by the authors over a 17-year period.

Universal Trichloroacetic Acid Peel Technique for Light and Dark Skin

Importance Despite their great potential, medium and deep trichloroacetic acid peels are underused in light-skinned patients and are rarely used in darker-skinned patients because of the widespread fear of pigmentary complications and scarring. This concern has led many physicians to opt for the use of lighter types of peels (glycolic acid peel, Jessner peel, etc) and different lasers and intense light technologies. Trichloroacetic acid peels have been described in numerous publications. However, no study to date has described the precise technique and the practical pearls of a successful trichloroacetic acid peel approach in a clear, detailed, and reproducible manner. Objectives To clarify a practical approach to a universal trichloroacetic acid peel and to offer novice and experienced facial plastic surgeons an organized, easy, and safe technique for medium and deep trichloroacetic acid peels. Design, Setting, and Participants This study was a case series of universal trichloroacetic acid peels in an academic setting. The study dates were January 1, 1996, to November 1, 2015. Main Outcomes and Methods This article discusses the preoperative evaluation for a chemical peel, a previously published genetico-racial skin classification, and the trichloroacetic acid peel technique, which aims at standardizing and controlling the application of the acid to improve results and lessen complications. The “strip” technique is described, which increases the physician’s control over the peel depth. Results A total of 923 trichloroacetic acid peels in 803 female patients (87.0%) and 120 male patients (13.0%) were reviewed (mean age, 41.59 years). The follow-up period ranged from 6 months to 13 years (mean, 13 months). This case series revealed a low incidence of complications, including 54 patients (5.9%) with persistent hyperpigmentation, 3 patients (0.3%) with mild telangiectasia, 2 patients (0.2%) with acute herpesvirus infection, 2 patients (0.2%) with bacterial Staphylococcus infection, and 1 patient (0.1%) with hypopigmentation. Conclusions and Relevance When properly applied, trichloroacetic acid peels are efficient and safe for light and dark skin. The technique can be an easily implementable addition to a physician’s cosmetic practice. Level of Evidence 4.

Minimal inframammary incision for breast augmentation

The inframammary approach in breast augmentation, still the most popular technique among plastic surgeons, has always been hampered by the undesirable appearance of its scar. The present paper describes a modified approach to inframammary augmentation with saline-filled prostheses. This approach uses a very short incision, thus resulting in a much less noticeable scar. The surgical technique is easy to learn, simple to execute, does not necessitate any special equipment and gives consistent results. Decreasing the scar length to an absolute minimum ensures higher patient and surgeon satisfaction.

Predicting the results of rhinoplasty before surgery: Easy noses versus difficult noses

A major problem for many rhinoplastic surgeons is the ability to predict, before surgery, the difficulty of the procedure (whether the rhinoplasties will be technically easy or technically difficult to perform) and the success rate of the result (whether the rhinoplasty will likely give good results or poor ones).The present paper outlines a systematic approach to nasal analysis, allowing the surgeon to consistently estimate, before surgery, the degree of technical difficulty of each rhinoplasty, as well as predicting its future result in terms of patient satisfaction. This preoperative evaluation is based on the analysis of the skin texture and the osteocartilagenous framework on lateral and frontal views. It allows for the nose to be classified as green (easy), yellow (moderate) or red (difficult), depending on two factors: the degree of surgical difficulty and the expected patients satisfaction with the result.The essence of the present paper is to introduce a simple, systematic approach to assist the novice rhinoplastic surgeon to assess the complexity, the risks and the expected outcome of a rhinoplasty in the preoperative period, rather than postoperatively.

New classification scheme for laser resurfacing and chemical peels: Modifications for the different ethnic groups

Historically, classifications for laser rejuvenation and chemical peels of the skin are based on pigmentary color, with skin quality playing a less prominent role. Although useful in predicting aesthetic outcomes, these classifications do not, for the most part, take into consideration the patient’s origin and its associated relevance in predicting final results. Herein, a new classification system is proposed that not only takes into account skin color but also genetic predisposition as a key determinant of a patient’s response to skin injury, namely, laser resurfacing and chemical peels. This de novo classification takes into account both skin pigmentation and physical attributes in hopes of improving the predictability of patients’ response to skin treatments by physicians. Six categories are described: Nordic, European, Mediterranean, Indo-Pakistani, African, and Asian. The reactions of each category to peels, laser resurfacing, or dermabrasion are analyzed, and the potential risks associated with each group are noted. Most popular classifications [1–6] for patients undergoing chemical peels, laser resurfacing, or dermabrasion are based primarily on the color of their facial skin. The general tendency is to relate the result of a peel, dermabrasion, or skin resurfacing to skin color. It is generally accepted that the lighter the skin color and pigmentation, such as Fitzpatrick types I and II, the better the final result. The converse of this is also considered true: the darker the skin, such as Fitzpatrick types III to VI, the poorer the result. Skin color is often subdivided into categories: white, olive, tan, brown, yellow, and black. Classifications such as those of Fitzpatrick, Obagi, and Glogau, in addition to accounting for skin color, also account for certain characteristics (dryness, oiliness, thickness, and so forth) and the skin response to sun exposure. Those additional criteria are all valid and, to date, the ‘‘gold standard’’ has been the Fitzpatrick classification scheme. The physician, however, faced with a prospective patient, must evaluate multiple and, occasionally, contradictory factors. Traditional classifications, useful as they are, may sometimes be inadequate or confusing. They ignore a crucial factor: the patient’s racial origin, which is often associated with a characteristic skin color and almost always with characteristic features.

Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases

BackgroundModern rhinoplasty is not just a reduction procedure. An optimal nasal esthetic result occasionally requires augmenting the nasal tip, the dorsum or the lateral wall with autografts or alloplasts. A large number of nasal implant types have been reported in the medical literature.ObjectiveThe goal of this article is to demystify the role and indications of nasal implants in rhinoplasty. As well, it offers both the novice and experienced nasal surgeon a basic, simplified and organized approach to the use of soft and firm nasal implants in rhinoplasty.MethodsThis article presents the authors experience with 311 rhinoplasties using both soft and firm alloplastic implants. The indications for both types of alloplasts are discussed, the surgical technique detailed and the outcomes analyzed.ResultsA total of 311 nasal implant cases were reviewed. This series revealed a low incidence of postoperative infection (5.57% for soft implants and 0.1% for the firm ones). The revision rate was 2.7% for the soft implants group and 7.1% for the firm implants group.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.