Wendy W. Wong

The Evolution of Breast Reconstruction: A Historical Perspective

Plastic surgeons have been performing operations to improve the aesthetic aspect of the breast for centuries. Throughout ancient times, great controversy produced many theories of how breast cancer occurred and the best treatment. Because of beliefs that closure of mastectomy sites could conceal tumor recurrence, breast reconstruction did not gain wide acceptance until the mid-1900s. Today, plastic surgeons have a variety of techniques to reconstruct the breast. The first autologous muscle flap for breast reconstruction was the latissimus dorsi myocutaneous flap, described in 1896 by Iginio Tansini. The introduction of Carl Hartrampf’s transverse rectus abdominis myocutaneous flap and Robert J. Allen’s deep inferior epigastric perforator flap have also provided excellent reconstructive options. With regard to augmentation, Vincenz Czerny attempted to enhance a woman’s breast in 1895 with implantation of a lumbar lipoma. Soon after, surgeons used paraffin injections and polyvinylic alcohol sponge implantation, which yielded disastrous results. In 1961, Thomas Cronin and Frank Gerow promoted the first silicone implant, paving the way for today’s silicone and saline prototypes. Although reduction mammaplasty techniques had originated centuries earlier than mastopexy methods, the advancements of both have largely paralleled one another. In 1949, the Wise pattern was introduced to preoperatively plan safer and predictable outcomes in breast reductions. Efforts to minimize scars were achieved with Claude Lassus’ introduction and Madeleine Lejour’s subsequent modification of the vertical scar mammaplasty. In hopes of fostering an understanding of current post-mastectomy procedures and instilling passion for innovating future techniques, we provide a near-complete, surgically focused historical account of the primary contributors to breast reconstruction.

The Quality of Internet Advertising in Aesthetic Surgery: An In-Depth Analysis

BACKGROUND The aesthetic market is a growing business, as evidenced by the American Society for Aesthetic Plastic Surgery (ASAPS) reporting an increase of 147% in the number of cosmetic procedures performed by members since 1997. This market is consumer-oriented, relying heavily on advertising for survival amid the increasing provider competition. OBJECTIVES The authors evaluate trends, ethics, and efficacy of Internet advertising in aesthetic surgery. METHODS Medical cosmetic providers in Southern California and their Web sites were catalogued through sales lists from manufacturers (Medicis and Allergan) and combined with advertised providers of surgical treatments. Using the ASAPS/American Society of Aesthetic Plastic Surgeons (ASPS) and American Medical Association Codes of Ethics as guidelines, scores were assigned to each Web site and evaluated with the providers board certification. A geographical analysis determined whether the presence of high numbers of competitors had an impact on the adherence to ethical guidelines for advertising. To examine patient preferences in physician advertising, a survey was conducted online. RESULTS Board-certified plastic surgeons showed the highest total ethical scores, followed by otolaryngologists, oromaxillofacial surgeons, and ophthalmologists. No decrement in the quality of the advertising was found in densely competitive environments. A consistent correlation was found between superior compliance with ethical guidelines and board certification in plastic surgery. The patient preference survey of 208 individuals demonstrated their desire for a well-trained, board-certified plastic surgeon to perform their cosmetic procedures. CONCLUSIONS Although plastic surgeons demonstrate greater overall compliance with the ASAPS/ASPS Advertising Code of Ethics, they can continue to improve. With the large variety of cosmetic physicians offering the same procedures, maintaining open, honest, and forthright communication with the public is essential.

Redefining the Ideal Buttocks: A Population Analysis.

Background: The buttocks are a key element of female beauty, with aesthetic gluteoplasty becoming one of the fastest growing plastic surgery procedures. However, there remains no clear standard for the ideal buttocks. The authors performed a population analysis of the characteristics of the ideal buttocks to guide surgical planning. Methods: Images of buttocks were digitally altered to create buttocks of varying proportions on posterior and lateral views. Waist-to-hip ratios and varying vertical proportions were studied. Data were stratified and analyzed according to age range, gender, ethnicity, and nationality of the respondents. Results: A total of 1146 responses were collected. Of 989 respondents who submitted their gluteal preferences, 482 respondents (48.7 percent) were women and 507 (51.3 percent) were men. Overall, the most attractive buttocks waist-to-hip ratio is 0.65 from the posterior view (44.2 percent of respondents). The next most attractive ratio was 0.60 (25 percent of respondents). Positioning of the lateral prominence at the inferior gluteal fold was rated by 26.3 percent of respondents as the most attractive. From the lateral view, the most attractive buttocks have a waist-to-hip ratio of 0.70 (29.8 percent of respondents), with the most prominent portion positioned at the midpoint of the buttocks (45.1 percent of respondents), which is a 50:50 vertical ratio. There were no significant differences in preferences between respondent ages, genders, or ethnicities. Conclusions: New ideal waist-to-hip ratios of 0.6 and 0.65 update the previous standards and indicate a more dramatic and “curvier” new ideal, signaling an important preference paradigm shift. The information derived from this study has the potential to guide gluteoplasty practices and techniques.

