ADRIANA PONTI, M
ADRIANA PONTI, M.D.
Mixed lipofilling
(Fat Tissue plus Polimethyl-methacrylate)
For many years Medicine has been looking for the substitute for fat tissue, especially for subdermic implants. We understand that fat tissue is one of the best elements for implants but it should be taken account its main drawback: the possibility of absorption. As Cosmetic Surgeons specialized in Liposuction, we have used fat tissue in more than 800 cases., with good results. For the last four years, we have been researching on the use of PMMA microspheres in order to obtain an injectable mixed implant (fat tissue PMMA). These microparticles are smooth, transparent and free from impurities, characteristics which allow sterilization by gas. These qualities of the product have also enabled us to satisfactorily emulsify it with fat tissue, thus obtaining the desired mixed implant, the advantage of which, according to our experience in more than 200 cases is the possibility to apply smaller volumes of fat tissue, with very satisfying results, without the necessity of fat reinjections to keep the desired volume. It is important to point out that this material is supplied by medical laboratories, since it is also used in Orthopaedic procedures.
Lipopenisculpture: Our experience in the last ten years with liposculture and lipofilling, has been used for the enhancement and rejuvenation of body. For the last 6 years we have used lipofilling techniques combining it with the section of the suspensory ligament of the penis in more than 600 cases. Thus we achieved through these two techniques the augmentation and elongation of the penis.
Conclusions: 90% of our patients are satisfied with the results of this surgery as it improved their psycosexual behaviour and selfesteem. This was due to the remarkable change of the penis size.
ALESSIO REDAELLI, M.D.
Polilactic Acid in association with Ca-Hydrossilapatyte in Treatment of facial depressions: our experience
Russo Rosalba, M.D., Modena, Forte Riccardo, M.D., Como,
Redaelli Alessio, M.D., Milan, Italy
The treatment of the wrinkles for expression and aging of the face has seen in the last years an exponential increase with the utilisation of many natural materials and not. Therefore to the use of the bovine Collagen followed the hyaluronic acid, before with small particles and in last with great particles. But nevertheless many patients complain themselves of the duration and prefer materials that last mainly in time. Above all, while for some wrinkles the hyaluronic acid maintains an indication (superior lip, crow’s feet) for others as those of puppet folds or the lateral ones of the cheek obtain sometimes results not so well. Polilactic acid places its employment just in these patients, with an innovative mechanism of action that allows to obtain best results when the other fillers must be repeated: about eight months, one year. Then, for areas as zygomas and nose- genenian folds the CaHA is a material of long duration, easy to use, and, in our experience, without important side effects.
The authors report their experience, exposing the injection technique, very important in order to obtain satisfactory results, and side effects that are reduced to a minimum with a rigorous technique.
Botulinum toxin in face rythidolisis.
Our experience
R.Forte, M.D., Como, Italy, A.Redaelli, M.D., Milan, Italy,
R.Russo, M.D., Modena, Italy
Treatment of face lines for many years has been based on use of dermal fillers in order to correct wrinkles caused by many factors: chrono and foto aging as well as muscular movement.
Botulinum toxin’s A (BtxA) action is based on the possibility of reducing muscular tone, with results often superior to the filler method.
The main indication is the upper third of face but also in the lower third it is possible to use botulinum toxin above all on mouth wrinkles and for Puppet folds.
Muscles are here strictly jointed and the technique details are very important.
Of prime importance is the study of agonist and antagonist muscles that lead up to any treatment, injection points and dosages that must be adapted to each patient, starting with very low amounts in order to absolutely avoid side effects while attaining best possible results.
The authors explain their technique, emphasizing toxin dilution, and the indications for upper, middle and lower third of face.
Importance of the botulinum toxin dilution in order
to avoid side effects. How to do it
A.Redaelli, M.D., Milan, Italy, R.Forte, M.D., Como, Italy,
R.Russo, M.D., Modena, Italy
The botulinum toxin, in the last years, more and more is used in aesthetic medicine in order to reduce mimical wrinkles, in particular in the superior third of face, but more and more also in other finer and, at the same time, more delicate indications. To reduce side effects, particularly in aesthetic indications, and above all in these particular fine indications (mouth, brow lift, eyes, neck) is of fundamental importance, and, between several methods, what covers particular relief in the author’s experience is the dilution of the employed substances, that allows to the just power with one absolutely sure spread.
In the international literature we can often read of side effects, also of relief, in front of dilution techniques, injection points and dosages not always agreeable. It appears therefore extremely useful to emphasise this particular aspect: the dilution of toxin.
In Italy it’s possible to use essentially two products diluted at the moment of use.
Then it’s possible to use adrenalin in order to minimize spread in nearby muscles.
With these devices in author’s experience, side effects are very low.
The authors consider therefore the several aesthetic indications and report their experience and the relative dilutions, for reducing side effects to a minimum.
Medical correction of face wrinkles and folds:
our experience
R.Forte, M.D., Como, R.Russo, M.D., Modena,
A.Redaelli, M.D., Milano, Italy
In the last years the correction of facial wrinkles and folds has seen an exponential increase.
In our experience there is the use of reabsorbable materials that offer total use security, with encouraging results, as hyaluronic acid with small and big particles and the collagen of bovine origin.
Lately we have joined to our baggage the use of Polilactic acid and of the Calcium Hydrossilapatyte that finds good use in order to give back important volumes, as for example on cheeks and zygoma, and in association with classical reabsorbable fillers.
The authors propose their experience, emphasising the implant technique of new materials, particularly to avoid side effects.
Botulinum toxin type A in the correction of upper lip wrinkles in combination with Hyaluronic acid
Alessio Redaelli, M.D., Milano, Italy,
Riccardo Forte, M.D., Como, Italy, R.Russo, M.D., Modena, Italy
The non surgical correction of upper lip wrinkles is a very frequent task for aesthetic doctors and surgeons, but very often, using a filler, the exaggerated activity of the orbicularis ori can cause an unsuccessful and/or short lasting result.
You don’t have anything other to do: surgery is too much, hard peelings are too much and soft peelings cannot remove the problem and, on the contrary, fillers are too light.
In these wrinkles, muscles hyperactivity is the main reason of their persistence in time, as appears in young smokers.
The authors present their own technique in using a combination of botulinum toxin and hyaluronic acid in order to improve duration of the filler implant and enhance quality of results.
The key to success lies in the dilution and sites of injection of the toxin:
the authors show also how to avoid side effects in such a sensitive area and how, in some cases, the use of the toxin on its own, can improve projection of upper lip.
ANDRES FRANCO, M.D.
Intracutaneus tricotherapy
Our hair and scalp constitute one of the corporal areas that require a great diversity of cosmetic care.
Multiple disfunctions can affect our hair and scalpnrequiring a suitable medical as well as a cosmetic treatment.
Nowadays, hair loss is a fact which is difficult to get over for many people. we, as doctors, know this as a result of the medical appointments we have with our patients day after day.
The t.i.d.( intracutaneus tricotherapy ) is a slightily invasive technique meant to achieve capillary regeneration in alopecic areas. there is no difference in the use of tid in both male and female patients and the average duration of the treatment is 16 to 18 weeks.
The i.c.t. ( intra cutaneus therapy ) is compleated with a treatment consisting of the application of a product on the surface by means of iontophoresis ( mesoforesis ) and topical application of complementary products as well as a calculated dosage of aminoacids.
Before treatment, some histological studies are done.
Cutaneus biopsies were carried out afterv6 and 12 weeks.
The biopsies had an appropriate depth containing subcutaneus cellular fabric ( 4 mm. or more ), longitudinal and transverse cuts were made and they were dyed using the hematoxylin-eosin technique.
In the first cutaneus biopsies, before treatment, were noticed signaling the diagnosis of alopecia: - pilosebaceas atrophic structures that bearly reached the depth of the subcutaneous tissue.
• sebaceus glands and erect isolated hair muscles ( lacking the corresponding piloso follicle ).
• scar and fibrosis areas and inflamatory infiltrated elements made up of round cells, being mainly lymphocytes.
The second cutaneous biopsy ( 6 weeks after beginning treatment ) clearly showed improvement with presence of pilosebaceas structures well constituted, althouh still able to observe considerable signs of atrophy, fibrosis and inflammation (swelling).
The third cutaneus biopsy, studied in all the cases, shows well developed pilosebaceas structures that reach a greater depth and most of them were in the phase of growth, anagena ( 50% to 80% ) alttuough still able to observe some atrophic follicle, it could also be noticed less fibrosis and less unespecific inflamatory reaction.
We can sum up the following histological discoveries after the treatment with tid :
1 It increases significantly the number of pilosebaceas structures that are of normal appearence. therefore, it decreases the atrophic or distrophic follicles.
2 It increases the depth of the aforementioned structures in the subcutaneous tissue.
3 More than 50% present aphase of growth of anagena ( 50% to 80%). although in a normal scalp, 85% of the folicles are in this phase.. we will have to wait for later studies to be able to evaluate if the treatment obtains total normality.
4 It improves the histological aspect of the cutaneus tissue, with a decrease of fibrosis and inflamation. there are less sebaceus glands and erect muscles of loose hair.
This product and technique has been developed by dr. franco et alt. for four years, it has turned into a complete therapy and has been an irrefutable method of healthy treatment for the scalp allowing the formation of new and completely healthy piloso follicles, as refered in the above summary.
Since the tid is the patented name of the whole therapeutic system, the products have been registered under the original name of “ tricodres “.
ВNGELO REBELO, M.D.
Breast augmentation tumescent local anesthesia cohesive gel silicone implants
Breast Implants, always a controversial subject. Why ?
Mainly because procedures and opinions vary so much.
• The Approach Via ( areolar, infra-mammary, axillary, endoscopic… )
• The Anaesthesia ( general, local… )
• The Positioning of the Implant ( retro-glandular, retro-pectoral )
• The type of Implant ( silicone, saline, hydrogel, triglyceride… )
The author, in his clinical practice and after years of studies and discussions, prefers and usually uses the following procedures because of fewer complications and better results.
THE AREOLAR VIA - his first choice ( inferior circunareolar or transareolar of Pitangui ) because there is no risk of hipertrophic or keloid scaring and it doesn’t disturb the normal breast anatomy and physiology .The criteria, the areola must be at least 3 cm in diameter. With a lesser diameter or if presented with a hipoplasic or atrofhic areola and he ops for a 4 – 5 cm infra-mammary incision in the inframammary fold.
THE RETROGLANDULAR PLACEMENT – first choice and in almost all cases he prefers this placement because it gives a more natural appearance, there is no discomfort for the patient like in the retropectoral position and no problem with dislocation of the implant.
Only in rare cases of severe hipoplasia or aplasia of the breast does he consider the retropectoral positions or in very special situations of prothesis substitution.
There is no other reason to put implants in the retro-pectoral position in normal procedures. One of the principles of Plastic Surgery is to imitate nature and that means the mammary gland is not placed under the pectoral muscle.
TUMESCENT LOCAL ANESTHESIA - if there are no counter-indications he prefers the tumescent local anaesthesia, with all patients monitored, (E.C.G., blood pressure, O2….) and with a periferical vein catheterised. All patients are given only oral pre-medication with Alprazolam 0,5 to 2 mg + Lisine Clonixinate 500 mg (analgesic).
He does the anaesthesia with the modified Klein’s formula, using 1,7-2 mm Klein’s canulas and the Byron compressed system.
ANESTHETIC SOLUTION
500 cc of Saline Serum (ambient temperature)
+ 1 ampoule of 1 ml of Adrenaline 1mg/ml
+ 1cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 40 cc of Lidocaine 2% WITHOUT Adrenaline
+ 5 cc of Bupivacaine 0,5% WITHOUT Adrenaline
In his anesthetical procedure he uses 5 cc of Lidocaine 2% WITHOUT Adrenaline + 5 cc of Bupivacaine 0,5% WITHOUT Adrenaline in the areola’s incision.
COHESIVE GEL SILICONE PROTHESIS - the author prefers the cohesive gel silicone implants because they are very safe and of excellent quality. In his opinion the silicone gel is the safest most effective material for breast implants. Silicone implants are the oldest most reliable world wide even taking into account the controversy created in the United States over the past 10 years. They have all the silicone characteristics plus the advantage of no “bleeding” because they are COHESIVE. After several studies world wide and especially in the United States we can conclude that the only “problem” of the silicone is the “controversy”. There are many problems with the alternative implants, especially with saline and trilucents. Many patients have reoperations to substitute saline and trilucent for silicone implants.
SURGICAL TECHNIQUE
About the usual surgical technique and procedure – the incision, approach at aponeurotical level, undermining to perform a pocket with at least 2-3 cm bigger than the prothesis diameter, careful hemostasias, put the implant in place, close by layers – the author does not drain (unless in a special case of uncontrolled bleeding), does not use dressing. The skin closure do with Vicryl Rapid (quicker reabsorption) plus “steri-strip” or more recently with “glue” Dermabond.
All patients have a complete clinical history, pre-op routine examinations and Mammography and/or mammary ecography.
The author gives all patients proposing breast augmentation with cohesive gel silicone written information with the characteristics, possible complications, etc. that they take home to read and reflect upon. It is then discussed with him in detail before surgery.
Some photos of the surgery, implant and clinical cases are presented.
Breast reduction areolo-vertical
tumescent local anesthesia
There are several techniques to do breast reduction and from the beginning all have the same principles:
• Preserve anatomy and physiology of the breast
• Avoid nipple necrosis
• Maintain sensibility of the nipple
• Do not stop lactation or ability to breast feed
• Have a final good shape and size
• Smaller scars with good final appearance
It was Ariй who first described minimal incisions with vertical scar to do breast reduction followed several years later by Lassus, Lejour and others.
The last techniques described have abandoned the “big” horizontal scar and in almost all kind of breasts the areolo-vertical or areolar incisions can be performed. One of the advantages is less risk of hypertrophic or keloid scaring and it doesn’t disturb the normal breast anatomy and physiology and doesn’t limit the use of any type of cloths, it’s less traumatic and patients have a quicker recovery.
The author describes one technique with areolo-vertical incision with indications in all kinds of hypertrophic breasts, in ptotic breasts and also in some gigantomastias. He makes the pre-op marking in the right breast having as the important point the position of the nipple all other markings are made by the handling of the breast. It’s similar to Lassus and Lejour pre-op marking, the main difference being an inferior dermal triangular flap that he uses to give consistency and shape to the breast thus preventing the future ptosis. After marking the right breast by hand measurements are taken and the other breast is marked. He performs under local tumescent anaesthesia with or without sedation and in some cases under general anaesthesia.
TUMESCENT LOCAL ANESTHESIA - if there are no counter-indications he prefers the tumescent local anaesthesia, with all patients monitored, (E.C.G., blood pressure, O2….) and with a periferical vein catheterised. All patients are given only oral pre-medication with Alprazolam 0,5 to 2 mg + Lisine Clonixinate 500 mg (analgesic).
He does the anaesthesia with the modified Klein’s formula, using 1,7-2 mm Klein’s cannulas and the Byron compressed system.
ANESTHETIC SOLUTION
500 cc of Saline Serum (room temperature)
+ 1 ampoule of 1 ml of Adrenaline 1mg/ml
+ 1cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 40 cc of Lidocaine 2% WITHOUT Adrenaline
In his anaesthetically procedure he uses 5 cc of Lidocaine 2% WITHOUT Adrenaline in the areola’s incision.
