Rod J. Rohrich

Xanthelasma palpebrarum: a review and current management principles.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the differential diagnosis of xanthelasma palpebrarum. 2. Discuss the various nonsurgical and surgical treatment options and their advantages and disadvantages. 3. Describe the circumstances in which recurrence is most likely after treatment. Xanthelasma palpebrarum is the most common cutaneous xanthoma. It typically presents in middle-aged and older adults, most often around the eyelids. The diagnosis can often be made on clinical grounds alone. For the plastic surgeon, it is important to apply an algorithmic approach to the treatment of these lesions. Depending on the size and location, several different methods can be used to address this problem, ranging from simple excision, to laser treatment, to chemical peeling. This article addresses the underlying pathophysiology of xanthelasma and the currently accepted modes of treatment.

A classification of clinical fat grafting: different problems, different solutions.

Background: Fat grafting has reemerged from a highly variable procedure to a technique with vast reconstructive and cosmetic potential. Largely because of a more disciplined and scientific approach to fat grafting as a transplantation event, early adopters of fat transplantation have begun to approach fat grafting as a process, using sound surgical transplantation principles: recipient preparation, controlled donor harvest, time-efficient transplantation, and proper postoperative care. Despite these principles, different fat grafting techniques yield impressive clinical outcomes. Methods: The essential variables of four types of fat grafting cases were identified and compared: harvesting, methods of cell processing, methods of transplantation, and management of the recipient site. Results: Each case differed for most of the variables analyzed. The two clinical drivers that most impacted these differences were the volume demands of the recipient site and whether the recipient site was healthy tissue or pathologic tissue. After these two drivers, a matrix classification of small-volume versus large-volume and regenerative versus nonregenerative cases yields four distinct categories. Conclusions: Not all fat grafting is the same. Fat grafting, once thought to be a simple technique with variable results, is a much more complex procedure with at least four definable subtypes. By defining the essential differences in the recipient site, the key driver in fat transplantation, the proper selection of technique can be best chosen. In fat transplantation, different problems require different solutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Cosmetic medicine: facial resurfacing and injectables.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the most common options available for minimally invasive facial rejuvenation. 2. Identify key elements essential to each treatment option. 3. Know how to avoid and manage complications for these procedures. Summary: Minimally invasive cosmetic procedures continue to increase in popularity. This article is intended to provide a broad and practical overview of common minimally invasive cosmetic techniques available to the plastic surgeon.

Breast reduction in gigantomastia using the posterosuperior pedicle: An alternative technique, based on preservation of the anterior intercostal artery perforators

Background: The purpose of this study was to describe and evaluate the outcomes of breast reduction in cases of gigantomastia using a posterosuperior pedicle. Methods: Four hundred thirty-one breast reductions were performed between 2004 and 2007. Fifty patients of 431 (11.6 percent) responded to the inclusion criteria (>1000 g of tissue removed per breast (100 breasts). The mean age was 33.2 years (range, 17 to 58 years). The average notch-to-nipple distance was 37.9 cm (range, 35 to 46 cm). The mean body mass index was 27 (range, 22 to 35 cm). The technique of the posterosuperior pedicle was used, in which the perforators from fourth anterior intercostal arteries are preserved (posterior pedicle). Results were evaluated by means of self-evaluation at 1 year postoperatively. Results: The average weight resected was 1231 g (range, 1000 to 2500 g). The length of hospital stay was 2.3 days (range 2 to 4 days). Thirty seven patients evaluated their results as “very good” (74 percent), nine as “good” (18 percent), and four as “acceptable” (8 percent). There were no “poor” results. The chief complaint was insufficient breast reduction (four patients), despite the considerable improvement in their daily life (8 percent). Back pain totally resolved in 46 percent and partially (with significant improvement) in 54 percent of cases. One major and seven minor complications were recorded. Conclusions: The posterosuperior pedicle for breast reduction is a reproducible and versatile technique. The preservation of the anterior intercostal artery perforators enhances the reliability of the vascular supply to the superior pedicle.

Mentors in medicine.

You can get everything in life you want, if you will just help enough other people get what they want.I am fearful that mentoring is becoming a lost art in medicine and plastic surgery. Mentors in medicine are generally experienced physicians who go out of their way to help medical students, residen

The Role of the Superwet Technique in Face Lift: An Analysis of 1089 Patients over 23 Years.

