Canadian Society for Aesthetic
Canadian Society for Aesthetic (Cosmetic) Plastic Surgery/ Société canadienne de chirurgie plastique esthétique
Abstracts presented at the 24th Annual Meeting/24ième Réunion Annuelle
September 5 to 6, 1997
Vancouver, British Columbia
PROGRAM CHAIRMEN:
Dr Stephen Brady, President
Dr Thomas Bell, Vice-President
C1
Abdominal contouring of the 1990s
PA Vogt MD FRCSC
Minneapolis, Minnesota
In the past 20 years many plastic and reconstructive surgeons have attempted to determine the safe parameters of combining traditional abdominal dermal lipectomies with suction assisted lipoplasty (SAL). The vasculature of the abdominal wall, the effect of previous abdominal surgical procedures and the safe limits of SAL are carefully explored in the abdominal wall, flank and hip roll area. Also, new incisions and new methods of reducing postoperative hematomas and seromas, as well as postoperative supra scar bulges, are carefully explored and presented in a concise and clear fashion.
C2
Brachioplasty and brachial suction-assisted lipoplasty (SAL)
PA Vogt MD FRCSC
Minneapolis, Minnesota
The author will present an update of seven years’ ongoing clinical research into both suction-assisted lipoplasty of the upper arm and para-axillary region, as well as various techniques that can be employed to enhance results of suction with varying lengths of incisions.
The paper is designed to reduce surgeon discomfort and to outline clearly methods of evaluating candidates for various surgical procedures. The author has written extensively on this subject.
C3
Calcification of 404 silicone-gel breast implant capsules
WJ Peters, KP Pritzker, DC Smith, D Ibanez, V Fornasier
Toronto, Ontario
Calcification was present in 66 (16.3%) of 404 capsules from silicone-gel breast implants explanted from 1981 to 1996. Sixty capsules had clinically visible plaques of calcification on the inner surface, two had intracapsular calcification and two had true heterotopic ossification. All 28 first generation implants (1963 to 1972) (with Dacron patches) had extensive calcification. Their mean duration in situ was 20.8 years (range 14 to 28 years). Thirty-seven of the 348 second generation implants (10.6%) (1973 to 1987) had capsular calcification. Their mean duration in situ was 16.0 years (range seven to 22 years). Only two had patches, and those were silicone, not Dacron. For second generation implants, calcification was related to duration in situ. None of the 294 implants in place for less than 13 years demonstrated calcification. Subsequently, the percentages calcified
were: 13 to 14 years, 33%; 15 to 16 years, 45%; 17 to 22 years, 57%. Among second generation implants, 17 had bilateral calcification and all were ruptured. Five had unilateral calcification, and calcification was present on the ruptured side, but not on the intact side. Calcification was analyzed according to distribution, density, mineral nature, crystal phases and elements within crystals using photography, histological staining, autofluorescence, transmission electron microscopy, electron diffraction and electron dispersive x-ray spectrometry.
C4
Comparative laser-tissue interactions
Gordon H Sasaki
Pasadena, California
The next generation of laser systems for skin rejuvenation has focused on reducing excessive thermal damage and removing precise layers of skin to promote faster healing with less erythema, pigmentary changes and scarring. This lecture will compare the effects of laser-tissue injury involving superficial/deeper modes from three different systems. These interactions will be related to clinical results, including photographic
dermocontractions. Laser systems: A more superficial lasering is achieved by the 1) Sharplan Feather Touch CW mode (30 to 75 W, 10% density, 5.2 to 12.7 J/cm2), Sharplan SurgiPulse mode (10 to 16 W, 250 to 400 mJ, 10% density, 8.2 to 12.7 J/cm2);
2) Coherent Ultrapulse CPG (60 W, 175 to 250 mJ, 30% density, 8.9 to 12.8 J/cm2), and 3) Luxar Surescan (5 to 9 W, 10% density, 5.5 to 9.9 J/cm2). A deeper lasering is obtained by the Sharplan SilkTouch (12 to 20 W, 5.4 to 9.0 J, 19.1 to 31.8 J/cm2) and Coherent Ultrapulse CPG (60 W, 300 to 450 mJ, 30% density, 15.4 to 23.1 J/cm2).
