William P. Adams

Autologous Human Fat Grafting: Effect of Harvesting and Preparation Techniques on Adipocyte Graft Survival

Background: Autogenous fat transfer with lipoinjection for soft-tissue augmentation is a commonly used technique without a universally accepted approach. The high percentage and variable amount of fat resorption reduce the clinical efficacy of this procedure and often result in the need for further grafting. The purposes of this study were to evaluate the effect of different harvesting and preparation techniques on human fat tissue viability and to determine fat tissue viability rates among the different fat preparations transplanted into a severe combined immune deficiency mouse model at 3 months. Methods: Using standard liposuction and syringe aspiration, fat was removed from patients (n = 3) undergoing elective body contouring. Tissue was prepared by six different combinations of centrifugation and/or washing the cells with lactated Ringers solution or normal saline. Metabolic activities of fat cell viability were monitored to assess overall cell viability. To analyze viability over 3 months, freshly harvested tissue specimens (minimum n = 5) were prepared by a combination of various procedures (wash, centrifugation, and different solutions) and subsequently injected under the dorsal flank skin of severe combined immune deficiency mice in two experiments. Mice were monitored for 12 weeks and the fat xenografts were removed for mass and histological evaluations. Results: Metabolic analyses showed improved cell viability in tissue specimens undergoing minimal manipulation. No significant differences in fat cell viability, as assessed by graft weight maintenance or histologic evaluations, were observed with regard to harvesting or preparation techniques. Conclusions: Improved viability of freshly harvested but untreated fat specimens may be expected as compared with grafts that have undergone additional manipulations. No unique combination of preparation or harvesting techniques appeared to be more advantageous on transplanted fat grafts at 3 months. This study also demonstrated a reliable animal model for future investigation into examining novel applications for augmenting fat graft survival.

Surgical anatomy of the midcheek and malar mounds.

The anatomy of the midcheek has not been satisfactorily described to adequately explain midcheek aging and malar mounds, nor has it suggested a logical approach to their correction or provided sufficient detail for safe surgery in this area. This cadaver study, which was complemented by many operative dissections, located a missing link: a glide plane space overlying the body of the zygoma. The space functions to allow mobility of the orbicularis oculi, where it overlies the zygoma and the origins of the elevator muscles to the upper lip. The space is a cleft between the sub-orbicularis oculi fat and the preperiosteal fat and is lined by a fine membrane. The anatomic boundaries are clearly defined by retaining ligaments, which correlate with the triangularity of the space. Several anatomic features provide the functional characteristics of the prezygomatic space, including the (1) absence of direct attachments between the orbicularis in the roof to the floor, (2) more rigid inferior boundary formed by the zygomatic ligaments, and (3) more mobile upper ligamentous boundary formed by the orbicularis retaining ligament (separating from the preseptal space of the lower lid). These components determine the characteristic aging changes that occur in this region and explain much about malar mounds. An appreciation of this anatomy has several surgical implications. The prezygomatic space is a junction area that can be approached from the temple, lower lid, and cheek. The zygomatic branches of the facial nerve to the orbicularis do not cross the space; rather, they course in the walls and in the sub-orbicularis fat within the roof of the space.

Surgical Anatomy of the Ligamentous Attachments of the Lower Lid and Lateral Canthus

Description of the surgical anatomy of the superficial fascia of the face must include its deep attachments. These attachments have been mapped out for the forehead, temple, and cheek as retaining ligaments. The deep attachments of the orbicularis oculi of the lower lid and lateral canthus have long been recognized in canthopexy surgery but have yet to be properly defined. Six fresh cadavers were dissected with histologic support, and the results were correlated with surgical observations. The fascia of the deep aspect of the orbicularis is attached to the periosteum of the orbital rim by an orbicularis retaining ligament. This attachment is weakest centrally and tightest over the inferolateral orbital rim. The retaining ligament fuses with an expanded fibrous attachment beyond the lateral canthus, the lateral orbital thickening, which extends over the lateral orbital rim onto the adjacent deep temporal fascia. Aging changes are associated with attenuation of the ligamentous support provided by the orbital thickening and the orbicularis retaining ligament, which then allows inferior displacement of the lower boundary of the lid and contributes to the typical effects of age in this region. The superficial fascia of the lateral orbital region has a continuous connective tissue structure linking the temporoparietal fascia and orbicularis fascia to the lateral canthal tendon by means of the tarsal plate connection. Release of the deep ligamentous attachments (lateral orbital thickening and orbicularis retaining ligament) of the orbicularis fascia is important in some canthopexy and in rejuvenation procedures. The release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar soft tissues.

Nasal Fracture Management: Minimizing Secondary Nasal Deformities

Current management techniques for acute nasal fractures result in a high incidence of posttraumatic nasal deformity (14 to 50 percent). Associated traumatic edema, preexisting nasal deformity, and occult septal injury account for most of these acute reduction failures. Working with a detailed patient history and a physical examination that included rigid nasal endoscopy, the authors formulated a clinical algorithm for acute nasal fracture management, the use of which can reduce the incidence of posttraumatic nasal deformity. In this article, the authors review the literature, then discuss their management techniques over the past 11 years in 110 cases with a 9 percent nasal revision rate. This low incidence of revision is attributed to complete nasal assessment (bony and septum), use of outpatient controlled general anesthesia, and primary septal reconstruction in cases with severe septal fracture dislocation.