A quantitative analysis of periorbital aging with three-dimensional surface imaging

BACKGROUND Studies of facial aging up to the present have largely been observational and subjective. This study applies state-of-the-art facial imaging and three-dimensional computer modelling to measure changes in the aging female face. The markers of facial aging discussed here go beyond descriptive accounts by individual practitioners and are presented as quantitative measurements of the volume change in the aging periorbital region. METHODS Three-dimensional image data sets were acquired of 42 mother-daughter matched pairs (83 individuals). Overall similarity of the faces of the mother-daughter pair were confirmed using best fit analyses prior to further processing of the data. The changes in facial structure secondary to aging were measured using volumetric comparisons of periorbital tissues in the daughter and mother. The age range of the individuals imaged range from 15 to 91 years. RESULTS A consistent pattern of volume difference and regression of soft tissues associated with the medial canthus nasojugal groove was demonstrated in the aged individual of each pair. The volume difference associated with the tear trough ranged from 0.02cc to 1.27cc with median values of 0.38cc and 0.42cc. Volume differences in the adjacent periorbital tissues are also measured. CONCLUSIONS Imaging clearly shows a consistent pattern of atrophy and regression of soft tissues associated with the medial canthus and nasojugal groove. Histogram depth analysis of the soft tissue shows greatest atrophy in the medial canthal region and soft tissues caudal to the lower lid. Volumetric analysis of the atrophy of these tissues is a useful adjunct in the accurate rejuvenation of the periorbital region.

The battle for hearts and minds: who is communicating most effectively with the cosmetic marketplace?

BACKGROUND Cosmetic surgery, historically the purview of plastic surgeons, has in recent years seen an influx of practitioners from other fields of training. Many of these new providers are savvy in marketing and public relations and are beginning to control a surprisingly large amount of cosmetic patient care. OBJECTIVES The purpose of this study is to measure the amount of traffic being attracted to the Web sites of individual practitioners and organizations vying for cosmetic patients. This study investigates the trends of the past 12 months and identifies changes of special concern to plastic surgeons. METHODS The Web sites of 1307 cosmetic providers were monitored over a years time. The Web activity of two million individuals whose computers were loaded with a self-reporting software package was recorded and analyzed. The Web sites were analyzed according to the specialty training of the site owner and total unique visits per month were tallied for the most prominent specialties. The dominant Web sites were closely scrutinized and the Web optimization strategies of each were also examined. RESULTS There is a tremendous amount of Web activity surrounding cosmetic procedures and the amount of traffic on the most popular sites is continuing to grow. Also, a large sum of money is being expended to channel Web traffic, with sums in the thousands of dollars being spent daily by top Web sites. Overall in the past year, the private Web sites of plastic surgeons have increased their reach by 10%, growing from 200,000 to approximately 220,000 unique visitors monthly. Plastic surgery remains the specialty with the largest number of Web visitors per month. However, when combined, the private Web sites of all other providers of aesthetic services have significantly outpaced plastic surgerys growth. The traffic going to non-plastic surgeons has grown by 50% (200,000 visitors per month in September 2008 to 300,000 visitors monthly in September 2009). CONCLUSIONS For providers of aesthetic services, communication with the public is of utmost importance. The Web has become the single most important information resource for consumers because of easy access. Plastic surgeons are facing significant competition for the attention of potential patients, with increasingly sophisticated Web sites and listing services being set up by independent parties. It is important for plastic surgeons to become familiar with the available Internet tools for communication with potential patients and to aggressively utilize these tools for effective practice building.

Pyoderma gangrenosum: the great pretender and a challenging diagnosis.

Background: The initial presentation of pyoderma gangrenosum (PG) is virtually indistinguishable from a pyogenic infection, making debridement appear necessary. However, operative approaches often lead to exacerbation and rapid extension through pathergy. Objective and Methods: In attempts to increase awareness of this condition and minimize misdiagnoses, a review of published reports involving PG of the hand and digits was performed and included 35 patients in addition to our case of a 14-year-old female with a history of ulcerative colitis. Results: Of the total cases, 29 patients were misdiagnosed as having an infection and subsequently treated with antibiotics; 13 of these patients also had debridement of their lesions. Twenty-eight patients had associated medical conditions, including ulcerative colitis, Crohn disease, diabetes mellitus, and cancer. Conclusion: When approached with a rapidly growing ulcerated lesion that does not respond to operative therapy, the possibility of PG should be entertained and a high-dose corticosteroid regimen and/or immunomodulator therapy implemented.

