Salvatore J. Pacella

Clinical experience with a fourth-generation textured silicone gel breast implant: a review of 1012 Mentor MemoryGel breast implants.

BACKGROUNDnSince the introduction of fourth- and fifth-generation silicone gel implants, manufacturers have conducted several prospective, multicenter trials to examine their safety and efficacy. However, these studies were not standardized with regard to surgeon skill, pocket placement, operative technique, adjunct therapies, or postoperative management.nnnOBJECTIVEnThe purpose of this study was to examine the surgical outcomes of a single surgeon (WGS) in a consecutive series of breast augmentation cases using a fourth-generation cohesive silicone MemoryGel breast implant (Mentor, Santa Barbara, CA).nnnMETHODSnA retrospective chart review was conducted to identify all patients who underwent silicone breast augmentation within the Mentor Adjunct Silicone MemoryGel breast implant by a single surgeon (WGS) within a single free-standing outpatient surgical center over a 13-year period (1992 to 2006). For each patient, demographic information, comorbidities, and surgical information (implant size and concomitant surgery) were recorded. In addition, outcomes were analyzed to identify complications and the need for surgical revision.nnnRESULTSnA total of 1012 fourth-generation, textured, cohesive silicone gel implants were placed in 511 patients during the 13-year study period. The overall complication rate per implant was 5.5% (n=56 implants in 43 patients). The most common complication was capsular contracture (n=26; 2.6 %) followed by abnormal scarring (n=11; 1.1%). The overall revision rates per patient and per implant were 8.0% (n = 41 patients) and 6.8% (n = 69 implants), respectively. The average time interval between initial implantation and revision was 18.5 months (range, 2 weeks to 26 months). The most common indication for surgical revision was patient desire for implant size change (n=15 patients) followed by Baker class III or IV capsular contracture (n=13 patients). The presence of previous surgery for capsular contracture was not statistically correlated to the need for revision (P= .326). Age (P= .568), previous history of breast surgery (P= .704), and history of smoking (P= .138) were also not statistically correlated to revision. Placement of the implant in the subglandular position (n=30 implants), however, was statistically correlated with need for revision (P< .01).nnnCONCLUSIONSnMentor fourth-generation cohesive silicone gel implants possess a complication and revision profile that is superior to earlier-generation silicone gel implants. Implantation with MemoryGel implants, when standardized with regard to surgeon and operative technique, can have significantly reduced complication and revision rates compared to the Mentor Core Data.

Safe and consistent outcomes of successfully combining breast surgery and abdominoplasty: an update.

BACKGROUNDnCombined cosmetic procedures have become increasingly popular. One of the most common combinations of cosmetic procedures includes abdominoplasty and cosmetic breast surgery. The shortened recovery and financial savings associated with combined surgery contribute to the increased demand for these combined surgeries.nnnOBJECTIVEnThe goal of this study was to evaluate the safety and efficacy of combined abdominoplasty and breast surgery at a single plastic surgery practice that performs a large volume of these cases. This is an update to a study published in 2006.nnnMETHODSnA retrospective review was performed for patients who underwent combined abdominoplasty and cosmetic breast surgery during the last 10 years at a single outpatient surgery center. Abdominoplasty inclusion criteria were defined as lower, mini, full, reverse, or circumferential abdominoplasty. Cosmetic breast surgery inclusion criteria were defined as augmentation, mastopexy, augmentation-mastopexy, reduction, or removal and replacement of implants. Pertinent preoperative and intraoperative data were recorded along with complications and revisions.nnnRESULTSnThere were 268 patients during the 10-year period between 1997 and 2007. There were no cases of death, pulmonary embolism, deep venous thrombosis, or other life-threatening complications. The overall complication rate was 34%. Abdominoplasty seroma and scars requiring revision comprised 68% (n = 74) of the complications. The total revision rate was 13%.nnnCONCLUSIONSnCombined abdominoplasty and cosmetic breast surgery was safe and effective in this large series of cases performed at a single plastic surgery practice. The complication and revision rates of the combined surgery were similar to those reported for individually staged procedures.

Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show.

Summary: Blepharoplasty remains one of the most popular operations in facial aesthetic surgery. Serious complications, which include blindness, retrobulbar hematoma, and ectropion, although relatively rare, are well reported in the literature. As techniques evolve in aesthetic eyelid surgery, minor complications continue to be very common. Nonetheless, management of these complications can be challenging and may require extended management or surgical revision. The authors discuss several of the most common minor complications, including hematoma, dry-eye syndrome, infections, atypical lesions, lid malposition, and scarring. In addition, preoperative assessment of risk factors, treatment, and management of these minor complications are presented.

The utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors’ study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.

Blepharoplasty and brow lift.

Learning Objectives: After reading this article, the participant should be able to: 1. Describe the surgical anatomy associated with aging within the periorbital and brow region. 2. Illustrate the aesthetic goals in performing periorbital and brow rejuvenation. 3. Demonstrate safe, effective, and reproducible surgical techniques in periorbital and brow rejuvenation. Summary: Brow lift and blepharoplasty are among the most commonly requested procedures in facial aesthetic surgery. The purpose of this article is to provide an overview of current concepts, including goals, surgical options, and outcomes for aesthetic improvement of the forehead and periorbital region. Preoperative patient assessment, anatomical and surgical concepts, advantages and disadvantages, and prevention and management of complications and expected results are discussed. Surgical results of endoscopic and lateral brow lift, upper lid blepharoplasty with supratarsal fixation, and lower lid blepharoplasty with correction of the tear trough are presented. Details of the perioperative techniques are presented in accompanying video format. A critical understanding of patient expectation, surgical anatomy, and operative technique is important for avoiding complications and achieving aesthetic results in brow and eyelid rejuvenation.

Transconjunctival Blepharoplasty for Upper and Lower Eyelids

Background: Transconjunctival blepharoplasty remains a popular and safe technique to treat periorbital aging. In the lower lid, it can be used successfully for orbital fat excision, redistribution, or septal tightening. In the upper lid, transconjunctival blepharoplasty has a role in removal of the nasal fat pad via an isolated, direct approach. Methods: The authors review anatomy, indications, and surgical approaches for upper and lower lid transconjunctival blepharoplasty. Results: Potential complications, patient results, and the senior authors personal series are discussed. Conclusions: In the lower lid, this technique can be advocated in an effort to avoid lower lid complications such as sclera show or lid malposition. In the upper lid, it can be effective in treating isolated fat pads with minimal skin excess.

The transaxillary approach to breast augmentation.

The transaxillary approach to breast augmentation provides patients with an option for augmentation that avoids any visible scars on the breast. The versatility of the endoscopic technique allows the surgeon to reliably dissect the submuscular pocket under direct visualization and to control the position of the inframammary fold while still enabling the use of any of a wide variety of both saline and silicone implants. This article addresses issues related to patient selection and preoperative assessment of this technique as well as technical aspects of performing this operation. In addition, the article reviews postoperative management of the endoscopic augmentation patient and describes potential complications associated with this technique.

Aesthetic and technical refinements in latissimus dorsi implant breast reconstruction: A 15-year experience