Injury depths: After a single pass in the superficial mode, lasers vaporize between 30 and 60 u with minimal thermal damage less than 20 u. In the deeper mode, lasers vaporized between 60 and 100 u with more diffuse thermal damage between 30 and 75 u. Multiple passes resulted in lesser amounts of vaporization and more extensive thermal injury. Clinical results: There appeared to be a direct correlation between depth of injury and degree of erythema, pigmentation and scarring in Fitzpatricks I to III skin type patients. Deeper dermal injury can result in 15% to 30% skin contraction. Conclusion: An individual laser approach is recommended for greater patient satisfaction and safety.
C5
Cost saving tips for office surgery units
RH Stubbs
Toronto, Ontario
Establishing and maintaining an ambulatory cosmetic surgical facility is an expensive proposition. The author will review his more than 13 years’ experience with cost saving measures in a 4000 square foot unit that he owns and directs.
C6
Failure mechanism of saline breast implants
WJ Peters, DC Smith, VC Fornasier
Toronto, Ontario
From 1992 to 1996, 189 saline breast implants were inserted into patients (54 for breast augmentation and 116 for replacement of explanted silicone-gel implants). Nine of these implants (4.8%) underwent spontaneous deflation at a mean time of 2.8 months postoperatively (range 0.5 to 10 months). Six deflations were partial (10% to 50% of important volume) and three were complete. All failed implants were from the same manufacturer and had the same leaf valves. None of the failed implants demonstrated any
visible defects in their walls or valve mechanisms when examined in the operating room. Subsequent analyses showed that all failed implants demonstrated a slow leak through the leaf valve mechanism – as slow as two to three drops per 12 h. This rate increased significantly when pressure was applied to the implants. In the three implants with delayed leakage (six to 10 months), fibrous tissue ingrowth was observed into the leaf valve mechanism. It is postulated that failure in all nine implants resulted because of defects in their valves, and that tissue ingrowth into the leaf catheter valve mechanism may have played a role in at least three of them. The tissue may have provided a ‘wick’ to stimulate fluid leakage. No failures have been observed in any of the 48 diaphragm valve implants inserted during the past eight months.
C7
Genital enhancement surgery
RH Stubbs
Toronto, Ontario
The author will review his more than 10 years’ experience with procedures for men and women that are often performed, but seldom discussed. Genital enhancement surgery probably represents the last anatomical frontier of cosmetic surgery. The informed plastic surgeon should be aware of what patients in the Canadian cultural mosaic may request.
C8
Is mastopexy an absolute after explantation?
Jean Paul Bossé
Montreal, Quebec
Is mastopexy an absolute after explantation? >From a logical point of view, it would seen so. But in reality there are a number of factors to be considered before suggesting a mastopexy after explanation. There are some clinical considerations such as pre-augmentation status of the breast, the size of the prosthesis and the breast, the site of the implantation and the age of the patient. The patient’s expectations and economic situation should also be taken into account. After having considered all of these, a fair number of women could be advised to have their implants removed and to wait and see whether they will adapt to their new shape. If mastopexy is considered, our technical approach would be the periareolar Benelli technique.