The angel flap for nipple reconstruction

Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.

Canary in a coal mine: does the plastic surgery market predict the american economy?

Background: Economic tools have been used in the past to predict the trends in plastic surgery procedures. Since 1992, U.S. cosmetic surgery volumes have increased overall, but the exact relationship between economic downturns and procedural volumes remains elusive. If an economic predicting role can be established from plastic surgery indicators, this could prove to be a very powerful tool. Methods: A rolling 3-month revenue average of an eight–plastic surgeon practice and various economic indicators were plotted and compared. An investigation of the U.S. procedural volumes was performed from the American Society of Plastic Surgeons statistics between 1996 and 2008. The correlations of different economic variables with plastic surgery volumes were evaluated. Lastly, search term frequencies were examined from 2004 to July of 2009 to study potential patient interest in major plastic surgery procedures. Results: The self-payment revenue of the plastic surgery group consistently proved indicative of the market trends approximately 1 month in advance. The Standard and Poors 500, Dow Jones Industrial Average, National Association of Securities Dealers Automated Quotations, and Standard and Poors Retail Index demonstrated a very close relationship with the income of our plastic surgery group. The frequency of Internet search terms showed a constant level of interest in the patient population despite economic downturns. Conclusions: The data demonstrate that examining plastic surgery revenue can be a useful tool to analyze and possibly predict trends, as it is driven by a market and shows a close correlation to many leading economic indicators. The persisting and increasing interest in plastic surgery suggests hope for a recovering and successful market in the near future.

Single-stage frontalis muscle flap for full-thickness reconstruction of the upper eyelid.

Background: Full-thickness upper eyelid defects present a reconstructive challenge. Defects greater than 50% of the upper eyelid have traditionally been reconstructed with bulky full-thickness forehead flaps, Cutler-Beard flaps, Mustarde eyelid switches, and cheek rotation advancements, all mandating a second-stage surgical procedure. We propose a novel technique for full-thickness upper eyelid reconstruction based on a frontalis muscle flap elevated from the resection defect, thus resulting in no additional forehead scar. Methods: Our patient is a 48-year-old woman with an enlarging right upper eyelid sebaceous cell carcinoma. A subsequent single-stage resection resulted in a medial full-thickness defect of 75% of the upper eyelid. The lateral and medial canthi were preserved. A palatal mucoperiosteal graft was harvested for the reconstruction of the posterior lamella. Dissection was carried through the excision defect in a preseptal plane over the supraorbital rim and subcutaneously over the frontalis muscle. A caudally pedicled frontalis muscle flap was elevated and inset to the defect edges with mild tension. Reconstruction of the skin defect of the upper eyelid was completed with a full-thickness preauricular skin graft. Results: The patient had no complications and demonstrated good function and aesthetic result at 15 weeks and at 9 months postoperatively. Conclusions: Frontalis muscle flap-based reconstruction offers a viable option for upper eyelid defects that are full thickness and encompass more than 50% of the eyelid. We obtained a functionally and aesthetically pleasing outcome with this single-stage procedure using a preexisting incision with minimal donor-site morbidity.

Massive congenital kaposiform hemangioendothelioma of the eyelid in a neonate.

BackgroundKaposiform hemangioendothelioma (KHE) is a rare and aggressive vascular tumor of infancy and childhood. It is associated with the development of Kasabach-Merritt syndrome, a life-threatening consumptive thrombocytopenia. We report an interesting case of a massive periorbital congenital KHE in a neonate to raise awareness of this aggressive diagnosis. MethodsA male neonate presented with a large congenital mass of the lower eyelid. To prevent development of amblyopia, this mass was surgically excised on the sixth day of life. ResultsHistologic investigation demonstrated spindle-shaped endothelial cells with surrounding crescentic vessels, which were GLUT-1 receptor–negative and D2-40 receptor–positive, consistent with KHE. Surgical excision of the periorbital KHE successfully cleared the neonate’s visual axis. At 1 year of follow-up, there was no evidence of tumor recurrence, and visual development was progressing normally. A pleasing surgical result was achieved without periorbital distortion. ConclusionsPediatric vascular tumors have historically been wrought with diagnostic confusion. With recent advances in immunohistochemistry, this previously uncharacterized group of tumors has been differentiated into multiple distinct clinical entities. Accurate and timely diagnosis is paramount because these tumors vary greatly in their clinical behavior, prognosis, and recommended treatment. Surgical excision is preferred and necessary in a neonate with visual access obstruction to prevent amblyopia and irreversible blindness.