External Ultrasound-Assisted Lipoplasty from Our Own Experience

External ultrasound-assisted liposuction (XUAL) is a new technique that requires traditional aspirative liposuction after the application of high frequency ultrasonic fields delivered through the skin into a wetted tissue. Initial data suggest that it has some advantages over the traditional procedure, especially regarding the achievement of less traumatic surgery with superior clinical outcome. This preliminary report describes a comparative study between conventional liposuction and the external ultrasound-assisted technique as the modality of treatment for fat deposits in 65 bilateral anatomical areas. The results showed considerable superiority of the ultrasound-assisted series. We found less resistance to the canulla with more rapid removal of fat and the aspirated tissue showed less blood content with intact viable fat cells. Patients report less pain and discomfort on the ultrasound-treated sides and we found less swelling and bruising, with superior skin shrinkage. Clinical recovery was also enhanced by the external ultrasound and no complications were reported with the technique.     

Contribution of vitamin C administration for increasing lipolysis

This experiment was designed to investigate whether addition of vitamin C to the solution used in tumescent technique of liposuction might increase lipolysis and whether increased fibrosis might improve skin retraction where liposuction did not work properly and the skin had poor retraction ability. Eighteen Sprague-Dawley rats were used in two groups. Both inguinal fat pads of rats with their vascular structures were elevated and the right inguinal fat pad was injected with 1 cc tumescent solution as a control and the left fat pad with a 1 cc vitamin C-tumescent solution. Histopathological examination showed that all fat pads injected with tumescent solution had normal adipocytes. Those injected with vitamin C-tumescent were shown to have extreme fibrosis and occasional adipocytes.     

Simultaneous Facelift and Carbon Dioxide Laser Resurfacing: A Safe Technique?

A modified facelifting technique with simultaneous carbon dioxide laser resurfacing makes for improved quality of the overlying skin, which enhances the effect of repositioning of the deep facial structures. Concerns have been expressed with regard to complications which may occur when this approach to facelifting is used. This paper presents guidelines which, if observed, allow this procedure to be performed safely in terms of laser skin injury. Over 100 patients have been treated using this combined technique, frequently with the addition of further ancillary procedures. Patient follow-up ranged from 1 to 36 months and showed none of the feared complications to have occurred. This combined approach has improved the results achieved previously by either technique used on its own. In addition, it saves time for both patient and surgeon, and apart from redness, the postoperative recovery period is similar. This technique requires patient education and a postoperative team effort by surgeon, nurse, and aesthetician. Experience has shown that this is a safe procedure which can produce good results with the proper pre- and postoperative management.     

The Minimal Facelift: Liposuction of the Neck and Jowls

We have used blunt liposuction for removing excess fat from the neck and jowls since 1983 with generally good results and few complications. Under local anesthesia with Valium and ketamine sedation and the use of the super-wet technique, and by using special precautions to avoid the complications of prominent platysmal bands, wrinkling of the neck, and salivary gland prominence, carefully performed liposuction to the neck and jowls has been shown to be a safe and dependable procedure with good results, and may delay or obviate the need for a facelift.     

Midiabdominoplasty: Indications and Technique

In the treatment of aesthetic deformities of the abdomen there are three points we should analyze: the skin, the fat tissue, and the muscles. Based on these points we can classify it into six groups. Midiabdominoplasty is indicated in the correction of deformities of groups 2, 3, and 4. A small fusiform resection of skin is done in the lower abdomen, undermining of the skin up to the umbilicus (or to the xiphoid appendix if necessary to treat diastasis of the rectus muscles in the supraumbilical region), and desinsertion of the umbilicus, with no external scar, are the main points in this technique. The main complication was the formation of seroma. No necrosis of the flap or unsightly scars were observed. The results were good, with the patients satisfied with their new abdomens.     