Background: The use of superwet technique of infiltration and autologous tissue sealants during rhytidectomy has benefits of decreasing bleeding and edema, improving visualization, and easing dissection. The purpose of this study was to analyze whether these intraoperative strategies resulted in more consistent and reproducible outcomes and significantly decreased hematoma rates. Methods: A retrospective review was performed on 1089 consecutive face lifts performed by a single surgeon. Fisher’s exact test was used to determine significant differences in hematomas between those patients who received platelet-rich plasma and superwet technique and those who did not. Multivariate logistic regression was used to evaluate demographic variables and intraoperative interventions for risk of complication. Results: Five hundred eighty-seven of 1089 face lifts received platelet-rich plasma and 926 of 1089 underwent a superwet technique. Ten hematomas were recorded, six in the group that did not receive platelet-rich plasma compared to four who did (p = 0.527). One hematoma was observed before implementation of the superwet technique and nine were in the group after (p = 1.00). Multivariate analysis showed male sex to be a significant factor for hematoma (p < 0.001). Conclusions: This analysis showed excellent outcomes with a hematoma rate of 0.9 percent. Although no significant differences were noted, the authors attribute their consistent and reproducible results to the use of the superwet technique and platelet-rich plasma. The superwet technique allows for improved safety and visualization with improved hemostasis. Platelet-rich plasma potentially decreases ecchymosis and edema. Prospective studies are needed to determine significant differences between these intraoperative interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Refining the anesthesia management of the face-lift patient: Lessons learned from 1089 consecutive face lifts

Background: The importance of anesthetic technique is often underappreciated in face-lift procedures and is sparsely written about in the literature. Appropriate control of blood pressure, anxiety, pain, and nausea is essential for reducing the complications of face lift, primarily, hematoma risk. This study discusses the standard anesthetic protocol provided at the authors’ institution and describes the preoperative, intraoperative, and postoperative management of face-lift patients resulting in low hematoma and complication rates. Methods: One thousand eighty-nine patients who underwent face-lift procedures performed by a single surgeon (R.J.R) were included in a retrospective chart review following institutional review board approval. Patient demographics, operative data including additional ancillary procedures, and the anesthesia regimen were recorded. In addition, postoperative complications and reoperation rates were documented. Results: Between 1990 and 2013, 1089 face-lift procedures were performed. Of these, 10 patients developed postoperative hematomas. Benzodiazepines were commonly administered preoperatively to reduce anxiety level. Intraoperatively, a specific regimen and combination of inhalation agents, neuromuscular blockers, antiemetics, antihypertensives, and narcotics was given to control the ease of induction and emergence from anesthesia. Postoperatively, nausea, vomiting, anxiety, pain, and hypertension were treated as needed. Conclusions: The described protocol is safe and has been instituted at the authors’ facility for approximately 20 years. The benefit of this regimen is related to the synergy of combination therapy. It is successful in reducing patient anxiety and pain, controlling blood pressure and postoperative emesis, and subsequently results in a reduced risk of hematoma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Are teachers born or do they develop over time

A colleague recently hired two new plastic surgeons for his department. They are bright, excellent clinicians who are proven investigators, and are eager to work with medical students and residents. Within the first few weeks of joining his staff, they both raised a variation of the same question, “I really enjoy teaching the students, and I want to do it better, but I’m really busy trying to establish my practice. I’m overwhelmed by the thought of how much time it would take to read a book on teaching and do not know the field of education well enough to attempt to find key articles online; I’m not sure I’d know where to begin looking. Where can I go to learn to be a better teacher, and how can I do it in a way that fits into my schedule?” How long does it take to develop into a good teacher and role model, and did you have any questions along the way? Perhaps the more important question is, are you truly a good teacher now? How can you become even better? Because of the tremendous necessity to develop true plastic surgery educators and role models today, Plastic and Reconstructive Surgery has developed a new Plastic Surgery Educator article series. The forthcoming series of articles arises out of the realization that most plastic surgeons are hired by academic institutions or clinical enterprises because of their patient care skills, with little attention paid to their teaching ability. I have asked Dr. Robert Weber to spearhead this article series, in the hope that it will benefit other plastic surgeons. He has developed into an exemplary plastic surgery educator and has worked hard at becoming a talented plastic surgery teacher. An informal survey of plastic surgeons showed that fewer than one in 10 have had any training in the theory or practice of adult education, yet they are expected to be training the next generation of practitioners. Plastic surgery residents are also expected to be teachers, but the curriculum of medical schools and surgical residencies has contained scant amounts of teacher training. As the need for practicing plastic surgeons continues to increase, more plastic surgery educators are required. The necessity to learn how to teach is not confined to academic plastic surgeons; rather, the necessity is placed on all of us. Robert Ruberg points out that all plastic surgeons should be teachers. He writes, “We have a unique opportunity—maybe even an obligation—to also become lifelong teachers.”1 Rather than “hiding out” in office practices, he admonishes plastic surgeons to present plastic surgery topics at medical staff meetings or offer in-services to nursing and office personnel in an effort to teach colleagues what a plastic surgeon does and why. Most importantly, Ruberg reminds us that patient education is a critical aspect of patient care.1 Good teachers make good doctors. Every discipline is one generation from extinction. The pejorative adage “Those who can, do; those who cannot, teach” reflects the low esteem many practitioners have toward teaching. Professional schools often have difficulty attracting good teachers because of the disparity of compensation between a practitioner and an educator. Medical institutions have had the tendency to reward professors more for research than for education. Surgery faces the situation where decreasing reimbursement and increasing patient loads have made it harder to carve out time to teach, let alone spend the time to learn how to improve teaching skills.