Robert W. Bernard

Autologous fat graft in nipple reconstruction.

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors’ preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.

Enhancing upper lid aesthetics with the lateral subcutaneous brow lift

BACKGROUND Surgical techniques for improving the upper eyelid aesthetic unit have recently focused on the management of eyebrow position. In our practice, we noticed that in some patients the lateral brow was low preoperatively, whereas in others it was well positioned but overly mobile. OBJECTIVE We describe our experience using the lateral subcutaneous brow lift (LSBL) to elevate and stabilize the lateral brow. METHODS An incision was marked at the junction of the hair-bearing scalp and forehead, beginning on a line extending superiorly from the mid-pupillary line, and carried down to the subcutaneous plane, just superficial to the frontalis muscle. The subcutaneous tissues were dissected from the frontalis muscle, and the skin and subcutaneous flap were retracted superiorly. The flap was divided vertically, a skin staple was placed, and after assessment of brow position and stability, the medial and lateral excess skin was excised. Tisseel (Baxter Hyland Immuno, Glendale, CA) was found to facilitate hemostasis and, to a lesser extent, flap adherence. At the end of the procedure, the brow was slightly overcorrected to compensate for some postoperative descent. If planned, an upper blepharoplasty was performed in the standard fashion. RESULTS The LSBL was performed in 117 patients during a 2-year period; in 82 of these cases the brow lift was performed in conjunction with upper lid blepharoplasty, and in 31 cases it was performed as part of a facial rejuvenation procedure that did not include upper eyelids. All patients reported their scars as imperceptible. Complications included 2 hematomas and 6 cases of hypesthesia confined to the region just posterior to the incision; all resolved within 8 weeks. In 1 case, the flap was inadvertently torn during its elevation; it was repaired and did not affect the outcome. CONCLUSIONS The LSBL is a safe and technically simple technique that allowed us to achieve optimal aesthetic results in the upper periorbita with few complications and a high patient acceptance rate.

Secondary Face Lift

Robert W. Bernard, MD Sherrell J. Aston, MD Phillip R. Casson, MD Stanley A. Klatsky, MD Dr. Bernard: The first patient is a 70-year-old nonsmoker who underwent a deep plane face lift about 10 years ago (Figure 1). She wants to see improvement in the jowls, cheek, neck, and jaw line. You will notice that there is some asymmetry of her face. She has had no nerve damage. She has what appears to be a pretragal incision. Given that this is a secondary face lift, how would you approach treating this patient? Figure 1. This 70-year-old woman is a nonsmoker who underwent a “deep plane” face lift about 10 years ago. Dr. Klatsky: She does have facial asymmetry and upper eyelid ptosis. She also looks as if she has some orbital dystopia where the right side of the nasojugal groove is lower than the left. Her asymmetry also reflects into the modiolus, the right corner of her mouth is lower than the left, and she shows more relaxation, at least in the frontal view, on the right. She has either a relaxed platysma or it could possibly be a ptotic submaxillary gland. I am not really concerned with what plane has been dissected. Sometimes we may be fortunate enough to have this information, but many times we simply have no way of knowing. I am concerned, however, with the placement of the incision. The photograph shows an incision anterior to the tragus that is hypopigmented, as well as a little dart near the earlobe that is also white. Most likely, I would approach this patient with a retrotragal incision. If I believed that the hairline would be shifted significantly, I might consider a pre-tricheal (anterior hairline) incision. I cannot tell from this photograph whether the patients previous incision was within the hairline …

Perspectives on the FDA Draft Guidances for Use of Adipose Tissue

2017, Vol 37(5) 622–625

The difficult forehead.

Stanley Klatsky, MD Bruce F. Connell, MD Robert W. Bernard, MD Rollin K. Daniel, MD Dr. Klatsky: The first patient is a 58-year-old woman who is unhappy with her forehead and upper lid appearance (Figure 1). People tell her she looks angry. Note that she is blind in her right eye. Dr. Bernard, how would you improve her forehead, brow, and upper lid complex? Figure 1 This 58-year-old woman is unhappy with her forehead and upper eyelids. People tell her that she looks angry. Dr. Bernard: She does look angry and sad, but it is not just because of her upper face. Her blindness in one eye is an important consideration. I might hesitate to remove fat from her upper eyelids just to avoid the possibility of retrobulbar hematoma. She has a reasonably high forehead, and her brows appear relatively low. I would seriously consider an endoscopic brow lift despite her somewhat high forehead and a skin, only upper lid blepharoplasty. I would resect the procerus and corrugator muscles medially, and I would consider Botox to further improve the transverse forehead lines. Dr. Klatsky: Dr. Connell, how would you approach treatment? Dr. Connell: I always like to see an early photograph from a time when the patient was pleased with his or her appearance; from this I note the desired brow position. Brow placement is easier to determine in women because I simply strive to make them look as pretty as possible, but for men there are about 5 different acceptable brow locations. From this photograph, the height from her nasion to her hairline is 16 cm, and the height from her nose to her chin is 12 mm. She is about 30% higher on the upper third of her face than the lower third. I would avoid making her forehead look …

Ten preoperative decisions for a successful face lift.