Orbital Septorhaphy for the Correction of Baggy Upper and Lower Eyelids

Eyelid bags are the result of relaxation of lid structures like the skin, the orbicularis muscle, and mainly the septum, with subsequent protrusion or pseudo herniation of intraorbital fat contents. The logical treatment of baggy upper and lower eyelids should therefore include repositioning the herniated fat into the orbit and strengthening the attenuated septum in the form of a septorhaphy as a hernia repair. The preservation of orbital fat results in a more youthful appearance. The operative technique of the orbital septorhaphy is demonstrated for the upper and lower eyelid. A prospective series of 60 patients (50 upper and 90 lower blepharoplasties) with a maximum follow-up of 17 months were analyzed. Pleasing results were achieved in 56 patients. A partial recurrence was noted in 3 patients and widening of the palpebral fissure in 1 patient. Orbital septorhaphy for baggy eyelids is a rational, reliable procedure to correct the herniation of orbital fat in the upper and lower eyelids. Tightening of the orbicularis muscle and skin may be added as usual. The procedure is technically simple and without trauma to the orbital contents. The morbidity is minimal, the rate of complications is low, and the results are pleasing and reliable.     

Ultrasound-assisted lipoplasty: Is it really safe?

During the last decade liposuction has become the most common aesthetic procedure. It has also become the most common aesthetic procedure performed by physicians not trained in plastic surgery. New developments such as the tumescent technique, finer cannulas, and, finally, the technique of ultrasound-assisted lipoplasty (UAL) have been paralleled by reports of larger amounts of extracted fat. At the same time we see an increasing number of fatal complications. I have undertaken an investigation of 28 patients during 16 months, undergoing liposuction with UAL, to find out how the procedure affected them in terms of blood loss. I found that, while undergoing UAL, our patients lost up to 53% of their blood volume on postoperative day 1, and the average patient still had a loss of 20% of the blood volume 1 week postoperatively.     

Very Superficial Ultrasound-Assisted Lipoplasty for the Treatment of Axillary Osmidrosis

Treatment of axillary osmidrosis has been mainly concerned with surgical excision of glandular tissues and involved major surgical procedures with high morbidities and many complications. Search for a less invasive procedure for axillary osmidrosis resulted in the use of liposuction. However, there have been controversies over the efficacy of this method. The problem was that liposuction could not effectively remove the apocrine gland located in the dermis and dermosubcutaneous junction. A high rate of residual malodor and dissatisfaction were reported. The author used ultrasound-assisted lipoplasty (UAL) in the very superficial plane to remove the apocrine gland located in the dermis and dermosubcutaneous junction. The purpose of this study was to prove the efficacy of the very superficial UAL (VSUAL) for the treatment of axillary osmidrosis. From December 1998 to December 1999, 21 consecutive patients underwent UAL in their axilla for axillary osmidrosis. The follow-up period ranged from 2 to 12 months (mean: 8 months). UAL was performed in the very superficial plane with an amplitude of 40%. The very superficial UAL (VSUAL) was done mainly in a withdrawing manner with the tip of the cannula against the skin. The UAL (VSUAL) was done aggressively until the skin changed slightly erythematous. The results were assessed subjectively and objectively, and classified as excellent, good, fair, and poor. Nineteen patients were graded as excellent and one patient as good. The total satisfaction rate was 95.2%. One patient complained of residual malodor in her left axilla. There were no cases of skin necrosis, hematoma, or seroma. Histology showed partial removal of the subcutaneous layer and deep dermis, and degenerative epithelial changes in the apocrine glands in the residual deep dermis. These microscopic findings meant near-total functional ablation of the apocrine gland in the axilla comparable to ``flap-to-graft conversion' or surgical excision of axillary skin. The UAL (VSUAL) for axillary osmidrosis has the advantages of a high success rate with minimal complications. Rapid recovery, less restriction of movement, and tiny scars were other major benefits of this technique. Therefore, UAL (VSUAL) is a viable option for treatment of axillary osmidrosis.     