SURGICAL TECHNIQUE
About the usual surgical technique and procedure – De-epithelialized ( Schwarmann’s maneuver ) of all the area from the upper part of the areola to the end of the inferior “triangle”. After this he does the necessary resection in the central and superior region and if not necessary does only the fixation of the dermal flap to the aponeurosis of the “major pectoralis” and closes in layers to avoid dead spaces and tension in the final wound closing with Vicryl Rapid (quicker reabsorption) plus “steri-strip” or more recently with “glue” Dermabond.
The author does not drain (unless in a special case of uncontrolled bleeding), does not use any dressing.
All patients have a complete clinical history, pre-op routine examinations and mammography and/or mammary ecography.
The author gives to all patients proposing breast reduction written information concerning scar placement, possible complications, etc. that they take home to read and reflect upon. It is then discussed with him in detail before surgery. Some photos of the surgery and clinical cases are presented.
Kosmopeel, Strechtpeel and Les Felins peelings
for everyone during all year
The author explains his philosophy in the application of the new peelings, Kosmopeel and Strechtpeel and Les Felins , invented by Dr. Alain Tenenbaum. Those peelings can be used without special precautions all over the year and very good results can be obtained. The protocol of utilization is very easy to perform and can be used on all types of skins in the classification of Fitzpatrick, can be used in black, yellow, bronze, dark skins, etc.
Performing four to six mild sessions, depending of the case, the principal indications are:
Kosmopeel: anti age treatment, anti free radicals treatment, acnes, smoker’s skin, hyper seborrhea, hyperkeratosis, prevention of cancerogenesis, dry and oil skin, sunburns, etc.
Strechtpeel: post peelings, dyschromies, surgical wounds, teleangiectasies, depigmentations, demarcation lines pigmented scars, etc.
Les Felins: to be used at home during the treatment as post peeling, hydratant and sunprotector.
Blepharoplasty with external mini-incisions
The author presents an efficient technique to improve the appearance of people with herniation of fat pad bags of the lower lids. Compared to the unsatisfactory results of the classical blepharoplasty with “sclera-show”, ”round eye” and ectropion and given the retractile skin capacity, of the eyelid region, the author has for several years used this technique, abandoning the classical blepharoplasty with the resultant 4 cm. scar.
It was Fontana, Spain – who described this technique to remove the fat pad bags of the lower lids through minimal transcutaneous incisions of 2-3 mm. It’s a very simple technique, easy to perform, with indication in cases with excess or herniation of the fat pad bags but the author also performs this procedure in patients with skin excess and/or wrinkles, with satisfactory results. It’s a good alternative to the conjuntival approach because of fewer risks to the patient. The author verified that the removal of the simple fat pad gives a much better appearance to patients with a good skin retraction and if necessary can be complemented with peeling or laser procedures.
Performed under local anaesthesia, through a small 2-3 mm incision with an 11 blade, in the lower lid at pupil level, cutting at once skin and muscle until the central bag, at the same time putting pressure on the eye to facilitate the extrusion of the fat with the removal of the blade. With the help of a forceps the fat is gently pushed and cut with a thermocauter (or electrocautery using low intensity, radiobisturi or laser). Through the same incision we have access to the internal and external fat pad bags always with gentle and directioned movements. Sufficient fat, not excess should be removed. Incision closure is carried out with a 6/0 nylon that is removed after 3 days. No dressing is used. Swelling is much less evident and recuperation is quicker. The author has also performed a similar procedure on the upper lid, but with very specific indications of herniation of the medial and internal fat pad bags, through a 2-3 mm incision in the inner portion of the upper lid, in a wrinkle near the nasal-frontal field with the same steps as for the lower lid. In all cases there are neither problems nor complications and there is no risk of eye deformation as the “sclera-show”,”round eye” and ectropion.
It’s a simple quick technique, with very good results, scars are almost invisible, recovery is quick, risks and complications are minimum.
Vibroliposuction
liposculpture assisted pneumatically - lipomatic
The author presents the vibroliposuction a new technique of liposuction/liposculpture assisted by compressed air – LIPOMATIC.
He begins referring the basic principles of Medicine and Surgery in which are the complete clinic history, the observation of the patient, the request of the routine prй-surgery exams, prй-surgery photodocumentation and a proper planification. This is a new technique that changes completely the old concepts of liposuction/liposculpture like the “pinch manouver”, the “criss-cross”, the liposuction levels that are not necessary to this kind of procedure.
It works with compressed air, using special thin “cannulas” between 3 and 5 mm.
This technique where are used coming and going moves as well as rotation-translation, caused by the passage of the compressed air and with a curse of 6 mm with 10 Hz. F., what allows the lise of the adipocits and at the same time the aspiration through out the central orifice of the machine of the emulsified fat.
It’s a small machine that weights about 600 g, can be sterilised and has no special manutention. There’s a “set” of cannulas between 3 and 5 mm with several lengths.
The kind of anaesthesia used can be general or local; being local’s his preference. It’s fundamental the use of tumescence for which he uses the formula:
ANESTHETIC SOLUTION
1000 cc physiologic serum (normal temperature)
+ 1 formula of Adrenaline 1 mg/ 1 ml
+ 1 cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 250 to 500 U.T.R of Hyaluronidase
+ 20 cc to 40 cc of Lydocaine 2% without adrenaline
Pre-medication at least 30 minutes before – Alprazolam 0,5 – 1 mg more Lysine Clonixinate 500 mg as analgesic.
After several years of classical liposuction with vacuum and six years of Pierre Fournier Technique and by comparison he concludes that this kind of liposuction is much less traumatic to the patient and causes less haematomas, less oedema, causing a quicker recovery. It’s a quicker and efficient technique with no dangers and with less physical effort to the surgeon.
The author presents the experience after 2 years experience with emphases for the particular aspects of this technique and the relationship with other techniques.
Concerning the efficacy, safety, results, less traumatic to the patient and much more less tired to the surgeon and the advances using this technique in difficult regions and secondary liposuction, the kind of emulsified fat, the skin retraction and the characteristics of less pain allows the use of less and less amounts of lydocaнne doing almost 95% of vibroliposuccions under local anaesthesia with consequent less risks and morbidity.
ANGELO D’UGO, M.D.
Authorized Artificial Hair Implant. A 5 years Experience with Biofibre CE 0373/TGA
Introduction: since 1995 implantation of artificial hair was officially accepted in Italy as prosthetic medical practice. After the issuing of European norm ruling medical devices (Directive 93/42/EEC) the Italian Health Ministry promulgated a law which indicates the requirements to authorize the use of medical devices, artificial fibers for hair restoration included. Italian fibers Biofibre® CE 0373/TGA meet such requirements and are authorized for artificial hair implant in Europe (mark CE 0373) besides Australia (TGA) and several other countries. The authors have a long experience with follicular unit hair transplantation and with artificial hair implant, having treated almost 3000 patients with hair implants and implanted altogether more than 9 million fibers.
Objective: the authors wish to inform the colleagues on the implant practice whom they have been exercising for more than 10 years and on the numerous additional possibilities that this method offers to surgeons dealing with hair restoration.
Material and methods: Main indications for artificial hair implant are irreversible alopecias, scalp scars from burning, trauma and surgery. The authors use artificial hair Biofibre® for hair restoration following the protocols formulated during their personal experience. A severe selection of patients is performed with examination and pre-implant test. Sessions consist of no more than 800 hair implants each, for an average of 3500 artificial hair implanted. Reactions to test and infections resistant to therapies were treated by explanting the fibers. Follow-up consists of periodical controls in order to verify the level of hygiene maintained by the patient, to complete cleaning of the scalp and to replace fallen fibers.
Discussion, results: observance of the protocols guarantees the safety of this methodology which is indicated for a variety of cases. For some of them this is the only proposable remedy for the patient (e.g.: exhaustion of donor area for autografts, total alopecia). Infectious complications were rare and normally solved with local therapy. Fibers explant was carried out in 1.2% of the cases. Implanted fibers are hardly depicted from other hair, aesthetic result is immediate and psychological effect very positive.
Conclusions: For the high degree of reliability, the good and immediate cosmetic result and the possibility to make up for otherwise incurable conditions, Biofibre® implant can be considered as a valid additional methodology available for the hair restoration surgeon.
ALESSIO REDAELLI, M.D.
Polilactic Acid in association with Ca-Hydrossilapatyte in Treatment of facial depressions: our experience
Russo Rosalba, M.D., Modena, Forte Riccardo, M.D., Como,
Redaelli Alessio, M.D., Milan, Italy
The treatment of the wrinkles for expression and aging of the face has seen in the last years an exponential increase with the utilisation of many natural materials and not. Therefore to the use of the bovine Collagen followed the hyaluronic acid, before with small particles and in last with great particles. But nevertheless many patients complain themselves of the duration and prefer materials that last mainly in time. Above all, while for some wrinkles the hyaluronic acid maintains an indication (superior lip, crow’s feet) for others as those of puppet folds or the lateral ones of the cheek obtain sometimes results not so well. Polilactic acid places its employment just in these patients, with an innovative mechanism of action that allows to obtain best results when the other fillers must be repeated: about eight months, one year. Then, for areas as zygomas and nose- genenian folds the CaHA is a material of long duration, easy to use, and, in our experience, without important side effects.
The authors report their experience, exposing the injection technique, very important in order to obtain satisfactory results, and side effects that are reduced to a minimum with a rigorous technique.
Botulinum toxin in face rythidolisis.
Our experience
R.Forte, M.D., Como, Italy, A.Redaelli, M.D., Milan, Italy,
R.Russo, M.D., Modena, Italy
Treatment of face lines for many years has been based on use of dermal fillers in order to correct wrinkles caused by many factors: chrono and foto aging as well as muscular movement.
Botulinum toxin’s A (BtxA) action is based on the possibility of reducing muscular tone, with results often superior to the filler method.
The main indication is the upper third of face but also in the lower third it is possible to use botulinum toxin above all on mouth wrinkles and for Puppet folds.
Muscles are here strictly jointed and the technique details are very important.
Of prime importance is the study of agonist and antagonist muscles that lead up to any treatment, injection points and dosages that must be adapted to each patient, starting with very low amounts in order to absolutely avoid side effects while attaining best possible results.
The authors explain their technique, emphasizing toxin dilution, and the indications for upper, middle and lower third of face.
Importance of the botulinum toxin dilution in order
to avoid side effects. How to do it
A.Redaelli, M.D., Milan, Italy, R.Forte, M.D., Como, Italy,
R.Russo, M.D., Modena, Italy
The botulinum toxin, in the last years, more and more is used in aesthetic medicine in order to reduce mimical wrinkles, in particular in the superior third of face, but more and more also in other finer and, at the same time, more delicate indications. To reduce side effects, particularly in aesthetic indications, and above all in these particular fine indications (mouth, brow lift, eyes, neck) is of fundamental importance, and, between several methods, what covers particular relief in the author’s experience is the dilution of the employed substances, that allows to the just power with one absolutely sure spread.
In the international literature we can often read of side effects, also of relief, in front of dilution techniques, injection points and dosages not always agreeable. It appears therefore extremely useful to emphasise this particular aspect: the dilution of toxin.
In Italy it’s possible to use essentially two products diluted at the moment of use.
Then it’s possible to use adrenalin in order to minimize spread in nearby muscles.
With these devices in author’s experience, side effects are very low.
The authors consider therefore the several aesthetic indications and report their experience and the relative dilutions, for reducing side effects to a minimum.
Medical correction of face wrinkles and folds:
our experience
R.Forte, M.D., Como, R.Russo, M.D., Modena,
A.Redaelli, M.D., Milano, Italy
In the last years the correction of facial wrinkles and folds has seen an exponential increase.
In our experience there is the use of reabsorbable materials that offer total use security, with encouraging results, as hyaluronic acid with small and big particles and the collagen of bovine origin.
Lately we have joined to our baggage the use of Polilactic acid and of the Calcium Hydrossilapatyte that finds good use in order to give back important volumes, as for example on cheeks and zygoma, and in association with classical reabsorbable fillers.
The authors propose their experience, emphasising the implant technique of new materials, particularly to avoid side effects.
Botulinum toxin type A in the correction of upper lip wrinkles in combination with Hyaluronic acid
Alessio Redaelli, M.D., Milano, Italy,
Riccardo Forte, M.D., Como, Italy, R.Russo, M.D., Modena, Italy
The non surgical correction of upper lip wrinkles is a very frequent task for aesthetic doctors and surgeons, but very often, using a filler, the exaggerated activity of the orbicularis ori can cause an unsuccessful and/or short lasting result.
You don’t have anything other to do: surgery is too much, hard peelings are too much and soft peelings cannot remove the problem and, on the contrary, fillers are too light.
In these wrinkles, muscles hyperactivity is the main reason of their persistence in time, as appears in young smokers.
The authors present their own technique in using a combination of botulinum toxin and hyaluronic acid in order to improve duration of the filler implant and enhance quality of results.
The key to success lies in the dilution and sites of injection of the toxin:
the authors show also how to avoid side effects in such a sensitive area and how, in some cases, the use of the toxin on its own, can improve projection of upper lip.
ANDRES FRANCO, M.D.
Intracutaneus tricotherapy
Our hair and scalp constitute one of the corporal areas that require a great diversity of cosmetic care.
Multiple disfunctions can affect our hair and scalpnrequiring a suitable medical as well as a cosmetic treatment.
Nowadays, hair loss is a fact which is difficult to get over for many people. we, as doctors, know this as a result of the medical appointments we have with our patients day after day.
The t.i.d.( intracutaneus tricotherapy ) is a slightily invasive technique meant to achieve capillary regeneration in alopecic areas. there is no difference in the use of tid in both male and female patients and the average duration of the treatment is 16 to 18 weeks.
The i.c.t. ( intra cutaneus therapy ) is compleated with a treatment consisting of the application of a product on the surface by means of iontophoresis ( mesoforesis ) and topical application of complementary products as well as a calculated dosage of aminoacids.
Before treatment, some histological studies are done.
Cutaneus biopsies were carried out afterv6 and 12 weeks.
The biopsies had an appropriate depth containing subcutaneus cellular fabric ( 4 mm. or more ), longitudinal and transverse cuts were made and they were dyed using the hematoxylin-eosin technique.
In the first cutaneus biopsies, before treatment, were noticed signaling the diagnosis of alopecia: - pilosebaceas atrophic structures that bearly reached the depth of the subcutaneous tissue.
• sebaceus glands and erect isolated hair muscles ( lacking the corresponding piloso follicle ).
• scar and fibrosis areas and inflamatory infiltrated elements made up of round cells, being mainly lymphocytes.
The second cutaneous biopsy ( 6 weeks after beginning treatment ) clearly showed improvement with presence of pilosebaceas structures well constituted, althouh still able to observe considerable signs of atrophy, fibrosis and inflammation (swelling).
The third cutaneus biopsy, studied in all the cases, shows well developed pilosebaceas structures that reach a greater depth and most of them were in the phase of growth, anagena ( 50% to 80% ) alttuough still able to observe some atrophic follicle, it could also be noticed less fibrosis and less unespecific inflamatory reaction.
We can sum up the following histological discoveries after the treatment with tid :
1 It increases significantly the number of pilosebaceas structures that are of normal appearence. therefore, it decreases the atrophic or distrophic follicles.
2 It increases the depth of the aforementioned structures in the subcutaneous tissue.
3 More than 50% present aphase of growth of anagena ( 50% to 80%). although in a normal scalp, 85% of the folicles are in this phase.. we will have to wait for later studies to be able to evaluate if the treatment obtains total normality.
4 It improves the histological aspect of the cutaneus tissue, with a decrease of fibrosis and inflamation. there are less sebaceus glands and erect muscles of loose hair.