C9
Lateral smasectomy rhytidectomy
Daniel C Baker MD
New York, New York
In an attempt to find a safe, reliable technique for rhytidectomy, which tightens the deeper facial structures, a lateral smasectomy approach has been developed. Technique: A strip of SMAS (superficial musculo-aponeuro ic system) several centimetres wide is resected from the angle of the mandible overlying the parotid gland and extending to the malar eminence. The SMAS is then advanced in a superior-posterior direction. This provides tightening for the jowls and nasolabial fold, and elevation of the malar fat pad without deep dissection. Tension on the skin flap is also minimized. Results: A total of 1500 rhytidectomies have been performed utilizing this technique since June 1992. There were no cases of facial weakness or paralysis; 16 patients developed large hematomas, three developed infections. Eighteen patients followed for over one year requested revisional surgery to improve their results. Advantages: In the author’s hands, this technique has proven safe, consistent and reliable, giving results comparable with those obtained with the deeper dissection techniques. Exposure of the facial nerves and muscles
and prolonged facial edema is avoided.
C10
Lift or laser
GD Waslen
Calgary, Alberta
This presentation will demonstrate the effect of CO2 laser resurfacing in facial aesthetic surgery practice. A total of 150 consecutive laser resurfacing cases, including patient type, indications, performed procedures and patient evaluation through questionnaire, will be reviewed. There will be an in-depth evaluation, comparing patients with facelifts and laser resurfacing. Statistics, results and before and after photographs will be presented.
C11
Modified vertical breast reduction
EJ Hall-Findlay MD FRCSC
Banff, Alberta
The Lejour type breast reduction has not been enthusiastically embraced in North America because the pedicle is difficult to inset and because the extensive undermining has led to healing problems. In the past three years, I have performed over 300 large and small breast reductions using a vertical scar. I have modified the Lejour technique so that is reproducible, predictable, simple and safe.
Improvements:
1) The pedicle not only has a more reliable blood supply, but also is much easier to rotate into position. 2) Healing problems are reduced since there is virtually no skin undermining.
3) Recovery is faster because there is no significant blood loss.
4) The shape settles quickly because there is only minimal need for liposuction.
5) It is easily adaptable to larger breasts.
The result is a better breast shape with significantly reduced scars. The procedure is easier for the patient and faster for the surgeon.
C12
Primary rhinoplasty
RK Daniel
Newport Beach, California
The review of 100 consecutive primary cosmetic rhinoplasty revealed the following:
1) Approach – 40% closed, 60% open
2) Tip work Resection only 35
Closed
Tip graft 5
Sutures only 33
Open
Graft 27
3) Osteotomies 88%, no osteotomies 12%
4) Functional surgery 35%
5) Grafts 90% (spreader grafts 72%)
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Conclusions:
1) Multiple techniques are required.
2) In cosmetic cases, function in 35%.
3) High percentage of grafts.
C13
Septal extension grafts: A method of controlling tip projection, rotation and shape
H Steve Byrd
Dallas, Texas
Failure to control the projection, shape and rotation of the nasal tip is a common occurrence among patients with weak lower lateral cartilages. These patients’ noses are characterized by a weak midvault, a plunging tip with Polly beak, and drawn-up alae. The purpose of our study was to identify methods for controlling the position and shape of the nasal tip in these high risk patients.
Twenty patients at risk of losing nasal tip projection were retrospectively identified, and measurements made from their pre- and postoperative photographs were compared. Loss of tip projection occurred in all but one patient, whose columella strut was fixed to the caudal septum. Prompted by these failures, we studied the relationship between the dorsum and tip in cadaveric specimens with and without a supratip break. From our observations, a structural extension of the septum – an anterior sepal extension graft – was developed to predictably control this relationship. The clinical application of sepal extension grafts in open rhinoplasty was subsequently evaluated in 20 patients who were deemed to be at risk of losing tip projection. Postoperative photographic analysis showed nasal tip projection to be maintained or increased in all but one patient with the use of septal extension grafts. A stable caudal septum is essential to the success of the technique.
C14
The hypertrophic scar equation – humidity = maturation
Jean Paul Bossé
Montreal, Quebec
For years we have been trying to find an efficient agent against hypertrophic scars and keloids. Our interest was focused on Asiatic acid compound, first in injectable and oral form in the ’70s and more recently as a topical. Incorporated in a liposome base, we used the cream on more than 400 patients. The results of our open study on 210 patients were quite positive and allowed us to proceed to a double-blind study. To our surprise the statistical analysis of our double-blind study could not differentiate the liposome base as a placebo from the active ingredient, Teca, both giving a similar positive response.