High-Tech Facelift

Recent technological advances in our specialty have made us reappraise the way we approach facial rejuvenation. Some of these technological interfaces have made it possible, in the author's exerpience, to improve results and to tackle difficult aesthetic problems. The purpose of this paper is to report how we combine these technological advances in an effort to improve the aesthetic outcomes. These technological advances are: laser skin resurfacing, endoscopy, newer fat grafting procedures, and new alloplastic materials for bone augmentation. Other technological advances are consultations via the Internet, computer imaging for simulation of possible outcomes, etc. Endoscopy is routinely used in our facial rejuvenative procedures, almost always for the forehead, often for the midface and less often for the neck. Fat grafting procedures using newly adapted concepts are used for the brow, glabella, tear trough deformity, cheeks, lips, chin, nasolabial folds, marionette lines, and other areas of soft tissue depressions apparent before or after the lifting procedures. This has allowed us to restore the tridimensional volume and treat the soft tissue atrophy. Patients with significant skeletal soft tissue disproportion due to aging, loss of dentition, prior trauma or congenital defects may receive one or more of the following implants: glabella, cheek, piriformis, angle of the mandible, mandibular body glove type of implant, prejawl implant, chin overlay or a glove type of implant. Our preference is for a porous polyethylene material because of its tissue ingrowth inductiveness. Individuals who have damaged skin due to solar exposure, aging, smoking, etc., may receive Ultrapulse CO₂ laser resurfacing at the same operative setting (more often) or in a delayed fashion. The Versapulse laser is also needed for the treatment of some skin changes secondary to aging such as telangiectasias (Variable Pulse Green) and brown spots (Q-Switch 532). The high-tech facelift has allowed us to treat the severely damaged skin, fat atrophy, bone atrophy in many patients, at the same time that the lifting procedure is performed. This provides a more comprehensive approach to facial rejuvenation. The combination of different techniques and technologies maximizes the effectiveness and minimizes the potential side effects of each one. Scars in the forehead and scalp are avoided. Incision and fat removal in the lower eyelid are often unnecessary. It provides a more precise vertical lifting with correction of the tear trough deformity and gives a tridimensional restoration of the facial volume. The facial disharmony is treated at every level starting from the facial skeletal support to the most external envelope (skin). Over 200 patients have been treated this way with a minimal rate of complications. The high-tech facial rejuvenation has allowed us to improve the surgical results of our patients compared with previous isolated techniques. The combination of each one of the techniques require a precise understanding of the limits and benefits of each. Case examples of the different combinations will be shown.     

Comparative Evaluation of Traditional, Ultrasonic, and Pneumatic Assisted Lipoplasty: Analysis of Local and Systemic Effects, Efficacy, and Costs of These Methods

Recently ultrasound assisted liposuction (UAL) and pneumatic assisted liposuction (PAL) have been introduced as an attempt to improve the results and reduce the pitfalls of standard liposuction (SAL). Until now no studies comparing, at the same time, UAL, PAL, and SAL have been published. The aim of this study was to analyze these methods from the surgeon's point of view, focusing not only on aesthetic results but also on local and systemic trauma, efficacy, handling, and cost. Forty-five cosmetic patients affected by local lipodystrophy, divided into three equal groups, have undergone liposuction with the three above-mentioned techniques. Quantitative and qualitative analysis of lipoaspirates, together with blood chemistry, local and systemic complications, time to aspirate 100 cm³, distress, fatigue, and costs of the procedures, has been recorded. Our results showed bloodier lipoaspirates in SAL and a higher percentage of triglycerides in UAL lipoaspirates. Blood tests revealed a slight decrease in the postoperative Hb in SAL only. Early complications observed were four erythemas in PAL, three ecchymoses in SAL, and one long-lasting edema in UAL. Aesthetic results rated by independent viewers were similar for all methods. Efficacy was higher in the PAL group (4 min × 100 cm³ fat aspirated) than in SAL (7 min × 100 cm³ fat) and UAL (10 min × 100 cm³ fat). Surgeon's distress was higher in PAL than in SAL and UAL. Surgeon's fatigue was much lower in the PAL group than in the others. Costs expressed as multiples of 1 unit (1 unit = $500 U.S.) were highest for UAL, low for PAL, and lowest for SAL. In conclusion, PAL and UAL caused reduced vascular injury, UAL being more selective for adipocyte removal. Complications of UAL and PAL were mostly related to the longer learning curve of these methods. The UAL procedure was much more expensive than PAL and, especially, SAL. PAL proved to be a handy technique, with the most favorable cost/benefit ratio, and seems to be the best option for busy liposuction practices or fast office procedures, even though the choice of the ideal technique always depends on the surgeon's preference.     