This product and technique has been developed by dr. franco et alt. for four years, it has turned into a complete therapy and has been an irrefutable method of healthy treatment for the scalp allowing the formation of new and completely healthy piloso follicles, as refered in the above summary.
Since the tid is the patented name of the whole therapeutic system, the products have been registered under the original name of “ tricodres “.
ВNGELO REBELO, M.D.
Breast augmentation tumescent local anesthesia cohesive gel silicone implants
Breast Implants, always a controversial subject. Why ?
Mainly because procedures and opinions vary so much.
• The Approach Via ( areolar, infra-mammary, axillary, endoscopic… )
• The Anaesthesia ( general, local… )
• The Positioning of the Implant ( retro-glandular, retro-pectoral )
• The type of Implant ( silicone, saline, hydrogel, triglyceride… )
The author, in his clinical practice and after years of studies and discussions, prefers and usually uses the following procedures because of fewer complications and better results.
THE AREOLAR VIA - his first choice ( inferior circunareolar or transareolar of Pitangui ) because there is no risk of hipertrophic or keloid scaring and it doesn’t disturb the normal breast anatomy and physiology .The criteria, the areola must be at least 3 cm in diameter. With a lesser diameter or if presented with a hipoplasic or atrofhic areola and he ops for a 4 – 5 cm infra-mammary incision in the inframammary fold.
THE RETROGLANDULAR PLACEMENT – first choice and in almost all cases he prefers this placement because it gives a more natural appearance, there is no discomfort for the patient like in the retropectoral position and no problem with dislocation of the implant.
Only in rare cases of severe hipoplasia or aplasia of the breast does he consider the retropectoral positions or in very special situations of prothesis substitution.
There is no other reason to put implants in the retro-pectoral position in normal procedures. One of the principles of Plastic Surgery is to imitate nature and that means the mammary gland is not placed under the pectoral muscle.
TUMESCENT LOCAL ANESTHESIA - if there are no counter-indications he prefers the tumescent local anaesthesia, with all patients monitored, (E.C.G., blood pressure, O2….) and with a periferical vein catheterised. All patients are given only oral pre-medication with Alprazolam 0,5 to 2 mg + Lisine Clonixinate 500 mg (analgesic).
He does the anaesthesia with the modified Klein’s formula, using 1,7-2 mm Klein’s canulas and the Byron compressed system.
ANESTHETIC SOLUTION
500 cc of Saline Serum (ambient temperature)
+ 1 ampoule of 1 ml of Adrenaline 1mg/ml
+ 1cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 40 cc of Lidocaine 2% WITHOUT Adrenaline
+ 5 cc of Bupivacaine 0,5% WITHOUT Adrenaline
In his anesthetical procedure he uses 5 cc of Lidocaine 2% WITHOUT Adrenaline + 5 cc of Bupivacaine 0,5% WITHOUT Adrenaline in the areola’s incision.
COHESIVE GEL SILICONE PROTHESIS - the author prefers the cohesive gel silicone implants because they are very safe and of excellent quality. In his opinion the silicone gel is the safest most effective material for breast implants. Silicone implants are the oldest most reliable world wide even taking into account the controversy created in the United States over the past 10 years. They have all the silicone characteristics plus the advantage of no “bleeding” because they are COHESIVE. After several studies world wide and especially in the United States we can conclude that the only “problem” of the silicone is the “controversy”. There are many problems with the alternative implants, especially with saline and trilucents. Many patients have reoperations to substitute saline and trilucent for silicone implants.
SURGICAL TECHNIQUE
About the usual surgical technique and procedure – the incision, approach at aponeurotical level, undermining to perform a pocket with at least 2-3 cm bigger than the prothesis diameter, careful hemostasias, put the implant in place, close by layers – the author does not drain (unless in a special case of uncontrolled bleeding), does not use dressing. The skin closure do with Vicryl Rapid (quicker reabsorption) plus “steri-strip” or more recently with “glue” Dermabond.
All patients have a complete clinical history, pre-op routine examinations and Mammography and/or mammary ecography.
The author gives all patients proposing breast augmentation with cohesive gel silicone written information with the characteristics, possible complications, etc. that they take home to read and reflect upon. It is then discussed with him in detail before surgery.
Some photos of the surgery, implant and clinical cases are presented.
Breast reduction areolo-vertical
tumescent local anesthesia
There are several techniques to do breast reduction and from the beginning all have the same principles:
• Preserve anatomy and physiology of the breast
• Avoid nipple necrosis
• Maintain sensibility of the nipple
• Do not stop lactation or ability to breast feed
• Have a final good shape and size
• Smaller scars with good final appearance
It was Ariй who first described minimal incisions with vertical scar to do breast reduction followed several years later by Lassus, Lejour and others.
The last techniques described have abandoned the “big” horizontal scar and in almost all kind of breasts the areolo-vertical or areolar incisions can be performed. One of the advantages is less risk of hypertrophic or keloid scaring and it doesn’t disturb the normal breast anatomy and physiology and doesn’t limit the use of any type of cloths, it’s less traumatic and patients have a quicker recovery.
The author describes one technique with areolo-vertical incision with indications in all kinds of hypertrophic breasts, in ptotic breasts and also in some gigantomastias. He makes the pre-op marking in the right breast having as the important point the position of the nipple all other markings are made by the handling of the breast. It’s similar to Lassus and Lejour pre-op marking, the main difference being an inferior dermal triangular flap that he uses to give consistency and shape to the breast thus preventing the future ptosis. After marking the right breast by hand measurements are taken and the other breast is marked. He performs under local tumescent anaesthesia with or without sedation and in some cases under general anaesthesia.
TUMESCENT LOCAL ANESTHESIA - if there are no counter-indications he prefers the tumescent local anaesthesia, with all patients monitored, (E.C.G., blood pressure, O2….) and with a periferical vein catheterised. All patients are given only oral pre-medication with Alprazolam 0,5 to 2 mg + Lisine Clonixinate 500 mg (analgesic).
He does the anaesthesia with the modified Klein’s formula, using 1,7-2 mm Klein’s cannulas and the Byron compressed system.
ANESTHETIC SOLUTION
500 cc of Saline Serum (room temperature)
+ 1 ampoule of 1 ml of Adrenaline 1mg/ml
+ 1cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 40 cc of Lidocaine 2% WITHOUT Adrenaline
In his anaesthetically procedure he uses 5 cc of Lidocaine 2% WITHOUT Adrenaline in the areola’s incision.
SURGICAL TECHNIQUE
About the usual surgical technique and procedure – De-epithelialized ( Schwarmann’s maneuver ) of all the area from the upper part of the areola to the end of the inferior “triangle”. After this he does the necessary resection in the central and superior region and if not necessary does only the fixation of the dermal flap to the aponeurosis of the “major pectoralis” and closes in layers to avoid dead spaces and tension in the final wound closing with Vicryl Rapid (quicker reabsorption) plus “steri-strip” or more recently with “glue” Dermabond.
The author does not drain (unless in a special case of uncontrolled bleeding), does not use any dressing.
All patients have a complete clinical history, pre-op routine examinations and mammography and/or mammary ecography.
The author gives to all patients proposing breast reduction written information concerning scar placement, possible complications, etc. that they take home to read and reflect upon. It is then discussed with him in detail before surgery. Some photos of the surgery and clinical cases are presented.
Kosmopeel, Strechtpeel and Les Felins peelings
for everyone during all year
The author explains his philosophy in the application of the new peelings, Kosmopeel and Strechtpeel and Les Felins , invented by Dr. Alain Tenenbaum. Those peelings can be used without special precautions all over the year and very good results can be obtained. The protocol of utilization is very easy to perform and can be used on all types of skins in the classification of Fitzpatrick, can be used in black, yellow, bronze, dark skins, etc.
Performing four to six mild sessions, depending of the case, the principal indications are:
Kosmopeel: anti age treatment, anti free radicals treatment, acnes, smoker’s skin, hyper seborrhea, hyperkeratosis, prevention of cancerogenesis, dry and oil skin, sunburns, etc.
Strechtpeel: post peelings, dyschromies, surgical wounds, teleangiectasies, depigmentations, demarcation lines pigmented scars, etc.
Les Felins: to be used at home during the treatment as post peeling, hydratant and sunprotector.
Blepharoplasty with external mini-incisions
The author presents an efficient technique to improve the appearance of people with herniation of fat pad bags of the lower lids. Compared to the unsatisfactory results of the classical blepharoplasty with “sclera-show”, ”round eye” and ectropion and given the retractile skin capacity, of the eyelid region, the author has for several years used this technique, abandoning the classical blepharoplasty with the resultant 4 cm. scar.
It was Fontana, Spain – who described this technique to remove the fat pad bags of the lower lids through minimal transcutaneous incisions of 2-3 mm. It’s a very simple technique, easy to perform, with indication in cases with excess or herniation of the fat pad bags but the author also performs this procedure in patients with skin excess and/or wrinkles, with satisfactory results. It’s a good alternative to the conjuntival approach because of fewer risks to the patient. The author verified that the removal of the simple fat pad gives a much better appearance to patients with a good skin retraction and if necessary can be complemented with peeling or laser procedures.
Performed under local anaesthesia, through a small 2-3 mm incision with an 11 blade, in the lower lid at pupil level, cutting at once skin and muscle until the central bag, at the same time putting pressure on the eye to facilitate the extrusion of the fat with the removal of the blade. With the help of a forceps the fat is gently pushed and cut with a thermocauter (or electrocautery using low intensity, radiobisturi or laser). Through the same incision we have access to the internal and external fat pad bags always with gentle and directioned movements. Sufficient fat, not excess should be removed. Incision closure is carried out with a 6/0 nylon that is removed after 3 days. No dressing is used. Swelling is much less evident and recuperation is quicker. The author has also performed a similar procedure on the upper lid, but with very specific indications of herniation of the medial and internal fat pad bags, through a 2-3 mm incision in the inner portion of the upper lid, in a wrinkle near the nasal-frontal field with the same steps as for the lower lid. In all cases there are neither problems nor complications and there is no risk of eye deformation as the “sclera-show”,”round eye” and ectropion.
It’s a simple quick technique, with very good results, scars are almost invisible, recovery is quick, risks and complications are minimum.
Vibroliposuction
liposculpture assisted pneumatically - lipomatic
The author presents the vibroliposuction a new technique of liposuction/liposculpture assisted by compressed air – LIPOMATIC.
He begins referring the basic principles of Medicine and Surgery in which are the complete clinic history, the observation of the patient, the request of the routine prй-surgery exams, prй-surgery photodocumentation and a proper planification. This is a new technique that changes completely the old concepts of liposuction/liposculpture like the “pinch manouver”, the “criss-cross”, the liposuction levels that are not necessary to this kind of procedure.
It works with compressed air, using special thin “cannulas” between 3 and 5 mm.
This technique where are used coming and going moves as well as rotation-translation, caused by the passage of the compressed air and with a curse of 6 mm with 10 Hz. F., what allows the lise of the adipocits and at the same time the aspiration through out the central orifice of the machine of the emulsified fat.
It’s a small machine that weights about 600 g, can be sterilised and has no special manutention. There’s a “set” of cannulas between 3 and 5 mm with several lengths.
The kind of anaesthesia used can be general or local; being local’s his preference. It’s fundamental the use of tumescence for which he uses the formula:
ANESTHETIC SOLUTION
1000 cc physiologic serum (normal temperature)
+ 1 formula of Adrenaline 1 mg/ 1 ml
+ 1 cc of Sodium Bicarbonate 8,4% / each 10 cc of Lydocaine
+ 250 to 500 U.T.R of Hyaluronidase
+ 20 cc to 40 cc of Lydocaine 2% without adrenaline
Pre-medication at least 30 minutes before – Alprazolam 0,5 – 1 mg more Lysine Clonixinate 500 mg as analgesic.
After several years of classical liposuction with vacuum and six years of Pierre Fournier Technique and by comparison he concludes that this kind of liposuction is much less traumatic to the patient and causes less haematomas, less oedema, causing a quicker recovery. It’s a quicker and efficient technique with no dangers and with less physical effort to the surgeon.
The author presents the experience after 2 years experience with emphases for the particular aspects of this technique and the relationship with other techniques.
Concerning the efficacy, safety, results, less traumatic to the patient and much more less tired to the surgeon and the advances using this technique in difficult regions and secondary liposuction, the kind of emulsified fat, the skin retraction and the characteristics of less pain allows the use of less and less amounts of lydocaнne doing almost 95% of vibroliposuccions under local anaesthesia with consequent less risks and morbidity.
ANTHONY ERIAN, M.D., FRCS (Eng) FRCS (Ed)
The role of fat transfer in facelifting
Fat grafting has been used for many years now either separately or in conjunction with facial procedures as a general filler much has been written about it. There has been a lot of discussion about longevity, technique and amount to be injected and the site that would give maximum advantage.
For the last five years we have been experimenting with fat grafting alongside a facelift together with various areas and we have now confirmed our position and identified the areas where fat can benefit the facelift dramatically, we have also modified our technique of facelifting to suit the fat transfer and to maximize its benefits.
We now insert the fat prior to the facelift in the designated areas and this had allowed us to do limited dissection for the lateral face and improved the mid-face result dramatically. The areas that we feel are very popular and always necessary with facelifting are:
1. The trough area.
2. The nasal labial fold.
3. The marionette area.
4. The cheek area.
5. Under the upper eyelid area. This compliments the atrophic areas in the face which seem to go hand in hand with ageing.
We have studied the longevity of these grafts in the patients and we found that in the static areas likes the nasal trough cheeks and eyebrow last longer than the other areas because they are less mobile with good blood supply. The injection technique is the same used by our colleagues using mainly micro-cannulas and used the droplet technique of inserting the fat. The commonest donor site is under the chin, this can be augmented by fat taken from the upper abdomen, outer thighs and knees.
We offer these patients a further fat transfer session two years onwards but we find that in the majority of cases either they do not need it or need only a small amount. The total amount of fat transferred in one session is about 20cc to fill the whole face.
B. P. SINGH, M.D.
Using Stored Homologous Autoclaved Fat
By using stored, homologous, autoclaved fat [ Singh’s lipo-injection technique, International Journal of Cosmetic Surgery and Aesthetic Dermatology, Vol 4, No.3, 2002 ] soft tissue augmentation has been done in 73 cases for last 10 years. Various body parts have been successfully treated, namely cheek filling B/L 58 cases, facial asymmetry 08 cases, penile augmentation 06 cases, depressions 02 cases, breast augmentation 04 cases[ 3 patients had lipoinjection in B/L Cheeks and Breast]
Results have been good. No complications seen. Patient’s satisfaction good.
Repeated Liposuctions at Shorter Intervals
Objective of achieving total body contouring with the help of Liposuction is been done by repeating liposuction procedure at shorter interval in same patient at different sites. Technique of wet liposuction is followed, repeat procedure done at the interval of 48–72 hours and if required third liposuction is done after another 48-72 hours.
Total of 118 cases treated till date on patients requiring liposuction at multiple sites. Tolerated well by the patients. Since recovery period is shorten, it is well accepted by the patients.
BOBAN DJORDJEVIC, M.D.
Reconstruction of completely avulsion of the scalp
after unsuccessful replantation – case report
Boban Djordjevic, M.D., Dobrica Jevtovic, M.D., Vladislav Krstic, M.D.,
Milomir Gacevic, M.D., Bojan Stevic, M.D.