So if a nonmedicated product can control the hypertrophic reaction, the mode of action can only come from its potential effect on intracellular water metabolism by preventing evaporation and bringing water into the cell (moisturizing effect). This would also explain the action of elastic garments and silicon sheets on scars.
C15
Tips from the great Canadian outdoors
Benjamin Gelfant
Vancouver, British Columbia
This presentation will show a few quick tips for surgeons doing primarily office-based aesthetic surgery, with money-saving or time-saving items or techniques adapted from the outdoors and campfire experience of the author.
These include:
* half hitch tool for endoforehead fixation
* mylar safety blanket for heat loss reduction
* clove hitch for drain tying
* Perrine fly-box for needle counts
* fish hook retractors.
C16
Transumbilical breast augmentation (TUBA)
Edwin C Pound III MD, Edwin C Pound Jr MD
Atlanta, Georgia
The transumbilical breast augmentation (TUBA) procedure is an innovative technique that uses a small incision in the navel as an access point for insertion of saline-filled breast implants. Advantages of the TUBA procedure over more traditional approaches include the following. 1) A single small scar is produced in a remote location (the navel)
from the breast.
2) The entire procedure takes only 30 to 45 mins to perform.
3) There is little tissue trauma and virtually no bleeding due to the minimal amount of cutting required.
4) There is minimal interruption of normal breast tissue and less risk of injury to nerves supplying sensation to the nipple area. We present our experience using this technique in over 600 patients.
C17
Vertical mammaplasty for hypertrophy and ptosis
Madeleine Lejour MD PhD
Brussels, Belgium
Vertical mammaplasty is a technique that uses adjustable markings, an upper pedicle for the areola and a central breast reduction with lower skin undermining. The shape of the breast is created by suturing the gland and does not rely on the skin. No scar is produced in the submammary fold. Liposuction is added whenever feasible (in 55% of the cases). This technique, which can be applied to small and large breasts, benefits from three innovative principles:
* wide lower skin undermining to promote skin retraction and reduce the amount of scarring;
* overcorrection of the deformities to produce better late results;
* liposuction to facilitate moulding of the breast and remove
* unnecessary tissue, prone to absorb when the patient loses weight.
A personal series of 220 cases is analyzed. Results have been very gratifying, not only as concerns the reduced scarring, but also for the durable beautiful shape obtained. Complications have been uncommon and only one case required a revision under general anesthesia.
The main drawback of this technique is that the result is not obtained immediately, but this is more a problem for the inexperienced surgeon than for the patient.
C18
Avoiding facial nerve injuries in rhytidectomy
Daniel C Baker MD
New York, New York
The facial nerve can be injured in any rhytidectomy, so the surgeon must be familiar with its normal anatomy, the variations and the high risk areas of this nerve. Fortunately, paralysis of the face following rhytidectomy has been uncommon, and it is usually segmental when it occurs. These injuries have been uncommon because the technique of face lifting has been standardized fairly well and the nerve is anatomically well protected by the parotid gland over its main trunk and by the superficial fascia and platysma muscle in its distal portions.
Recently, however, because the improvement in appearance of the ageing or fatty neck from a standard face lift was sometimes disappointing to both the patient and the surgeon, more extensive and deeper techniques have been developed. With these more aggressive methods, in which the surgeon elevates the SMAS (superficial musculo-aponeurotic system) including platysmal and subplatysmal flaps, the dissection is deeper in the face and neck, and this increases the risk of facial nerve injury, especially when the surgeon is
inexperienced. A discussion of the detailed anatomy of the muscular branches of the facial nerve, how to prevent injuries to them during rhytidectomy and how to manage injuries when they do occur will be presented, with a review of the world literature of facial nerve injuries in rhytidectomy.
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