Coblation: A New Technology and Technique for Skin Resurfacing and Other Aesthetic Surgical Procedures

After years performing CO₂ laser skin resurfacing, I started testing a new technology based on the modification of a bipolar electrosurgical unit in 1998. This technology called Coblation works by a radiofrequency mechanism and from the beginning it showed many advantages over lasers. My histologic and clinical preliminary results have already been published, but now, with a larger group and a 2-year follow-up, I can state that this new device is very effective and safe for skin resurfacing. The device works at low temperatures, avoiding the great thermal injury of a CO₂ laser, but is able to cause some damage in the superficial dermis. The working temperature is high enough to cause shrinkage of collagen and the dermal damage promotes the deposition of new collagen during the postoperative months. During surgery, Coblation can act as an electrosurgical unit and can coagulate the small vessels, achieving a bloodless surgical field. The clinical results show good, long-term results with a short and comfortable recovery period and minimal complications. I combined this resurfacing with face lifts without any special problems. The new cutting-coagulating terminals allow this new technology to be used in other surgical procedures, like transconjunctival blepharoplasties. The Coblation transconjunctival blepharoplasty, combined with Coblation resurfacing, seems to be very effective, with fast healing, due to the low temperatures used during the procedure, and a good aesthetic result. The device is small, light, and it is safer than a laser since it doesn't need any safety measures, such as goggles. After two years and more than 80 patients, I can state that Coblation is a very good alternative to laser skin resurfacing and that it will be used for many other aesthetic surgery procedures in the future.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.     

Presacral Donor Site for Lip Augmentation

For over a century surgeons have been in search of the perfect tissue filler. In recent years lip augmentation has become quite popular. Despite the numerous methods employed to enhance the fullness of lips, autogenous free dermal fat grafting (FDFG) still remains a preferred method. FDFG has been extensively investigated clinically as well as histologically. However, despite its efficacy, FDFG has failed to gain widespread clinical acceptance. One reason has been concern about donor-site morbidity. In this paper, we describe a method of lip augmentation, which utilizes a dermal fat graft from the presacral region. This site is optimal because it has thick skin with minimal hair follicles and leaves a minimal scar.     

A New Extrasupported Tip Graft in the Treatment of Bulbous Nasal Tip

Treatment of bulbous nasal tip is difficult. In the presence of thick, inelastic skin, cartilaginous framework should be supported in special areas. Many tip grafting techniques have been described but the results usually are not satisfactory. We developed a new tip grafting technique to provide extra support and extra length to the nasal tip. The graft is prepared from the septal cartilage and has an extended ``A' appearance. The tip graft is supported with a columellar strut graft. Both grafts are inserted into small separate pockets through separate incisions. If necessary, the alar base is reduced with a modified Weir technique. Fifty-two patients were treated with this technique over the last 3 years. Results were satisfactory in all patients without any complications such as graft displacement, infection, or resorption. Extrasupported tip graft is an effective method in the treatment of bulbous nasal tip with thick skin.     

Pitanguy's Method of Protruding Ear Correction from Our Own Experience: Review of 80 Cases

A recent review of the literature revealed more than 20 methods of correction of protruding ears. Pitanguy's cartilage island flap technique is still not widespread. However, it is extraordinarily versatile and effective from our own experience. The aim of this study is to present our own experience in the correction of prominent ears using this method. According to Pitanguy's cartilage island flap technique, 80 patients were operated on at the Private Plastic Surgery Clinic from 1992 to 1999. There were 45 (56%) female and 35 (44%) male patients, aged from 9 to 37 years (22 years on average). All procedures were performed under local anesthesia. In the follow-up period of 1 to 8 years the final aesthetic results were estimated as very good in 68 (85%) patients and good in 12 (15%) patients. Early complications in the form of bleeding occurred in three (3.75%) patients. Asymmetry in the ears' position was qualified as a late complication and occurred in four (5%) patients.     