Scalp avulsions of various origins are frequently seen, due to rapid industrialization and the increased incidence of road-traffic accidents. The victims were predominantly young females.
In July 1999, a 19-year-old girl sustained a total scalp avulsion including the entire right and the left eyebrow, the upper third of the skin of the dorsum of the nose.
The first two attempts by direct replantation and split thickness skin grafting (Thiersch), which were performed before the patient came to us, did not give satisfactory aesthetic and functional result. After first attempt, in a short period of time a partial necrosis occurred. The second attempt using split thickness skin grafts (Thiersh) was also unsuccessful, because the transplants went under necrosis.
We have obtained good aesthetic and functional result using the method of immediate large soft tissue expansion in two stages. A Radovan-type expander was used in first stage in order to expand the skin on the neck and left abdominal wall, which was later in second stage harvested and used for scalp reparation with full-thickness skin grafts. Finally eyebrow reconstruction was performed using hair grafts.
The operative procedures, pre- and post-operative treatment care are described and discussed.
Of course, since used the grafts do not grow hair, and the patients need to wear a wig for total psychological and functional rehabilitation.
Eyelid suspension with frontalis muscle flap advancement in the surgery of congenital blepharoptosis
Boban Djordjevic, Dobrica Jevtovic, Milomir Gacevic, Bojan Stevic
PURPOSE: Transposition of frontalis muscle flap with method of advancement at the upper tarsal border is an effective technique for correction of blepharoptosis with poor levator function.
METHODS: Twenty-five patients with congenital blepharoptosis (43 eyelids) had frontalis muscle flap procedures. Thirty- seven eyelids had poor levator function. Six had fair levator function. The frontalis action ranged from 8 to 14 mm.
RESULTS: The average of follow-up evaluation was 32 months. The postoperative results were evaluated with various sensation tests of the forehead, and with presence of forehead wrinkles. The frontalis muscle flap provided an even distribution of upward pull on the tarsus without tenting the lid margin. Lagophthalmos was transitory, usually disappearing within 3 months. Lid lag was mild-to-moderate. Mild hypesthesia of the forehead returned completely to normal in all patients, followed more than 24 months. Slight lowering of the medial portion of the eyebrow and incomplete wrinkling of the forehead on upward gaze were mild cosmetic defects after correction in 4 patients with unilateral ptosis.
CONCLUSIONS: Frontalis flap advancement is a technically simple, safe, and effective technique for the repair of congenital ptosis. The frontalis muscle flap advancement technique, is a simple technique with a good operative field, single incision on supratarsal fold, no depression on the forehead, no risk of neurovascular injury, and relatively easy technique with rare complication and yields satisfactory functional and cosmetic results in patients with poor levator function
CARLOS PEDROZA, M.D.
Alar Base Reduction
Alar base reduction should be made when the alar anatomy creates an aesthetic disproportion to the final rhinoplasty result.
Alar reduction of any tipe must be carried out in conservative and symmetric manner. Any asymetries or overreduction can create a major deformity
These lecture will show a conservative technique that provide natural, symmetric and aesthetic results.
Nasal tip graft
The nasal tip is believed to be the most complex and challenging aspect of Rhinoplasty.
The goal is to sculp a nose in harmony with patient’s facial morphology and ethnic features.
Nasal tip graft will provide a proper suport, projection and counter rotation. Help in camouflage asymetries and reconstruction partial or total lower lateral cartilage.
Autogenos cartilage is the best preferable implant material for the nasal tip grafting.
These lecture will review the differents tipes of nasal tip graft, how and when to use them.
CLARA SANTOS, M.D.
Medium Peel (Weekend Peel) + Botulin Toxin
(Botox+ Dysport) – Little Procedures, Big Results.
Aging is an inevitable stage in the late years of anyone’s life. Cosmetic Surgery, Plastic Surgery and Dermatology are specialties that never stop searching what can be of real value in the treatment of this natural process.
Regarded to the face what mostly bother the patients are the wrinkling, spots, usually associated with the loose of even coloration and firmness.
Until couple decades ago, the aging face was basically treated with surgical facelift. The cons against surgical facelift are the invasiveness of the technique, the long down time, presence of scars and post-operatory potential complications. Besides, these limits no improving in skin quality, or in central areas wrinkles are obtained with face lift. By the other hand, a combination of two office’s small procedure Medium Peel + Toxin Botulin, can offer a real nice improvement in the skin surface, firmness, coloration and reducing or making wrinkles (temporailily) disappeared.
We note that today many patients feel extremely satisfied with the results obtained in this easier, shorter, cheaper, safer and quicker way. If the patient wants to maintain or keeping improving the results, the treatment can be repeated about twice a year and at any time if the patient desires, new or additional techniques can be performed anytime.
Dark Skin and Acne Scar – A Therapeutic Challenge
Acne is a very old and common dermatosis that affects a wide spectrum of the population all over the world. Many patients can get ride of it without any mark. Others, unfortunately undergo a more severe form of it and the scars formation is a sequealae very difficult to be dealed with and to treat.
Most if not all patients with acne scars have a tremendous unhappy feeling with their own face image. Some really suffer a real psychological disturbance because there is what we call an auto-rejection.
Treating acne scar is not as easy compared to the treatment of melasmas, blemishes or spots. Acne scar in patients with lighter skin is easier to treat, compared to the darker skin patient, as darker skin are more prone to post inmflammatory hyperpigmentation. This fact becomes even more delicate when they also have a thin and delicated skin.
We will present here peelings of different levels, (superficial.medium and deep) combined with abrasive technique at the same time. Through theses techniques we have reach nice and encouraging results.
Peeling and Exfoliation
in the treatment of Active Acne
We certainly have a special interest in the field of acne treatment. We think that this dermatosis causes lots of emotional impairment among the people who have it, specially the teenager group.
We have treated a group of teenagers and young adult with Acne I or II just performing sequential chemical peeling with exfoliation at the same section. The maintenance treatment was based only in the use of Kligman’s and sun protection factor. No patient had received topic/oral antibiotic, neither accutane. All improvement was obtained only by the use of chemical peeling+ exfoliation.
Exoderm, by Yoram Fintsi –
The best, easiest and safest deep peel.
The treatment of the aged face done by deep peels have presented nice rejuvenation results, but some problems related to the consequence of the phenol are sometimes difficult to avoid. So, for example, hypopigmentation, bacterial or viral infections, scars and sometimes systemic absorption can cause problems when phenol peels are performed.
In 1985 †Yoram Fintsi (1950 – 2001) from Tel-Aviv created the Exoderm, a phenol solution by adding to the phenol a mixture of oils, which resulted in an balanced, buffred controlled and safe agent for deep peel.. Exoderm is unique because it has an auto block at mid-dermis that does not allow deeper penetration, giving the safe desired result by doctors and patients within eight days. It is performed ambulatory under local sedation.
Exoderm has been performed successfully in many countries in the world.
After Dr. Fintsi has died, I was invited by his family to continue his work, to keep teaching and spreading his technique all over the world.
Exoderm has been performed by some doctors in USA, but I think it must be more known between Dermatologist and Cosmetic Surgeon as it is so useful, safe, fast and easy to perform.
Liposuction Totally by Tumescent Anesthesia
Unwanted fat is a common cause of distress and unhappiness for many patients. Among the many techniques to treat this problem, Liposuction Totally by Tumescent Anesthesia has shown to be an easy and safe method. When the tumescent is completely done, there is no need of venous sedation, there is no pain and no blood loss. Absence or minimal equimosis, almost no bruising and a prompt recovery are some of the many positive aspects of this technique.
EDVIN TURKOF, M.D.
The vibro-assisted liposuction with three-dimensional rotating canulas: atraumatic and highly effective; report about 1000 treated areas
Introduction: Since Giorgio Fischer initiated in 1980 the most frequently performed intervention in aesthetic surgery, methods and concepts changed continuously. The main goal was to reduce the trauma caused by the intervention, since bleeding, shock and embolism become more and more frequent. The wet technique was introduced, followed by tumescent infiltration where tissue is filled until saturation is achieved in order to reduce the friction of the cannula. Simultaneously, diameters of the cannulas were reduced to 2mm-4mm. Technical development were achieved with the ultrasonic assisted liposuction (external and internal), the high-frequency current method and the water beam method. All these developments showed distinct disadvantages, so that none of them could replace the conventional method, which still remains the most frequently applied technique. However, in 1998 Jean Malak invented the vibro-assisted liposuction. The cannula is fixed to a hand piece that contents a pneumatic driven engine that makes the cannula moving forward and backward with 10 Hertz. The range of movement can be adjusted from 4mm to nearly 10 mm by changing the pressure of the air, the motion itself is both elliptic and eccentric, causing a three-dimensional movement. The surgeon moves the cannula slowly through the fatty tissue, the tip digs itself forward like a mole. Vessels, nerves and connective tissue (septa) are speared, hence less damaged. Sweating of the surgeon become inexistent, the working time is reduced considerably.
We report about our experience on over 1000 operated areas, including the inner side of the thigh, inner side of the knees, calves and upper arms . We compared the performance with the ultrasonic assisted method and the conventional liposuction. In 11 cases liposuction was combined with an abdominoplaty, a thigh lift or an upper arm lift, hence enabling the visualization of the method’s effect on the fatty tissue.
Methods: From October 2001 to April 2003 we implemented this method on 334 patients (range of age: 18a – 82a, 212 female, 52 male, mean 42a). The following areas have been operated on: skin under the chin, upper lateral area of the breast, abdomen, flank, back, upper arms, lateral thigh, inner thigh, inner side of the knee, frontal thigh, dorsal thigh, calves. In all cases infiltrating time, suction time, suction quantity and the relation fat/water has been meticulously documented. In 10 cases we used the vibro-assisted liposuction on one thigh and the conventional method on the other thigh.
Results were compared with prior operations performed with the ultrasonic assisted technique.
Results: 12 patients were operated on at the skin under the chin (1 region), 42 patients on the abdomen (2 regions), 22 patients on the lateral thigh (2 regions), 23 patients the upper arms (2 regions), 123 patients on the lateral and the medial aspect of the thigh (4 regions), 48 patients on the lateral and the medial aspect of the thigh and the inner side of the knee (six regions), 29 patients on the calves and the lateral and inner thigh (6 regions), 12 patients the frontal and the dorsal aspect of the thigh (4 regions), 9 patients on the lateral upper aspect of the breast (2 regions), and 14 patients on the flank and the back (4 regions). 14 patients were operated on in general anaesthesia upon personal request, all others had the areas anaesthetized by infiltration. Infusion time ranged from 15 seconds to 210 seconds, suction time from 4 minutes to 28 minutes per region, mean 18 minutes. Overall operation time varied from 18 minutes to 3h10, mean 128 minutes. All patients become mild compression garments immediately after surgery and wore them between 4 to 8 weeks. Stitches were removed after 10 days. The quantity of suction fluid varied from 800ml to 12.000 ml (exceptional case of obesity) per patient, with an average of 3400 ml and an fat/water ratio of 6:1 (range: 1:1 – inner side of the thigh, 1:10, upper abdomen, lateral side of the thigh). 65% of the patients agreed to undergo postoperative treatment with endermology. Patients treated in local anaesthesia were dismissed from hospital after the intervention. 12 patients requested unexpected overnight at the clinic (low blood pressure). Low molecular heparin was only given to overnight-patients, as well as antibiotic treatment.
18 patients requested corrections because of indentions and/or asymmetric results.
Discussion: The vibro-assisted liposuction invented by Jean Malakh has clearly to be differentiated from the commonly called power assisted liposuction, since the three dimensional movement of this machine has been patented, while all other ‘power-assisted’ products have their cannulas moving in a horizontal plane alone with a range less then 4mm.
Conclusion: The vibro-assisted liposuction showed to be highly effective in our hands. Its performance showed no disadvantage and we highly recommend this method.
B-Technique (Rйgnault) and dermis-suspension:
a new technique for breast reduction combining
small scars, speed, secure nippel vascularisation
and durability of results
Introduction: There are several techniques for reduction mammoplasties. All attempts to improve existing methods have the goal to achieve durable results, minimizing the scar and to achieve aesthetic shapes. Paul Rйgnault introduced in 1974 a technique based on the upper pedicle for the blood supply of the mammilla, that could be applied in small and large breasts and showed a rounded, L-shaped scar (B-technique), sparing completely the medial aspect of the inframammary fold. The technique is fast, bloodless, easy to learn and has to be regarded as milestone in the numerous attempts to reduce the scar in reduction mammoplasty.
Other attempts were made to enhance the durability of the results. Another milestone was the idea to use the deepithelized skin (dermis) in that a flap is formed and sutured to ribs in order to avoid late drops of the breast. Provided that the flaps remains vascularized, the idea to from an interior brassiere to avoid droping of the tissue deserves close attention. Eren uses a central pedicle with Strцmbeck’s skin incisions, Frey a central pedicle with Rйgnault’s skin incision. Techniques with central pedicle can show problems with the vascularization of the nipple, since the blood supply is restricted to the ascending vessels through the breast tissueas all dermal vessels are transsected. In order to avoid this inconvenient, we searched for a technique combining the advantageous skin-incision from the B-technique and the innovative idea of the stabilizing dermis-suspension.
Methods: The technique consists of the B-technique from Paul Rйgnault and adds to it the interior brassiиre introduced by Eren. The difference lays in the fact that the dermal flap at Eren’s technique is vascularized by the underlying breast tissue, while in this new method the dermis has to be elevated and placed back -subsequent to the removal of the breast tissue - as a more or less free flap, attached on the caudal aspect of the areola alone and sutured to ribbs.
Results: From 1999 to 2002 we applied this method on 20 women (range of age: 24a-64a, median 36a). Elevation of the nipple ranged from 4cm to 16cm (median: 8,5cm), weight of removed breast tissue ranged from 180g to 840g (median: 410 g). In all cases the blood supply of the nipple-areola complex remained excellent. Follow up ranged from 12 to 36 months. 1 patient had to be revised due to asymmetry. Patient’s satisfaction was overall good.
Discussion: It is our opinion that this technique is easy to learn, nearly as fast as the B-technique, equally bloodless but more durable. It avoids the well known, even though not frequently occurring problem of the areole’s blood supply encountered with the methods using a central pedicle.
Conclusion: We can recommend this new method as a simple and safe technique to perform reduction mammoplasties.
My experience with the use of sutures
in forming and stabilizing the nasal cartilage
in aesthetic rhinoplasty
Introduction: The use of sutures to modify the cartilaginous skeleton of the nose in aesthetic rhinoplasties become frequent in the last decade only. In the University Clinic of Vienna, Austria not a single rhinoplasty was performed which sutures to modify the nasal cartilage during my residency (1985-1991). Aiach, Guyuron, Tardy and Tebbeth (alphabetic order) are probably the best known pioneers in modelling the tip of the nose with sutures. The use of grafts, struts, and sutures widened the spectrum of correction and achieved better and longer lasting results in aesthetic rhinoplasties. In this descriptive retrospective study we want to present our experience with these techniques and to show and discuss some selected cases.
Methods: 112 patients (82 females, 30 males, range of age: 18a – 64a, median 38a) who underwent rhinoplasties during January 1995 and December 1997 were enrolled in this retrospective study. In all patients sutures were used to correct, form or stabilize the cartilaginous skeleton of the nose. 52 patients (group A) requested aesthetic changes alone, 60 patients (group B) performed surgery for other reasons (posttraumatic deformities, septal deviations etc.), but interventions were completed with aesthetic operations. In group A the hump was the primary indication for surgery, (n=32, 61%), in 14 cases (27 %) it was the tip of the nose, 6 patients (11%) had miscellaneous reasons. In group B, septal deviation was present in 71 % (n=17), a deviated back of the nose in 32 % (n= 19), deformities of the tip in 42% (n=25) and a hump in 66 % (n= 40). Photos were taken from all patients before and after surgery, with follow ups varying from 1 one to 4 years. In 92 patients, intraoperative photos were made as well.