Capsular contracture: what is it? What causes it? How can it be prevented and managed?

For more than 40 years capsular contracture has plagued plastic surgery as the most common complication of aesthetic and reconstructive breast surgery. This article reviews the basis for capsular contracture and defines the methods to prevent it and treat it when it occurs. Capsular contracture is most commonly a result of a subclinical colonization of the implant pocket with bacteria. Sound techniques-including precise, atraumatic, bloodless dissection; appropriate triple antibiotic breast pocket irrigation; and minimizing any points of contamination during the procedure-have produced very low capsular contracture rates. Treatment of capsular contracture is most often surgical total capsulectomy with site change when indicated and replacement with a new implant.

Optimizing breast pocket irrigation: an in vitro study and clinical implications.

Subclinical infections have been implicated in the etiology of capsular contracture. Intraoperatively, breast pocket irrigation with povidone-iodine or other antibiotic solutions has been popularized; however, detrimental effects on wound healing for these agents have been reported and their efficacy against common organisms found around breast implants has not been studied. The purpose of this study was to compare the in vitro efficacy of serial dilutions of povidone-iodine and two double antibiotic solutions DAB-1 (gentamicin/polymyxin B) and DAB-2 (gentamicin/cefazolin), against organisms most commonly found around breast implants. In phase I trials, serial dilutions of povidone-iodine and DAB were combined 1:1 with cultures of five common organisms found around implants. In phase II, povidone-iodine was serially diluted in DAB-1 rather than saline. In phase III, povidone-iodine was serially diluted with DAB-2. Efficacy for all phases was determined by plating the mixture onto agar plates and incubating at 37 degrees C for 48 hours. Povidone-iodine was 100 percent effective at a dilution of 12.5% against Staphylococcus epidermidis and 25% against Staphylococcus aureus but relatively ineffective against Escherichia coli and Pseudomonas, DAB-1 was found to be ineffective against S. epidermidis but effective against S. aureus, Propionibacterium acnes, E. coli, and Pseudomonas. In phase II trials, a concentration of 12.5% povidone-iodine in DAB was effective at killing all experimental bacteria. In phase III trials, 10% povidone-iodine in DAB-2 was effective at killing all bacteria tested. In conclusion, to maximize bacterial control of common breast implant organisms and to minimize the detrimental effects on wound healing, 10% povidone-iodine in gentamycin/cefazolin may be used with excellent results and its use clinically may reduce the incidence of capsular contracture.

Functional donor site morbidity following latissimus dorsi muscle flap transfer.

The latissimus dorsi flap is highly versatile and reliable, making it a commonly transferred muscle flap. This study evaluated the subjective donor site morbidity, with special attention to activities of daily living. A review of 85 consecutive female patients who underwent latissimus dorsi muscle transfer was performed. Patients were mailed detailed questionnaires concerning cosmesis, use of the shoulder, time to return to work, weakness, and multiple specific activities of daily living. Up to 39% of patients reported at least moderate weakness, 50% experienced back numbness/tightness, and 22% of patients rated their scar as unacceptable. A significant number of patients had difficulty with vigorous activities of daily living (P < 0.05) compared with more sedentary activities. We conclude that latissimus harvest is not totally without postoperative donor site morbidity, and patients should be counseled accordingly prior to flap transfer.

The deviated nose: Optimizing results using a simplified classification and algorithmic approach

The deviated nose presents a particular challenge to the rhinoplasty surgeon because, frequently, both a functional problem (airway obstruction) and an aesthetic problem must be addressed. An approach to the deviated nose is presented that relies on accurate preoperative planning and precise intraoperative execution of corrective measures to return the nasal dorsum to midline, restore dorsal aesthetic lines, and maintain airway patency. The principles of correction include wide exposure through the open approach, release of all deforming forces to the septum, straightening of the septum while maintaining an adequate dorsal and caudal strut, restoring long-term support, reducing the hypertrophied turbinates, and performing controlled stable percutaneous osteotomies. An operative algorithm is described that emphasizes simplicity and reproducibility, and case studies demonstrate the results that can be achieved with this approach.

The boxy nasal tip: classification and management based on alar cartilage suturing techniques.

The boxy nasal tip is characterized by a broad, rectangular appearance of the tip lobule on basal view. This manifests anatomically as one of three types: type I, which features an increased intercrural angle of divergence (greater than 30 degrees) and normal domal arc (4 mm or less) manifesting as the tip-defining points; type II, which features an increased angulation of the domes of the lower lateral segments of cartilage, creating a widened domal arc (greater than 4 mm) and normal angle of divergence (30 degrees or less); and type III, which features a combination of increased angle of divergence (greater than 30 degrees) and widened crural domal arc (4 mm or greater). In this article, the available techniques for correction of the boxy tip are reviewed and an algorithmic approach for the management of this problem is demonstrated using the open approach to rhinoplasty. Using an individualized algorithmic approach with intraoperative nasal tip analysis and three nasal tip suture reshaping techniques, consistent aesthetic results can be obtained in the correction of the boxy nasal tip.

Rhinophyma: Review and update

LEARNING OBJECTIVES After studying this article, the participant should be able to discuss: 1. Clinical features and anatomy of rhinophyma. 2. The etiology and epidemiology of rhinophyma. 3. Associated diagnosis that can complicate rhinophyma. 4. Common nonsurgical and surgical therapies for rhinophyma. 5. A safe and integrated treatment plan for the patient with rhinophyma.