Abdominal Etching

The development of blunt liposuction by Illouz [1] in 1978 ushered in a new era in body sculpting. For the first time it had become possible to dependably remove large amounts of subcutaneous fat and decrease saddlebags and bulges to provide a smoother contour. Refinements in liposuction techniques have made it possible to dramatically resculpt the subsurface plane and improve body contour virtually from head to toe [2–4]. Mark Gilliland first performed abdominal etching by removing specific grooves of subcutaneous fat to accentuate the appearance of the abdominal musculature [5–8]. We have developed a new cannula for precision etching. This technique has been used in 25 patients with good results and has resulted in only one complication, which was the result of placing one of the horizontal etching lines at the level of the umbilicus. This created an unseemly fold that is best avoided.     

Aesthetic Breast Surgery with Inverted-T Scar Placed above the Inframammary Sulcus

This article describes the inverted-T incision technique with the scar placed above the inframammary sulcus for cases of pexy, breast reduction, and augmentation–reduction mammaplasty. This technique preserves the inframammary fold as an important factor in natural breast suspension; the breast mound is easily shaped independent of the skin tension. The gland- and skin sutures are placed separately and independently. This technique has been used on 380 patients in the last 13 years.     

Mammographic findings following reduction mammoplasty

Breast reduction mammoplasty is becoming an increasingly common procedure. A baseline mammogram is recommended after 35 years of age as the most effective method for detection of small breast cancers. A prospective study was conducted for the evaluation of the mammographic findings after reduction mammoplasty. During the last 7 years, 113 patients over 35 years of age underwent bilateral reduction mammoplasty. All patients had a preoperative mammogram. A new mammogram was obtained at 6 and 18 months after the procedure. All films were reviewed by the same two radiologists. Breast reduction was performed with the vertical bipedicle flap technique (McKissock) and the inferior pedicle technique. There were no apparent differences in the findings between the two methods. Most common findings were parenchymal redistribution in 102 (90.2%) and elevation of the nipple in 96 (84.9%), produced by a shift of the breast tissue to a lower position. Calcifications were seen in 29 (25.6%), and ``oil cysts' in 22 (19.4%), caused by localized fat necrosis. A retroareolar fibrotic band was found in 23 (20.3%), from the transposed flap. Areolar thickening was observed in six (5.3%), and skin thickening in only two (1.7%), from scar tissue. Mammographic findings after reduction mammoplasty are predictable, thus preventing unnecessary biopsies and making the diagnosis of lesions unrelated to the procedure easier. All patients over 35 years of age should have a preoperative and a postoperative mammogram for future reference.     

Wineglass Pattern for Vertical Mammaplasty

The ideal reduction mammaplasty technique should create a pleasing breast shape with minimal scarring. The long and conspicuous scar associated with the classic inverted ``T' pattern mammaplasty techniques are not acceptable for many patients. Periareolar mammaplasty techniques cause less scarring, but they have major disadvantages such as scar widening, areolar distortion, and insufficient breast projection. We used a new pattern for vertical mammaplasty to overcome the insufficient breast projection caused by the round block technique and applied it to 51 patients during the last 3 years. This method results in a single vertical scar and a periareolar scar, allows sufficient volume reduction, and provides good breast shape and projection; the results are durable. This procedure is safe, causes few complications, and is easy to learn and perform.     

Blepharoplasty: A Personal Tactical Approach

The author presents his tactical approach and personal instruments for blepharoplasties. To remove the skin excess in the upper eyelid, a special half-moon forceps grasps the excess of skin, and with a very sharp scissors, it is removed in just one cut. Treatment of fat pads uses a special hemostatic forceps, unlike the conventional one that has transverse grooves, with longitudinal grooves to prevent fat sliding after the fat pads are cut, thereby preventing problems with hemostasis. In the lower eyelid, wide undermining and excision of a significant strip of skin and muscle allow an adequate correction. Ectropion is prevented, and the correction done is stabilized with orbicular muscle and skin flap anchorage on the lateral canthal tendon. Fifteen years of experience with this technique has provided excellent results.