Results: In group A, 18 interventions were performed with the open technique (12 primary, 6 secondary interventions), 24 with the semi-open technique (full delivery of the lower laterals by intercartilaginous and rim incisions) and 10 with the close technique. In all cases 52 cases sutures were used either to narrow the tip, to elevate the tip, to stabilize it or to reduce the diameter of the dome. In 18 cases struts were used (1mm thick, 2mm wide, variable length, made with the Aiache plate) to stabilize the columella by strengthening the medial crura of the lower laterals, 7x struts were used to strengthen the lateral crus of the lower laterals to correct inspiratory problems caused by a valve-effect during inspiration (collapse). 12 x the tip was elevated by anchoring the cranial edge of the lower lateral to the septum. 11 x tip augmentation was performed with one or more layers of septal cartilage sutured together on top the domes.
In group B, all corrections made on the tip of the nose were performed in addition to the correction of the posttraumatic deformities. In 20 times (30%) the open technique was implemented, (14 primary, 6 times secondary), in 32 patients we used the semi-open technique (50,5%) and in 8 cases the closed technique. Sutures were used to narrow the tip (n=42) , to reduce the diameter of the dome (n= 32), to reposition the septum on the nasal spine ( n= 12), to fix struts (n=18), to position grafts for tip augmentation (n= 9), to stabilize the alar wings to correct inspiratory problems (n= 5), to anchor the cranial edge of the lower laterals on to the septum to prevent a later drop of the tip (supratip, n= 11) and to stabilize the columella (n= 8).
Follow ups: Out of 112 patients, 8 requested corrections, which all have been performed, and 2 patients had to be operated on a third time to achieve satisfaction. All secondary operations were performed with the open technique, correction consisted of elevating further the tip (n= 4), of narrowing again the tip (n=3) and of correcting a deviated position of the tip (n=1). Secondary surgery was performed in all cases at least 12 months after the primary intervention. All these corrective interventions could be accomplished without major difficulties since the existing sutures were simply removed and replaced.
Conclusion: The use of sutures in aesthetic rhinoplasty showed to be highly effective. It considerably widens the surgical spectrum and . If corrections become necessary, the operations is not too difficult since sutures can easily be removed and replaced.
FERNANDO PEDROZA, M.D.
Correction of the asymmetric nose
The main goal is the presentation of the surgical techniques used in the correction of the Asymmetric Nose.
The Asymmetric Nose includes the differences in the shape, size, position, and the orientation of each one of the structural parts of the right half of the nose, comparing it to the left half and the relation with the medial nasofacial vertical axis. One hundred patients are analized from a total of more than three thousand rhinoplasties performed in private practice in a period of time of 15 years (1981-1996). The ethiology of the Asyummetry may be congenital, traumatic, secondary to the facial development and iatrogenic. The surgical technique is directed to achieve the symmetry of each one of the nasal parts in relation to the medial facial axis, it includes the asymmetries of the bony and cartilaginous dorsum, of the nasal tip and of the nasal alae. The techniques exposed are preferably used according to each particular case: 1. In the nasal dorsum: resections, rasp, osteotomies, grafts and implants; 2. In the nasal tip: redistribution of the lobular cartilage, creation of new domes, interdomal and transdomal sutures, partial resections, partial grafts or total reconstruction of the cartilages; 3. In the nasal alae: vestibular alae Dresection and advancing sutures from the resection borders. Comparative slides are shown pre and post-operative of the patients which illustrate the results of the techniques used, as well as trans-operative slides. In conclusion, it is necessary a detailed observation of the patient and its photographs to diagnose the nasal asymmetries and plan the adequate correction. The achievement of the nasal symmetry is very difficult but it is necessary to know the most conservative techniques which offer a better result to be able to correct the nasal asymmetries.
Septal perforation closure
The main objective is the explanation of the techniques used in the Closure of big Septal Perforations between 1 to 3 centimeters of diameter, successful in 90% of the cases treated.
72 cases of patients operated of big septal perforations performed in private practice are presented in a period of time of 10 years (1981-1998).
All the cases are documentated with photographs pre and post-operative of the patients.
Described are an analysis of the ethiology, size of the perforation, simptomatology, age, sex, surgical approach, grafting, follow-up and results obtained.
The surgical technique used is illustrated, and shown several patients operated.
In conclusion, the technique used for big septal perfortion, although it is difficult to achieve, permit successful results of the closure perforation, in more than 90% of the cases.
Endoscopic forehead lift fixation technique
In this paper I present the indications for the realization of the Frontoplasty:
A) In young patients with ptosis of the eye-brow which produces a sad look, we perform an attractive rejuvenated look with bigger eyes and a fresher appearance.
B) In patients with signs of aging like wrinkles in the forehead or crow-foot (wrinkle at the corner of the eyes), and ptosis of the eye brow, it is also possible to leave a younger and fresh looking.
I use the endoscopic approach through 5 incisions from 2 to 3 centimeters long in the scalp.
I do a sub-galeal dissection at the posterior area of the hair implantation, dissection between the superficial and deep fascia of the temporal muscle, and sub-periostical dissection in the frontal area. Then, I do the communication and unification in between the dissected areas.
I show the technique in video-tape, including the cutting of the periosteum at the superior rim of the orbit, preserving the neuro-vascular pedicle, the cutting of the corrugate and procerus muscles, and the fixation with non-absorbable sutures for the stabilization of the lifting of the Eye Brow.
I show the slides pre and post op. with patients operated with this endoscopic technique used during the past two years.
The advantage of this endoscopic technique over the coronal incision is to avoid the large incision, the cutting of the supra-orbital nerve, and the resection of scalp with bigger alopecia and scar.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties 20 years experience - personal technique
I present the personal technique used for obtention of the Autologus Graft from the Auricular Conchae for the total reconstruction of the inferior lateral crura of the nasal lobule, including the lateral and media Crura in a unique block, similar to the normal anatomic structure of the nasal tip.
I show in detail with slides and video-tape, the anterior incision, the exact place for obtention of the Cartilage, its sculpturing and how I perform an almost exactly anatomical, an physiological structure as that of the normal nose lobule, obtaining support for the nasal tip, natural projection and a normal appearance in patients with severe iatrogenic secuelaes. I present the technique to fit position and fixation of the graft, using the endonasal or external approach to nasal tip surgery. I also show the successful results obtained in patients of Revisional Rhinoplasties, the long term results with an experience of 16 years, being operated the first patient in 1981, and obtaining a recognition award during the Colombian Congress of Otolaryngology in 1985. Also the Award “ERMIRO DE LIMA” in September 1993 in Sao Paulo, Brazil, during the celebration of the Latin-American Meeting of Rhinology and Facial Plastic Surgery.
The comparative pre and post operative photographs show the correction of iatrogenic secuelaes, like asimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appearance, etc.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties – 20 years experience personal technique. “Sea Gull Wings” technique
1. Objective. I present the personal technique used with success in patients with notorious nasal tip secuelaes of previous Rhinoplasty surgeries, who could not obtain a natural look with partial grafting, because they required a Total Reconstruction of the lobular cartilages with autologous graft of auricular conchae.
2. Design. I describe the surgical technique of: 1) Obtention of the autologous graft of auricular conchae; 2) Sculpturing of the graft obtaining cartilages of anatomic threedimentional conformation, similar to the normal lobular cartilages; 3) Placing and fixation via Endonasal or External. The results are obtained at long term following patients for as long as 16 years.
3. Setting. The patients were institutional and private and the intervention was ambulatory or with 1 day of hospitalization.
4. Patients. A total of 65 patients were examined with photography controls pre and post surgery, for a period of 16 years between 1981-1997. The consultation were to correct the Rhinoplasty iatrogenic secuelaes, as assimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appeareance, nasal obstruction, etc.
5. Intervention. I show in detail the anterior auricular incision, the exact place ant the way to obtain the autologous conchae cartilage, its sculpturing and how I perform an almost exactly anatomical and physiological structure, as that of the normal nasal lobule, its position and fixation using endonasal or external approach, obtaining support for the nasal tip, natural projection and a normal appearance in patients of severe iatrogenic secuelaes.
6. Main outcome Measure. Analyzis of the improvement of the Aesthetic appeareance in the inferior nasal third, in patients with Nasal Surgery secuelaes.
7. Results. The comparative pre and post operative photograps show the success in the correction of iatrogenic tip nose secuelaes and its permanent good results, by long term follow-ups.
8. Conclusions. This personal technique of Total Reconstruction of the Lobular Nasal Cartilages, including the lateral and media crura in a unique block, with autologous conchae cartilage is recommended for the surgical treatment of severe iatrogenic secuelaes in Tip Nose Rhinoplasties, obtaining excelent results similar to the normal anatomic structure of the nasal tip.
Dynamics and successful technology
for nasal tip surgery
1. Objective. Present a basic and successful personal technique to modify in a conservative way the shape and position of the nasal tip remodeling the cartilages, and using sutures through the domo level to re-distribute the length of the lateral and medial crura, without vertical section of cartilage to conserve its continuity. The purpose of this technique is to narrow, project and rotate the nasal tip. Also to present other complementary techniques to correct additional difficulties as weakened cartilages, thick skin, short collumela, sub-projected and over-projected tip, asymmetric tip, revisional tip, secuelaes of leporine nose, etc.
2. Design. Completion of the expose technique, has been the result of the utilization, analysis and control at long term, in a period of 18 years, with pre, post and inter-surgical photograph and slide studies, and examination of the results of this technique.
3. Setting. Patients were institutional and private, and the surgical interventions ambulatory or with 1 day of hospitalization.
4. Patients. Have been analized and grouped according to the degree of nasal tip problems and difficulties of correction, observing the use of the various techniques and the results in more than 3.000 patients.
5. Intervention. Show in detail the pre and post cartilaginous incisions, the endonasal access way with liberation of lobular cartilages, and the complementary techniques with partial cartilaginous grafting in the columella, in the tip or in the lateral part of the lobule, or with total reconstruction of the lobular cartilages using cartilaginous conchae graft in difficult Revisional Tips.
6. Main outcome measures. Determine the right utilization of the surgical techniques, to correct the shape and position of the nasal tip, based in pre-operative analysis and the determination of the surgical plan by each patient.
7. Results. Comparative pre and post operative photographs show the dynamics and success of the conservative techniques utilized to correct nasal tip deformities, based on the progressive difficulties presented in each case.
8. Conclusions. This personal basic technique for the re-distribution of the lobular cartilages, based on the dynamics of those cartilages and the complementary techniques used in the deformity of the nasal tip of each patient, is a conservative but successful one, recommended to obtain an attractive and natural nasal tip.
The New Domes Technique –
15 years of experience
Nasal tip surgery, which has been considered the most interesting and difficult part of Rhinoplasty, obliges the surgeon to perform a detailed pre-surgical study of each individual patient, analyzing characteristics, skin thickness, cartilage strength and nasal tip shape and position, and requires millimetric precision in the surgical techniques used in order to achieve nasal tip placement in the desired and appropriate position for each patient’s face.
In this presentation, we deal with a patient with a drooping nasal tip whose skin is not very thick and who has good alar cartilage in terms of thickness and consistency. The nasal tip must be projected, rotated and narrowed for aesthetic improvement. We shall clearly describe the post-cartilaginous and pre-cartilaginous incisions, the endonasal approach with cartilage release, and conservational, predictable and stable technique—“the new dome technique”, which places these new domes in a position which is more lateral to the patient’s own domes, and then suturing one to the other, thus forming an aesthetic triangle which results in a natural-looking nasal tip. This technique is generally complemented with the resection of the vestibular skin of the fibrous septum, the resection of the septal caudal edge and, if necessary, the placement of a columellar strut and columellar-septal fixation in order to sustain the results.
The “new domes technique” allows us to obtain a nasal tip which is more projected, cephalically rotated and narrowed natural in appearance, through the use of a procedure which preserves the integrity and continuity of the lower lateral cartilage.
DONGHAK JUNG, M.D.
Aesthetic Nasal Tip Surgery
Nasal tip surgery is the finishing touch of rhinoplasty and it is not too much to say that the success of whole surgery depends on tip surgery. The need for tip surgery occurs from anatomical characteristics of lower lateral cartilage. Contrary to Upper lateral cartilage which is supported by nasal septum, lower lateral cartilage is only maintained by soft tissues. Hence understanding of anatomical characteristic must be preceded to nasal tip surgery. If silicon implant is inserted reaching to the tip of the nose, ‘Poly beak deformity’ often appears since lower lateral cartilage is not firmly supported.
Moreover, the silicon located in the nose tip could be risky since transition or extrication could happen. The key points for successful outcome are firstly, recognizing anatomical diversity of soft tissue and lower lateral cartilage and understanding its influence to exterior of nose. Secondly, understanding the structure and the mechanics that support nasal tip. Lastly, full recognition of the effect of each operative techniques and estimation of final outcome (Gunter 1997). The ultimate purpose of nasal tip surgery is gaining delicate, stable and aesthetically satisfactory outcome. Incessant consideration for symmetry is necessary during nasal tip surgery since lower lateral cartilage is consisted of 2 pieces. As characteristic of lower lateral cartilage widely varies per patient, preoperative and intraoperative anatomical evaluation is critical.
Besides, understanding of the graft material, constant effort for dexterity improvement and learning various techniques are required quality for the surgeons (Tardy 1993).
EDUARD G. COEUGNIET, M.D., Ph.D.
Non- surgical therapy of cellulite and
localised fatty deposits
Our method is a modification of Bernstein’s lipotomy.
We use a combination of :
1. Mesotherapy with medicaments which are increasing the circulation (buflomedil, pentoxyifillin, procaine), decrease the oedemas ( aescin), stimulate the fat –metabolism (ephedrine)
2. Tumescence anaesthesia with hypotonic natrium chloride solutions, ephedrine)
3. Endermology
4. Skin- applications of gels and creams with caffeine, ephedrine, yohimbine
5. Warm- compresses with jodide containing salts.
6. Normalisation of the digestion
7. Increase of sport activity.
10-12 treatments are necessary, the results are very good, without complications.
Non-surgical therapy of stretch marks.
The old, white, atrophic stretch marks were treated at the beginning with mesotherapy (ascorbic acid and aetoxysclerol in procaine) in order to become a light und steady inflammation. This method improuved the production of elastin and collagene .
Four applications (once a week) were enough to get the picture of a “young” cellulite.
The red, young cellulite almost like described by Deprez.
1. Sandabrasion
2. Jessner- Peel (our modification)
3. TCA 15 %
4. Application of cream and an impermeable, plastic film around the area for 48 hours in order to augment the maceration
5. Application of bismuth subgallate powder
6. Dayly application of creams with bleaching- blending and “radical catcher” effect
The therapy was repeated 4 to 8 time (once a month), the results were excellent
CLARA SANTOS, M.D.
Medium Peel (Weekend Peel) + Botulin Toxin
(Botox+ Dysport) – Little Procedures, Big Results.
Aging is an inevitable stage in the late years of anyone’s life. Cosmetic Surgery, Plastic Surgery and Dermatology are specialties that never stop searching what can be of real value in the treatment of this natural process.