An overly elevated preauricular hairline, a flat malar region, and a shallow sternomandibular trough are examples of undesirable postoperative results in rhytidectomy. The author describes 10 preoperative decisions that will help to avoid such pitfalls. (Aesthetic Surg J 2002;22:551-553.).

On Scientific Truth

I do not have earlobes. I could not dream of sporting clip earrings. In my younger years, my earlobes-or lack of them-caused me to be the butt (or lobe) of an occasional joke. More recently, however, I have worn this anatomic anomaly with a certain smugness. You see, a few years ago a study published in a prestigious medical journal demonstrated that individuals with a crease in their earlobe had a substantially increased risk of dying from heart disease compared with persons with no earlobe crease. And its true. To date, three pastrami sandwiches a week and innumerable visits to the local pizza parlor have not altered the immutable scientific fact that, without any earlobes at all, I will …

Aesthetic Surgery Practice: Another Nigersaurus?

The dinosaur Nigersaurus wandered the earth 110 million years ago. Its shovel-shaped mouth, which contained 50 rows of teeth, was uniquely adapted for the purpose of eating massive quantities of grass as it ambled along, head constantly to the ground, perhaps consuming as much as a football field worth of “munchies” in a day. Unfortunately, as the climate changed, the specific grasses to which it had become uniquely adapted were replaced by different vegetation. Nigersaurus did not adapt along with its environment and thereby became extinct. Although this story may not seem relevant at first, I propose that this is a situation—one of failure to adapt and subsequent extinction—in which the independent plastic surgeon (or independent groups of plastic surgeons) whose practice exclusively or primarily comprises aesthetic surgery may soon find himself or herself. The downturn in the economy, along with certain medical insurance issues, has accelerated a dynamic that has been evolving for several years in the medical community. “Strength in numbers” has become the byword. Multispecialty medical groups have rapidly expanded across the United States, in many cases forcing the independent practitioner to join them. For example, a urologist who has served a community well might be informed by a multispecialty group that unless he joins their practice, they will bring in their own urologist and his referral base will disappear. Although practitioners in this dilemma may initially resist, many eventually succumb to the pressure. In an editorial published in the Archives of Family Medicine (May 31, 2010), Kevin Grumbach, MD, called the small independent practice an “endangered species.”1 It is true that large medical groups offer certain economic advantages. For example, the larger groups can negotiate more favorable …

IntroductionThe Science and Technology of Dermicol-P35: Utility and Safety in Aesthetic Procedures

Aging is both chronologic and environmental, resulting in skin that increasingly loses structural integrity, elasticity, and regenerative capability.1 In a culture that values a youthful appearance, its loss can often have psychological effects on an individual. Consequently, aesthetic rejuvenation is linked with better self-esteem and work performance.2 From 2006 to 2007, the total number of cosmetic procedures in the United States increased by between 2.4% and 4%.3,4 Injectable medical devices are an important addition to the choices that aesthetic surgeons and dermatologists can offer patients for restoration of a youthful appearance. The ideal characteristics of an injectable medical device for aesthetic use are biocompatibility, a predictably long duration of clinical effect (>12 months; ie. the retention of 3-dimensional structure at the site of implantation), minimal adverse effects, reduced or no hypersensitivity reaction, and no need for a pretreatment skin test. Dermal fillers fall into 2 main categories, depending on whether they are based on hyaluronic acid (HA) or collagen.5 Constituting approximately 2% of the skin, HA is a glycosaminoglycan polysaccharide with a repeating disaccharide structure and is therefore inherently unlikely to provoke an immune response.6,7 It is also very …

The Science and Technology of Dermicol-P35: Utility and Safety in Aesthetic Procedures

Aging is both chronologic and environmental, resulting in skin that increasingly loses structural integrity, elasticity, and regenerative capability.1 In a culture that values a youthful appearance, its loss can often have psychological effects on an individual. Consequently, aesthetic rejuvenation is linked with better self-esteem and work performance.2 From 2006 to 2007, the total number of cosmetic procedures in the United States increased by between 2.4% and 4%.3,4 Injectable medical devices are an important addition to the choices that aesthetic surgeons and dermatologists can offer patients for restoration of a youthful appearance. The ideal characteristics of an injectable medical device for aesthetic use are biocompatibility, a predictably long duration of clinical effect (>12 months; ie. the retention of 3-dimensional structure at the site of implantation), minimal adverse effects, reduced or no hypersensitivity reaction, and no need for a pretreatment skin test. Dermal fillers fall into 2 main categories, depending on whether they are based on hyaluronic acid (HA) or collagen.5 Constituting approximately 2% of the skin, HA is a glycosaminoglycan polysaccharide with a repeating disaccharide structure and is therefore inherently unlikely to provoke an immune response.6,7 It is also very …