BACKGROUNDnThe latissimus dorsi myocutaneous flap and implant breast reconstruction procedure has undergone many refinements over its lifetime. In fact, the authors have made many aesthetic and technical refinements to their own approach to breast reconstruction.nnnOBJECTIVESnThe authors review the historical progression of latissimus flap and breast reconstruction techniques and compare these to their own 15-year experience.nnnMETHODSnA retrospective chart review was conducted for all latissimus and implant breast reconstructions performed by the senior author (MAC) from July 1994 to June 2009, for a total of 52 procedures in 31 patients. Surgical and oncological data, complications, and outcomes data were recorded.nnnRESULTSnThe mean age of the patients at time of surgery was 47.6 years. Average mastectomy weight was 283 grams and average final implant volume was 364 cc. Average follow-up was three years, four months. Of the 52 total procedures, 34.6% were immediate breast reconstructions utilizing skin-sparing mastectomy (SSM); 13.5% of the reconstructed breasts also had preservation of the areola (areolar-sparing mastectomy [ASM]). The most common complication was donor site seroma (40.4%). Aesthetic and surgical refinements identified over the time period included the adoption of SSM and ASM techniques, immediate nipple reconstruction, the placement of an adjustable saline implant to allow for postoperative size adjustment, and implant placement in the prepectoral position. The overall latissimus dorsi implant reconstruction success rate was 94.2% (49/52).nnnCONCLUSIONSnThe data demonstrated a successful outcome for latissimus dorsi and implant breast reconstruction for patients with a low or normal body mass index and a small (A to C cup) breast size. The aesthetic outcome of latissimus dorsi breast reconstruction has been improved over the past 15 years by the adoption of SSM and ASM techniques. Immediate nipple reconstruction and the placement of an adjustable saline implant potentially render this procedure a true single-stage reconstruction. Prepectoral implant position provides good aesthetics while preserving the subpectoral space for future management of capsular contracture if required.

Single-stage breast reconstruction following areola-sparing mastectomy.

The evolution of skin-sparing mastectomy has greatly improved the cosmetic appearance of the reconstructed breast. Traditionally, reconstruction of the nipple-areola complex has been performed as a subsequent procedure. However, the unique coloration and texture of the areola have proven difficult to reproduce. By preserving the native areolar tissue during mastectomy, we are able to achieve more natural appearing results. In these cases, we have performed immediate nipple reconstruction in our autologous reconstruction patients in an effort to complete our breast reconstruction in a single stage. This method of reconstruction is both efficient and economical by making additional procedures unnecessary.

Patient Retention and Replacement Trends After Saline Breast Implants: Are Deflations Inflationary?

BackgroundThis study aimed to examine serial operative trends with patients who have experienced surgical implant deflation. In addition, the economic impact of deflation on practice caseload was analyzed.MethodsA retrospective review was conducted to examine patients who experienced deflation from 2000 to 2007. Patient demographics, implant data, and the presence of secondary (performed at explantation) or tertiary (performed later) procedures were examined. Financial information was tabulated to determine the economic multiplier effect (i.e. the expected value of revenue from secondary and tertiary procedures divided by explantation cost) of taking on deflation cases in a practice.ResultsFor this study, 285 patients with an average age of 38.4xa0years were identified. The average time to explantation was 50xa0months. Slightly more than half of the patients (55%) had both implants replaced at the time of explantation, whereas 59% switched to silicone implants and 41% continued with saline implants. A larger implant was chosen by 54% of the patients (average increase, 82xa0ml), whereas 18% underwent secondary procedures at the time of explantation including mastopexy (nxa0=xa022), facial rejuvenation (nxa0=xa08), liposuction (nxa0=xa07), or a combination of the two (nxa0=xa08). Tertiary procedures were performed for 31% of the patients after their explantation/reimplantation (average time frame, 13xa0months). The tertiary procedures included replacement with silicone (33.7%), liposuction (24.7%), abdominoplasty (11.2%), facial rejuvenation (13.5%), or nonsurgical rejuvenation using Botox, Restylane, or laser procedure (33.7%). Economic multiplier analysis showed that the financial impact of revenue derived from implant deflation on downstream practice revenue is 1.02.ConclusionAt the time of explantation, replacement with silicone after saline deflation is common (59% of patients). In this study, patients who chose replacement with saline had a significant tendency to replace with silicone (33%) as a tertiary procedure. Saline deflation represents a substantial opportunity for practice development. In particular, it has a positive impact on patient retention for additional aesthetic surgical or nonsurgical procedures. Economic multiplier analysis can be used to quantify the financial impact of saline deflation.