Regarded to the face what mostly bother the patients are the wrinkling, spots, usually associated with the loose of even coloration and firmness.
Until couple decades ago, the aging face was basically treated with surgical facelift. The cons against surgical facelift are the invasiveness of the technique, the long down time, presence of scars and post-operatory potential complications. Besides, these limits no improving in skin quality, or in central areas wrinkles are obtained with face lift. By the other hand, a combination of two office’s small procedure Medium Peel + Toxin Botulin, can offer a real nice improvement in the skin surface, firmness, coloration and reducing or making wrinkles (temporailily) disappeared.
We note that today many patients feel extremely satisfied with the results obtained in this easier, shorter, cheaper, safer and quicker way. If the patient wants to maintain or keeping improving the results, the treatment can be repeated about twice a year and at any time if the patient desires, new or additional techniques can be performed anytime.
Dark Skin and Acne Scar – A Therapeutic Challenge
Acne is a very old and common dermatosis that affects a wide spectrum of the population all over the world. Many patients can get ride of it without any mark. Others, unfortunately undergo a more severe form of it and the scars formation is a sequealae very difficult to be dealed with and to treat.
Most if not all patients with acne scars have a tremendous unhappy feeling with their own face image. Some really suffer a real psychological disturbance because there is what we call an auto-rejection.
Treating acne scar is not as easy compared to the treatment of melasmas, blemishes or spots. Acne scar in patients with lighter skin is easier to treat, compared to the darker skin patient, as darker skin are more prone to post inmflammatory hyperpigmentation. This fact becomes even more delicate when they also have a thin and delicated skin.
We will present here peelings of different levels, (superficial.medium and deep) combined with abrasive technique at the same time. Through theses techniques we have reach nice and encouraging results.
Peeling and Exfoliation
in the treatment of Active Acne
We certainly have a special interest in the field of acne treatment. We think that this dermatosis causes lots of emotional impairment among the people who have it, specially the teenager group.
We have treated a group of teenagers and young adult with Acne I or II just performing sequential chemical peeling with exfoliation at the same section. The maintenance treatment was based only in the use of Kligman’s and sun protection factor. No patient had received topic/oral antibiotic, neither accutane. All improvement was obtained only by the use of chemical peeling+ exfoliation.
Exoderm, by Yoram Fintsi –
The best, easiest and safest deep peel.
The treatment of the aged face done by deep peels have presented nice rejuvenation results, but some problems related to the consequence of the phenol are sometimes difficult to avoid. So, for example, hypopigmentation, bacterial or viral infections, scars and sometimes systemic absorption can cause problems when phenol peels are performed.
In 1985 †Yoram Fintsi (1950 – 2001) from Tel-Aviv created the Exoderm, a phenol solution by adding to the phenol a mixture of oils, which resulted in an balanced, buffred controlled and safe agent for deep peel.. Exoderm is unique because it has an auto block at mid-dermis that does not allow deeper penetration, giving the safe desired result by doctors and patients within eight days. It is performed ambulatory under local sedation.
Exoderm has been performed successfully in many countries in the world.
After Dr. Fintsi has died, I was invited by his family to continue his work, to keep teaching and spreading his technique all over the world.
Exoderm has been performed by some doctors in USA, but I think it must be more known between Dermatologist and Cosmetic Surgeon as it is so useful, safe, fast and easy to perform.
Liposuction Totally by Tumescent Anesthesia
Unwanted fat is a common cause of distress and unhappiness for many patients. Among the many techniques to treat this problem, Liposuction Totally by Tumescent Anesthesia has shown to be an easy and safe method. When the tumescent is completely done, there is no need of venous sedation, there is no pain and no blood loss. Absence or minimal equimosis, almost no bruising and a prompt recovery are some of the many positive aspects of this technique.
EDVIN TURKOF, M.D.
The vibro-assisted liposuction with three-dimensional rotating canulas: atraumatic and highly effective; report about 1000 treated areas
Introduction: Since Giorgio Fischer initiated in 1980 the most frequently performed intervention in aesthetic surgery, methods and concepts changed continuously. The main goal was to reduce the trauma caused by the intervention, since bleeding, shock and embolism become more and more frequent. The wet technique was introduced, followed by tumescent infiltration where tissue is filled until saturation is achieved in order to reduce the friction of the cannula. Simultaneously, diameters of the cannulas were reduced to 2mm-4mm. Technical development were achieved with the ultrasonic assisted liposuction (external and internal), the high-frequency current method and the water beam method. All these developments showed distinct disadvantages, so that none of them could replace the conventional method, which still remains the most frequently applied technique. However, in 1998 Jean Malak invented the vibro-assisted liposuction. The cannula is fixed to a hand piece that contents a pneumatic driven engine that makes the cannula moving forward and backward with 10 Hertz. The range of movement can be adjusted from 4mm to nearly 10 mm by changing the pressure of the air, the motion itself is both elliptic and eccentric, causing a three-dimensional movement. The surgeon moves the cannula slowly through the fatty tissue, the tip digs itself forward like a mole. Vessels, nerves and connective tissue (septa) are speared, hence less damaged. Sweating of the surgeon become inexistent, the working time is reduced considerably.
We report about our experience on over 1000 operated areas, including the inner side of the thigh, inner side of the knees, calves and upper arms . We compared the performance with the ultrasonic assisted method and the conventional liposuction. In 11 cases liposuction was combined with an abdominoplaty, a thigh lift or an upper arm lift, hence enabling the visualization of the method’s effect on the fatty tissue.
Methods: From October 2001 to April 2003 we implemented this method on 334 patients (range of age: 18a – 82a, 212 female, 52 male, mean 42a). The following areas have been operated on: skin under the chin, upper lateral area of the breast, abdomen, flank, back, upper arms, lateral thigh, inner thigh, inner side of the knee, frontal thigh, dorsal thigh, calves. In all cases infiltrating time, suction time, suction quantity and the relation fat/water has been meticulously documented. In 10 cases we used the vibro-assisted liposuction on one thigh and the conventional method on the other thigh.
Results were compared with prior operations performed with the ultrasonic assisted technique.
Results: 12 patients were operated on at the skin under the chin (1 region), 42 patients on the abdomen (2 regions), 22 patients on the lateral thigh (2 regions), 23 patients the upper arms (2 regions), 123 patients on the lateral and the medial aspect of the thigh (4 regions), 48 patients on the lateral and the medial aspect of the thigh and the inner side of the knee (six regions), 29 patients on the calves and the lateral and inner thigh (6 regions), 12 patients the frontal and the dorsal aspect of the thigh (4 regions), 9 patients on the lateral upper aspect of the breast (2 regions), and 14 patients on the flank and the back (4 regions). 14 patients were operated on in general anaesthesia upon personal request, all others had the areas anaesthetized by infiltration. Infusion time ranged from 15 seconds to 210 seconds, suction time from 4 minutes to 28 minutes per region, mean 18 minutes. Overall operation time varied from 18 minutes to 3h10, mean 128 minutes. All patients become mild compression garments immediately after surgery and wore them between 4 to 8 weeks. Stitches were removed after 10 days. The quantity of suction fluid varied from 800ml to 12.000 ml (exceptional case of obesity) per patient, with an average of 3400 ml and an fat/water ratio of 6:1 (range: 1:1 – inner side of the thigh, 1:10, upper abdomen, lateral side of the thigh). 65% of the patients agreed to undergo postoperative treatment with endermology. Patients treated in local anaesthesia were dismissed from hospital after the intervention. 12 patients requested unexpected overnight at the clinic (low blood pressure). Low molecular heparin was only given to overnight-patients, as well as antibiotic treatment.
18 patients requested corrections because of indentions and/or asymmetric results.
Discussion: The vibro-assisted liposuction invented by Jean Malakh has clearly to be differentiated from the commonly called power assisted liposuction, since the three dimensional movement of this machine has been patented, while all other ‘power-assisted’ products have their cannulas moving in a horizontal plane alone with a range less then 4mm.
Conclusion: The vibro-assisted liposuction showed to be highly effective in our hands. Its performance showed no disadvantage and we highly recommend this method.
B-Technique (Rйgnault) and dermis-suspension:
a new technique for breast reduction combining
small scars, speed, secure nippel vascularisation
and durability of results
Introduction: There are several techniques for reduction mammoplasties. All attempts to improve existing methods have the goal to achieve durable results, minimizing the scar and to achieve aesthetic shapes. Paul Rйgnault introduced in 1974 a technique based on the upper pedicle for the blood supply of the mammilla, that could be applied in small and large breasts and showed a rounded, L-shaped scar (B-technique), sparing completely the medial aspect of the inframammary fold. The technique is fast, bloodless, easy to learn and has to be regarded as milestone in the numerous attempts to reduce the scar in reduction mammoplasty.
Other attempts were made to enhance the durability of the results. Another milestone was the idea to use the deepithelized skin (dermis) in that a flap is formed and sutured to ribs in order to avoid late drops of the breast. Provided that the flaps remains vascularized, the idea to from an interior brassiere to avoid droping of the tissue deserves close attention. Eren uses a central pedicle with Strцmbeck’s skin incisions, Frey a central pedicle with Rйgnault’s skin incision. Techniques with central pedicle can show problems with the vascularization of the nipple, since the blood supply is restricted to the ascending vessels through the breast tissueas all dermal vessels are transsected. In order to avoid this inconvenient, we searched for a technique combining the advantageous skin-incision from the B-technique and the innovative idea of the stabilizing dermis-suspension.
Methods: The technique consists of the B-technique from Paul Rйgnault and adds to it the interior brassiиre introduced by Eren. The difference lays in the fact that the dermal flap at Eren’s technique is vascularized by the underlying breast tissue, while in this new method the dermis has to be elevated and placed back -subsequent to the removal of the breast tissue - as a more or less free flap, attached on the caudal aspect of the areola alone and sutured to ribbs.
Results: From 1999 to 2002 we applied this method on 20 women (range of age: 24a-64a, median 36a). Elevation of the nipple ranged from 4cm to 16cm (median: 8,5cm), weight of removed breast tissue ranged from 180g to 840g (median: 410 g). In all cases the blood supply of the nipple-areola complex remained excellent. Follow up ranged from 12 to 36 months. 1 patient had to be revised due to asymmetry. Patient’s satisfaction was overall good.
Discussion: It is our opinion that this technique is easy to learn, nearly as fast as the B-technique, equally bloodless but more durable. It avoids the well known, even though not frequently occurring problem of the areole’s blood supply encountered with the methods using a central pedicle.
Conclusion: We can recommend this new method as a simple and safe technique to perform reduction mammoplasties.
My experience with the use of sutures
in forming and stabilizing the nasal cartilage
in aesthetic rhinoplasty
Introduction: The use of sutures to modify the cartilaginous skeleton of the nose in aesthetic rhinoplasties become frequent in the last decade only. In the University Clinic of Vienna, Austria not a single rhinoplasty was performed which sutures to modify the nasal cartilage during my residency (1985-1991). Aiach, Guyuron, Tardy and Tebbeth (alphabetic order) are probably the best known pioneers in modelling the tip of the nose with sutures. The use of grafts, struts, and sutures widened the spectrum of correction and achieved better and longer lasting results in aesthetic rhinoplasties. In this descriptive retrospective study we want to present our experience with these techniques and to show and discuss some selected cases.
Methods: 112 patients (82 females, 30 males, range of age: 18a – 64a, median 38a) who underwent rhinoplasties during January 1995 and December 1997 were enrolled in this retrospective study. In all patients sutures were used to correct, form or stabilize the cartilaginous skeleton of the nose. 52 patients (group A) requested aesthetic changes alone, 60 patients (group B) performed surgery for other reasons (posttraumatic deformities, septal deviations etc.), but interventions were completed with aesthetic operations. In group A the hump was the primary indication for surgery, (n=32, 61%), in 14 cases (27 %) it was the tip of the nose, 6 patients (11%) had miscellaneous reasons. In group B, septal deviation was present in 71 % (n=17), a deviated back of the nose in 32 % (n= 19), deformities of the tip in 42% (n=25) and a hump in 66 % (n= 40). Photos were taken from all patients before and after surgery, with follow ups varying from 1 one to 4 years. In 92 patients, intraoperative photos were made as well.
Results: In group A, 18 interventions were performed with the open technique (12 primary, 6 secondary interventions), 24 with the semi-open technique (full delivery of the lower laterals by intercartilaginous and rim incisions) and 10 with the close technique. In all cases 52 cases sutures were used either to narrow the tip, to elevate the tip, to stabilize it or to reduce the diameter of the dome. In 18 cases struts were used (1mm thick, 2mm wide, variable length, made with the Aiache plate) to stabilize the columella by strengthening the medial crura of the lower laterals, 7x struts were used to strengthen the lateral crus of the lower laterals to correct inspiratory problems caused by a valve-effect during inspiration (collapse). 12 x the tip was elevated by anchoring the cranial edge of the lower lateral to the septum. 11 x tip augmentation was performed with one or more layers of septal cartilage sutured together on top the domes.
In group B, all corrections made on the tip of the nose were performed in addition to the correction of the posttraumatic deformities. In 20 times (30%) the open technique was implemented, (14 primary, 6 times secondary), in 32 patients we used the semi-open technique (50,5%) and in 8 cases the closed technique. Sutures were used to narrow the tip (n=42) , to reduce the diameter of the dome (n= 32), to reposition the septum on the nasal spine ( n= 12), to fix struts (n=18), to position grafts for tip augmentation (n= 9), to stabilize the alar wings to correct inspiratory problems (n= 5), to anchor the cranial edge of the lower laterals on to the septum to prevent a later drop of the tip (supratip, n= 11) and to stabilize the columella (n= 8).
Follow ups: Out of 112 patients, 8 requested corrections, which all have been performed, and 2 patients had to be operated on a third time to achieve satisfaction. All secondary operations were performed with the open technique, correction consisted of elevating further the tip (n= 4), of narrowing again the tip (n=3) and of correcting a deviated position of the tip (n=1). Secondary surgery was performed in all cases at least 12 months after the primary intervention. All these corrective interventions could be accomplished without major difficulties since the existing sutures were simply removed and replaced.
Conclusion: The use of sutures in aesthetic rhinoplasty showed to be highly effective. It considerably widens the surgical spectrum and . If corrections become necessary, the operations is not too difficult since sutures can easily be removed and replaced.
FERNANDO PEDROZA, M.D.
Correction of the asymmetric nose
The main goal is the presentation of the surgical techniques used in the correction of the Asymmetric Nose.
The Asymmetric Nose includes the differences in the shape, size, position, and the orientation of each one of the structural parts of the right half of the nose, comparing it to the left half and the relation with the medial nasofacial vertical axis. One hundred patients are analized from a total of more than three thousand rhinoplasties performed in private practice in a period of time of 15 years (1981-1996). The ethiology of the Asyummetry may be congenital, traumatic, secondary to the facial development and iatrogenic. The surgical technique is directed to achieve the symmetry of each one of the nasal parts in relation to the medial facial axis, it includes the asymmetries of the bony and cartilaginous dorsum, of the nasal tip and of the nasal alae. The techniques exposed are preferably used according to each particular case: 1. In the nasal dorsum: resections, rasp, osteotomies, grafts and implants; 2. In the nasal tip: redistribution of the lobular cartilage, creation of new domes, interdomal and transdomal sutures, partial resections, partial grafts or total reconstruction of the cartilages; 3. In the nasal alae: vestibular alae Dresection and advancing sutures from the resection borders. Comparative slides are shown pre and post-operative of the patients which illustrate the results of the techniques used, as well as trans-operative slides. In conclusion, it is necessary a detailed observation of the patient and its photographs to diagnose the nasal asymmetries and plan the adequate correction. The achievement of the nasal symmetry is very difficult but it is necessary to know the most conservative techniques which offer a better result to be able to correct the nasal asymmetries.
Septal perforation closure
The main objective is the explanation of the techniques used in the Closure of big Septal Perforations between 1 to 3 centimeters of diameter, successful in 90% of the cases treated.
72 cases of patients operated of big septal perforations performed in private practice are presented in a period of time of 10 years (1981-1998).
All the cases are documentated with photographs pre and post-operative of the patients.
Described are an analysis of the ethiology, size of the perforation, simptomatology, age, sex, surgical approach, grafting, follow-up and results obtained.
The surgical technique used is illustrated, and shown several patients operated.
In conclusion, the technique used for big septal perfortion, although it is difficult to achieve, permit successful results of the closure perforation, in more than 90% of the cases.
Endoscopic forehead lift fixation technique
In this paper I present the indications for the realization of the Frontoplasty:
A) In young patients with ptosis of the eye-brow which produces a sad look, we perform an attractive rejuvenated look with bigger eyes and a fresher appearance.
B) In patients with signs of aging like wrinkles in the forehead or crow-foot (wrinkle at the corner of the eyes), and ptosis of the eye brow, it is also possible to leave a younger and fresh looking.
I use the endoscopic approach through 5 incisions from 2 to 3 centimeters long in the scalp.
I do a sub-galeal dissection at the posterior area of the hair implantation, dissection between the superficial and deep fascia of the temporal muscle, and sub-periostical dissection in the frontal area. Then, I do the communication and unification in between the dissected areas.
I show the technique in video-tape, including the cutting of the periosteum at the superior rim of the orbit, preserving the neuro-vascular pedicle, the cutting of the corrugate and procerus muscles, and the fixation with non-absorbable sutures for the stabilization of the lifting of the Eye Brow.
I show the slides pre and post op. with patients operated with this endoscopic technique used during the past two years.
The advantage of this endoscopic technique over the coronal incision is to avoid the large incision, the cutting of the supra-orbital nerve, and the resection of scalp with bigger alopecia and scar.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties 20 years experience - personal technique
I present the personal technique used for obtention of the Autologus Graft from the Auricular Conchae for the total reconstruction of the inferior lateral crura of the nasal lobule, including the lateral and media Crura in a unique block, similar to the normal anatomic structure of the nasal tip.
I show in detail with slides and video-tape, the anterior incision, the exact place for obtention of the Cartilage, its sculpturing and how I perform an almost exactly anatomical, an physiological structure as that of the normal nose lobule, obtaining support for the nasal tip, natural projection and a normal appearance in patients with severe iatrogenic secuelaes. I present the technique to fit position and fixation of the graft, using the endonasal or external approach to nasal tip surgery. I also show the successful results obtained in patients of Revisional Rhinoplasties, the long term results with an experience of 16 years, being operated the first patient in 1981, and obtaining a recognition award during the Colombian Congress of Otolaryngology in 1985. Also the Award “ERMIRO DE LIMA” in September 1993 in Sao Paulo, Brazil, during the celebration of the Latin-American Meeting of Rhinology and Facial Plastic Surgery.
The comparative pre and post operative photographs show the correction of iatrogenic secuelaes, like asimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appearance, etc.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties – 20 years experience personal technique. “Sea Gull Wings” technique
1. Objective. I present the personal technique used with success in patients with notorious nasal tip secuelaes of previous Rhinoplasty surgeries, who could not obtain a natural look with partial grafting, because they required a Total Reconstruction of the lobular cartilages with autologous graft of auricular conchae.
2. Design. I describe the surgical technique of: 1) Obtention of the autologous graft of auricular conchae; 2) Sculpturing of the graft obtaining cartilages of anatomic threedimentional conformation, similar to the normal lobular cartilages; 3) Placing and fixation via Endonasal or External. The results are obtained at long term following patients for as long as 16 years.
3. Setting. The patients were institutional and private and the intervention was ambulatory or with 1 day of hospitalization.
4. Patients. A total of 65 patients were examined with photography controls pre and post surgery, for a period of 16 years between 1981-1997. The consultation were to correct the Rhinoplasty iatrogenic secuelaes, as assimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appeareance, nasal obstruction, etc.
5. Intervention. I show in detail the anterior auricular incision, the exact place ant the way to obtain the autologous conchae cartilage, its sculpturing and how I perform an almost exactly anatomical and physiological structure, as that of the normal nasal lobule, its position and fixation using endonasal or external approach, obtaining support for the nasal tip, natural projection and a normal appearance in patients of severe iatrogenic secuelaes.
6. Main outcome Measure. Analyzis of the improvement of the Aesthetic appeareance in the inferior nasal third, in patients with Nasal Surgery secuelaes.
7. Results. The comparative pre and post operative photograps show the success in the correction of iatrogenic tip nose secuelaes and its permanent good results, by long term follow-ups.
8. Conclusions. This personal technique of Total Reconstruction of the Lobular Nasal Cartilages, including the lateral and media crura in a unique block, with autologous conchae cartilage is recommended for the surgical treatment of severe iatrogenic secuelaes in Tip Nose Rhinoplasties, obtaining excelent results similar to the normal anatomic structure of the nasal tip.
Dynamics and successful technology
for nasal tip surgery
1. Objective. Present a basic and successful personal technique to modify in a conservative way the shape and position of the nasal tip remodeling the cartilages, and using sutures through the domo level to re-distribute the length of the lateral and medial crura, without vertical section of cartilage to conserve its continuity. The purpose of this technique is to narrow, project and rotate the nasal tip. Also to present other complementary techniques to correct additional difficulties as weakened cartilages, thick skin, short collumela, sub-projected and over-projected tip, asymmetric tip, revisional tip, secuelaes of leporine nose, etc.
2. Design. Completion of the expose technique, has been the result of the utilization, analysis and control at long term, in a period of 18 years, with pre, post and inter-surgical photograph and slide studies, and examination of the results of this technique.
3. Setting. Patients were institutional and private, and the surgical interventions ambulatory or with 1 day of hospitalization.
4. Patients. Have been analized and grouped according to the degree of nasal tip problems and difficulties of correction, observing the use of the various techniques and the results in more than 3.000 patients.
5. Intervention. Show in detail the pre and post cartilaginous incisions, the endonasal access way with liberation of lobular cartilages, and the complementary techniques with partial cartilaginous grafting in the columella, in the tip or in the lateral part of the lobule, or with total reconstruction of the lobular cartilages using cartilaginous conchae graft in difficult Revisional Tips.
6. Main outcome measures. Determine the right utilization of the surgical techniques, to correct the shape and position of the nasal tip, based in pre-operative analysis and the determination of the surgical plan by each patient.
7. Results. Comparative pre and post operative photographs show the dynamics and success of the conservative techniques utilized to correct nasal tip deformities, based on the progressive difficulties presented in each case.
8. Conclusions. This personal basic technique for the re-distribution of the lobular cartilages, based on the dynamics of those cartilages and the complementary techniques used in the deformity of the nasal tip of each patient, is a conservative but successful one, recommended to obtain an attractive and natural nasal tip.
The New Domes Technique –
15 years of experience
Nasal tip surgery, which has been considered the most interesting and difficult part of Rhinoplasty, obliges the surgeon to perform a detailed pre-surgical study of each individual patient, analyzing characteristics, skin thickness, cartilage strength and nasal tip shape and position, and requires millimetric precision in the surgical techniques used in order to achieve nasal tip placement in the desired and appropriate position for each patient’s face.
In this presentation, we deal with a patient with a drooping nasal tip whose skin is not very thick and who has good alar cartilage in terms of thickness and consistency. The nasal tip must be projected, rotated and narrowed for aesthetic improvement. We shall clearly describe the post-cartilaginous and pre-cartilaginous incisions, the endonasal approach with cartilage release, and conservational, predictable and stable technique—“the new dome technique”, which places these new domes in a position which is more lateral to the patient’s own domes, and then suturing one to the other, thus forming an aesthetic triangle which results in a natural-looking nasal tip. This technique is generally complemented with the resection of the vestibular skin of the fibrous septum, the resection of the septal caudal edge and, if necessary, the placement of a columellar strut and columellar-septal fixation in order to sustain the results.
The “new domes technique” allows us to obtain a nasal tip which is more projected, cephalically rotated and narrowed natural in appearance, through the use of a procedure which preserves the integrity and continuity of the lower lateral cartilage.
FAKHR ALKHAIRY, M.D.
Analytical approach in nasal tip-plasty
To construct an ideal tip in aesthetic rhinoplasty is the most challenging aspect in entire cosmetic surgery. There are two general ways to restore an ideal tip. One is anatomical alteration with substitution and other is alteration without any substitution. Substitution is of tip-cartilage graft. Both depends on the disproportionate anatomy of the aesthetic candidate as well as his or her wishes for the future nose. Two people living in the same culture may have different mind image of the tip of the nose though they may have similar disproportionate anatomy. In other words the surgeon should have the ability to meet the mind image of the aesthetic candidate for better out come by critically analyzing the situation and executing surgery to be within normal range and yet satisfying the demand of the aesthetic candidate.
In restoring tip we have to consider two things in general:-
1. Various angles of the tip.
a- columella-tip angle, b-angle of divergence c- angle of domal definition.
2. Tip projection
Changing all the angles mentioned above may or may not provide sufficient projection of the tip. Decision to substitute cartilage graft depends on the configuration of the domes of alar cartilage in respect to rest of the dorsum in lateral view. A slight lift from Sheen’s central cephalic dot to bilateral lateral dots ( domes ) is required. This lift can be provided by placing a tip graft and /or by placing a cartilage graft on the dorsum. In hypoplastic noses graft on the dorsum as well as on the tip provides better projection than hyperplastic noses. In hyperplastic noses tip graft is sufficient or even may not be required to provide projection of the tip. Bringing the domes of the alar cartilage together by narrowing the angle of divergence is sufficient for tip projection in these cases.
Tip projection as mentioned above is an issue to be decided after seeing all the possibilities. Two things are very crucial for long term result. One is that all cartilage graft at the tip of the nose should be stitched with non-absorbable elastic sutures atleast at two places to avoid sinking into the columella and lateral drifts of the graft. Second is that thick skin on tip demands over projection as compared to thin skin.
Columella-lip angle can be altered by altering caudal part of septum, septal spine & maxilla. Columella-tip angle can be changed by altering caudal part of septum, junction of middle & inferior part of alar cartilage and substituting tip graft. Angle of divergence is narrowed by bringing the domes of alar cartilages together.
Surgical constraint is directly related to surgeon’s ability, patient’s anatomy and interaction of nose aesthetic between surgeon & patient. Surgeon’s ability is directly related to his or her level of training and continued refining of the surgical techniques and tackling the problems rationally. Severely disproportionate anatomy of the nose is a true surgical constraint with frustration on the part of the surgeon. A conflict between patient’s and surgeon’s aesthetic , with in the normal range, also remains on the front foot in solving the problems of aesthetic candidate. What counts at the end is to meet the mind image of the aesthetic candidate with happy outcome. This is really a great task to accomplish in its true sense.
This paper presents the analytical approach in nasal tip plasty.
CLARA SANTOS, M.D.
Medium Peel (Weekend Peel) + Botulin Toxin
(Botox+ Dysport) – Little Procedures, Big Results.
Aging is an inevitable stage in the late years of anyone’s life. Cosmetic Surgery, Plastic Surgery and Dermatology are specialties that never stop searching what can be of real value in the treatment of this natural process.
Regarded to the face what mostly bother the patients are the wrinkling, spots, usually associated with the loose of even coloration and firmness.
Until couple decades ago, the aging face was basically treated with surgical facelift. The cons against surgical facelift are the invasiveness of the technique, the long down time, presence of scars and post-operatory potential complications. Besides, these limits no improving in skin quality, or in central areas wrinkles are obtained with face lift. By the other hand, a combination of two office’s small procedure Medium Peel + Toxin Botulin, can offer a real nice improvement in the skin surface, firmness, coloration and reducing or making wrinkles (temporailily) disappeared.
We note that today many patients feel extremely satisfied with the results obtained in this easier, shorter, cheaper, safer and quicker way. If the patient wants to maintain or keeping improving the results, the treatment can be repeated about twice a year and at any time if the patient desires, new or additional techniques can be performed anytime.
Dark Skin and Acne Scar – A Therapeutic Challenge
Acne is a very old and common dermatosis that affects a wide spectrum of the population all over the world. Many patients can get ride of it without any mark. Others, unfortunately undergo a more severe form of it and the scars formation is a sequealae very difficult to be dealed with and to treat.
Most if not all patients with acne scars have a tremendous unhappy feeling with their own face image. Some really suffer a real psychological disturbance because there is what we call an auto-rejection.
Treating acne scar is not as easy compared to the treatment of melasmas, blemishes or spots. Acne scar in patients with lighter skin is easier to treat, compared to the darker skin patient, as darker skin are more prone to post inmflammatory hyperpigmentation. This fact becomes even more delicate when they also have a thin and delicated skin.
We will present here peelings of different levels, (superficial.medium and deep) combined with abrasive technique at the same time. Through theses techniques we have reach nice and encouraging results.
Peeling and Exfoliation
in the treatment of Active Acne
We certainly have a special interest in the field of acne treatment. We think that this dermatosis causes lots of emotional impairment among the people who have it, specially the teenager group.
We have treated a group of teenagers and young adult with Acne I or II just performing sequential chemical peeling with exfoliation at the same section. The maintenance treatment was based only in the use of Kligman’s and sun protection factor. No patient had received topic/oral antibiotic, neither accutane. All improvement was obtained only by the use of chemical peeling+ exfoliation.
Exoderm, by Yoram Fintsi –
The best, easiest and safest deep peel.
The treatment of the aged face done by deep peels have presented nice rejuvenation results, but some problems related to the consequence of the phenol are sometimes difficult to avoid. So, for example, hypopigmentation, bacterial or viral infections, scars and sometimes systemic absorption can cause problems when phenol peels are performed.
In 1985 †Yoram Fintsi (1950 – 2001) from Tel-Aviv created the Exoderm, a phenol solution by adding to the phenol a mixture of oils, which resulted in an balanced, buffred controlled and safe agent for deep peel.. Exoderm is unique because it has an auto block at mid-dermis that does not allow deeper penetration, giving the safe desired result by doctors and patients within eight days. It is performed ambulatory under local sedation.
Exoderm has been performed successfully in many countries in the world.
After Dr. Fintsi has died, I was invited by his family to continue his work, to keep teaching and spreading his technique all over the world.
Exoderm has been performed by some doctors in USA, but I think it must be more known between Dermatologist and Cosmetic Surgeon as it is so useful, safe, fast and easy to perform.
Liposuction Totally by Tumescent Anesthesia
Unwanted fat is a common cause of distress and unhappiness for many patients. Among the many techniques to treat this problem, Liposuction Totally by Tumescent Anesthesia has shown to be an easy and safe method. When the tumescent is completely done, there is no need of venous sedation, there is no pain and no blood loss. Absence or minimal equimosis, almost no bruising and a prompt recovery are some of the many positive aspects of this technique.
EDVIN TURKOF, M.D.
The vibro-assisted liposuction with three-dimensional rotating canulas: atraumatic and highly effective; report about 1000 treated areas
Introduction: Since Giorgio Fischer initiated in 1980 the most frequently performed intervention in aesthetic surgery, methods and concepts changed continuously. The main goal was to reduce the trauma caused by the intervention, since bleeding, shock and embolism become more and more frequent. The wet technique was introduced, followed by tumescent infiltration where tissue is filled until saturation is achieved in order to reduce the friction of the cannula. Simultaneously, diameters of the cannulas were reduced to 2mm-4mm. Technical development were achieved with the ultrasonic assisted liposuction (external and internal), the high-frequency current method and the water beam method. All these developments showed distinct disadvantages, so that none of them could replace the conventional method, which still remains the most frequently applied technique. However, in 1998 Jean Malak invented the vibro-assisted liposuction. The cannula is fixed to a hand piece that contents a pneumatic driven engine that makes the cannula moving forward and backward with 10 Hertz. The range of movement can be adjusted from 4mm to nearly 10 mm by changing the pressure of the air, the motion itself is both elliptic and eccentric, causing a three-dimensional movement. The surgeon moves the cannula slowly through the fatty tissue, the tip digs itself forward like a mole. Vessels, nerves and connective tissue (septa) are speared, hence less damaged. Sweating of the surgeon become inexistent, the working time is reduced considerably.
We report about our experience on over 1000 operated areas, including the inner side of the thigh, inner side of the knees, calves and upper arms . We compared the performance with the ultrasonic assisted method and the conventional liposuction. In 11 cases liposuction was combined with an abdominoplaty, a thigh lift or an upper arm lift, hence enabling the visualization of the method’s effect on the fatty tissue.
Methods: From October 2001 to April 2003 we implemented this method on 334 patients (range of age: 18a – 82a, 212 female, 52 male, mean 42a). The following areas have been operated on: skin under the chin, upper lateral area of the breast, abdomen, flank, back, upper arms, lateral thigh, inner thigh, inner side of the knee, frontal thigh, dorsal thigh, calves. In all cases infiltrating time, suction time, suction quantity and the relation fat/water has been meticulously documented. In 10 cases we used the vibro-assisted liposuction on one thigh and the conventional method on the other thigh.
Results were compared with prior operations performed with the ultrasonic assisted technique.
Results: 12 patients were operated on at the skin under the chin (1 region), 42 patients on the abdomen (2 regions), 22 patients on the lateral thigh (2 regions), 23 patients the upper arms (2 regions), 123 patients on the lateral and the medial aspect of the thigh (4 regions), 48 patients on the lateral and the medial aspect of the thigh and the inner side of the knee (six regions), 29 patients on the calves and the lateral and inner thigh (6 regions), 12 patients the frontal and the dorsal aspect of the thigh (4 regions), 9 patients on the lateral upper aspect of the breast (2 regions), and 14 patients on the flank and the back (4 regions). 14 patients were operated on in general anaesthesia upon personal request, all others had the areas anaesthetized by infiltration. Infusion time ranged from 15 seconds to 210 seconds, suction time from 4 minutes to 28 minutes per region, mean 18 minutes. Overall operation time varied from 18 minutes to 3h10, mean 128 minutes. All patients become mild compression garments immediately after surgery and wore them between 4 to 8 weeks. Stitches were removed after 10 days. The quantity of suction fluid varied from 800ml to 12.000 ml (exceptional case of obesity) per patient, with an average of 3400 ml and an fat/water ratio of 6:1 (range: 1:1 – inner side of the thigh, 1:10, upper abdomen, lateral side of the thigh). 65% of the patients agreed to undergo postoperative treatment with endermology. Patients treated in local anaesthesia were dismissed from hospital after the intervention. 12 patients requested unexpected overnight at the clinic (low blood pressure). Low molecular heparin was only given to overnight-patients, as well as antibiotic treatment.
18 patients requested corrections because of indentions and/or asymmetric results.
Discussion: The vibro-assisted liposuction invented by Jean Malakh has clearly to be differentiated from the commonly called power assisted liposuction, since the three dimensional movement of this machine has been patented, while all other ‘power-assisted’ products have their cannulas moving in a horizontal plane alone with a range less then 4mm.
Conclusion: The vibro-assisted liposuction showed to be highly effective in our hands. Its performance showed no disadvantage and we highly recommend this method.
B-Technique (Rйgnault) and dermis-suspension:
a new technique for breast reduction combining
small scars, speed, secure nippel vascularisation
and durability of results
Introduction: There are several techniques for reduction mammoplasties. All attempts to improve existing methods have the goal to achieve durable results, minimizing the scar and to achieve aesthetic shapes. Paul Rйgnault introduced in 1974 a technique based on the upper pedicle for the blood supply of the mammilla, that could be applied in small and large breasts and showed a rounded, L-shaped scar (B-technique), sparing completely the medial aspect of the inframammary fold. The technique is fast, bloodless, easy to learn and has to be regarded as milestone in the numerous attempts to reduce the scar in reduction mammoplasty.
Other attempts were made to enhance the durability of the results. Another milestone was the idea to use the deepithelized skin (dermis) in that a flap is formed and sutured to ribs in order to avoid late drops of the breast. Provided that the flaps remains vascularized, the idea to from an interior brassiere to avoid droping of the tissue deserves close attention. Eren uses a central pedicle with Strцmbeck’s skin incisions, Frey a central pedicle with Rйgnault’s skin incision. Techniques with central pedicle can show problems with the vascularization of the nipple, since the blood supply is restricted to the ascending vessels through the breast tissueas all dermal vessels are transsected. In order to avoid this inconvenient, we searched for a technique combining the advantageous skin-incision from the B-technique and the innovative idea of the stabilizing dermis-suspension.
Methods: The technique consists of the B-technique from Paul Rйgnault and adds to it the interior brassiиre introduced by Eren. The difference lays in the fact that the dermal flap at Eren’s technique is vascularized by the underlying breast tissue, while in this new method the dermis has to be elevated and placed back -subsequent to the removal of the breast tissue - as a more or less free flap, attached on the caudal aspect of the areola alone and sutured to ribbs.
Results: From 1999 to 2002 we applied this method on 20 women (range of age: 24a-64a, median 36a). Elevation of the nipple ranged from 4cm to 16cm (median: 8,5cm), weight of removed breast tissue ranged from 180g to 840g (median: 410 g). In all cases the blood supply of the nipple-areola complex remained excellent. Follow up ranged from 12 to 36 months. 1 patient had to be revised due to asymmetry. Patient’s satisfaction was overall good.
Discussion: It is our opinion that this technique is easy to learn, nearly as fast as the B-technique, equally bloodless but more durable. It avoids the well known, even though not frequently occurring problem of the areole’s blood supply encountered with the methods using a central pedicle.
Conclusion: We can recommend this new method as a simple and safe technique to perform reduction mammoplasties.
My experience with the use of sutures
in forming and stabilizing the nasal cartilage
in aesthetic rhinoplasty
Introduction: The use of sutures to modify the cartilaginous skeleton of the nose in aesthetic rhinoplasties become frequent in the last decade only. In the University Clinic of Vienna, Austria not a single rhinoplasty was performed which sutures to modify the nasal cartilage during my residency (1985-1991). Aiach, Guyuron, Tardy and Tebbeth (alphabetic order) are probably the best known pioneers in modelling the tip of the nose with sutures. The use of grafts, struts, and sutures widened the spectrum of correction and achieved better and longer lasting results in aesthetic rhinoplasties. In this descriptive retrospective study we want to present our experience with these techniques and to show and discuss some selected cases.
Methods: 112 patients (82 females, 30 males, range of age: 18a – 64a, median 38a) who underwent rhinoplasties during January 1995 and December 1997 were enrolled in this retrospective study. In all patients sutures were used to correct, form or stabilize the cartilaginous skeleton of the nose. 52 patients (group A) requested aesthetic changes alone, 60 patients (group B) performed surgery for other reasons (posttraumatic deformities, septal deviations etc.), but interventions were completed with aesthetic operations. In group A the hump was the primary indication for surgery, (n=32, 61%), in 14 cases (27 %) it was the tip of the nose, 6 patients (11%) had miscellaneous reasons. In group B, septal deviation was present in 71 % (n=17), a deviated back of the nose in 32 % (n= 19), deformities of the tip in 42% (n=25) and a hump in 66 % (n= 40). Photos were taken from all patients before and after surgery, with follow ups varying from 1 one to 4 years. In 92 patients, intraoperative photos were made as well.
Results: In group A, 18 interventions were performed with the open technique (12 primary, 6 secondary interventions), 24 with the semi-open technique (full delivery of the lower laterals by intercartilaginous and rim incisions) and 10 with the close technique. In all cases 52 cases sutures were used either to narrow the tip, to elevate the tip, to stabilize it or to reduce the diameter of the dome. In 18 cases struts were used (1mm thick, 2mm wide, variable length, made with the Aiache plate) to stabilize the columella by strengthening the medial crura of the lower laterals, 7x struts were used to strengthen the lateral crus of the lower laterals to correct inspiratory problems caused by a valve-effect during inspiration (collapse). 12 x the tip was elevated by anchoring the cranial edge of the lower lateral to the septum. 11 x tip augmentation was performed with one or more layers of septal cartilage sutured together on top the domes.
In group B, all corrections made on the tip of the nose were performed in addition to the correction of the posttraumatic deformities. In 20 times (30%) the open technique was implemented, (14 primary, 6 times secondary), in 32 patients we used the semi-open technique (50,5%) and in 8 cases the closed technique. Sutures were used to narrow the tip (n=42) , to reduce the diameter of the dome (n= 32), to reposition the septum on the nasal spine ( n= 12), to fix struts (n=18), to position grafts for tip augmentation (n= 9), to stabilize the alar wings to correct inspiratory problems (n= 5), to anchor the cranial edge of the lower laterals on to the septum to prevent a later drop of the tip (supratip, n= 11) and to stabilize the columella (n= 8).
Follow ups: Out of 112 patients, 8 requested corrections, which all have been performed, and 2 patients had to be operated on a third time to achieve satisfaction. All secondary operations were performed with the open technique, correction consisted of elevating further the tip (n= 4), of narrowing again the tip (n=3) and of correcting a deviated position of the tip (n=1). Secondary surgery was performed in all cases at least 12 months after the primary intervention. All these corrective interventions could be accomplished without major difficulties since the existing sutures were simply removed and replaced.
Conclusion: The use of sutures in aesthetic rhinoplasty showed to be highly effective. It considerably widens the surgical spectrum and . If corrections become necessary, the operations is not too difficult since sutures can easily be removed and replaced.
FERNANDO PEDROZA, M.D.
Correction of the asymmetric nose
The main goal is the presentation of the surgical techniques used in the correction of the Asymmetric Nose.
The Asymmetric Nose includes the differences in the shape, size, position, and the orientation of each one of the structural parts of the right half of the nose, comparing it to the left half and the relation with the medial nasofacial vertical axis. One hundred patients are analized from a total of more than three thousand rhinoplasties performed in private practice in a period of time of 15 years (1981-1996). The ethiology of the Asyummetry may be congenital, traumatic, secondary to the facial development and iatrogenic. The surgical technique is directed to achieve the symmetry of each one of the nasal parts in relation to the medial facial axis, it includes the asymmetries of the bony and cartilaginous dorsum, of the nasal tip and of the nasal alae. The techniques exposed are preferably used according to each particular case: 1. In the nasal dorsum: resections, rasp, osteotomies, grafts and implants; 2. In the nasal tip: redistribution of the lobular cartilage, creation of new domes, interdomal and transdomal sutures, partial resections, partial grafts or total reconstruction of the cartilages; 3. In the nasal alae: vestibular alae Dresection and advancing sutures from the resection borders. Comparative slides are shown pre and post-operative of the patients which illustrate the results of the techniques used, as well as trans-operative slides. In conclusion, it is necessary a detailed observation of the patient and its photographs to diagnose the nasal asymmetries and plan the adequate correction. The achievement of the nasal symmetry is very difficult but it is necessary to know the most conservative techniques which offer a better result to be able to correct the nasal asymmetries.
Septal perforation closure
The main objective is the explanation of the techniques used in the Closure of big Septal Perforations between 1 to 3 centimeters of diameter, successful in 90% of the cases treated.
72 cases of patients operated of big septal perforations performed in private practice are presented in a period of time of 10 years (1981-1998).
All the cases are documentated with photographs pre and post-operative of the patients.
Described are an analysis of the ethiology, size of the perforation, simptomatology, age, sex, surgical approach, grafting, follow-up and results obtained.
The surgical technique used is illustrated, and shown several patients operated.
In conclusion, the technique used for big septal perfortion, although it is difficult to achieve, permit successful results of the closure perforation, in more than 90% of the cases.
Endoscopic forehead lift fixation technique
In this paper I present the indications for the realization of the Frontoplasty:
A) In young patients with ptosis of the eye-brow which produces a sad look, we perform an attractive rejuvenated look with bigger eyes and a fresher appearance.
B) In patients with signs of aging like wrinkles in the forehead or crow-foot (wrinkle at the corner of the eyes), and ptosis of the eye brow, it is also possible to leave a younger and fresh looking.
I use the endoscopic approach through 5 incisions from 2 to 3 centimeters long in the scalp.
I do a sub-galeal dissection at the posterior area of the hair implantation, dissection between the superficial and deep fascia of the temporal muscle, and sub-periostical dissection in the frontal area. Then, I do the communication and unification in between the dissected areas.
I show the technique in video-tape, including the cutting of the periosteum at the superior rim of the orbit, preserving the neuro-vascular pedicle, the cutting of the corrugate and procerus muscles, and the fixation with non-absorbable sutures for the stabilization of the lifting of the Eye Brow.
I show the slides pre and post op. with patients operated with this endoscopic technique used during the past two years.
The advantage of this endoscopic technique over the coronal incision is to avoid the large incision, the cutting of the supra-orbital nerve, and the resection of scalp with bigger alopecia and scar.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties 20 years experience - personal technique
I present the personal technique used for obtention of the Autologus Graft from the Auricular Conchae for the total reconstruction of the inferior lateral crura of the nasal lobule, including the lateral and media Crura in a unique block, similar to the normal anatomic structure of the nasal tip.
I show in detail with slides and video-tape, the anterior incision, the exact place for obtention of the Cartilage, its sculpturing and how I perform an almost exactly anatomical, an physiological structure as that of the normal nose lobule, obtaining support for the nasal tip, natural projection and a normal appearance in patients with severe iatrogenic secuelaes. I present the technique to fit position and fixation of the graft, using the endonasal or external approach to nasal tip surgery. I also show the successful results obtained in patients of Revisional Rhinoplasties, the long term results with an experience of 16 years, being operated the first patient in 1981, and obtaining a recognition award during the Colombian Congress of Otolaryngology in 1985. Also the Award “ERMIRO DE LIMA” in September 1993 in Sao Paulo, Brazil, during the celebration of the Latin-American Meeting of Rhinology and Facial Plastic Surgery.
The comparative pre and post operative photographs show the correction of iatrogenic secuelaes, like asimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appearance, etc.
Total reconstruction of the nasal tip cartilages
in revisional rhinoplasties – 20 years experience personal technique. “Sea Gull Wings” technique
1. Objective. I present the personal technique used with success in patients with notorious nasal tip secuelaes of previous Rhinoplasty surgeries, who could not obtain a natural look with partial grafting, because they required a Total Reconstruction of the lobular cartilages with autologous graft of auricular conchae.
2. Design. I describe the surgical technique of: 1) Obtention of the autologous graft of auricular conchae; 2) Sculpturing of the graft obtaining cartilages of anatomic threedimentional conformation, similar to the normal lobular cartilages; 3) Placing and fixation via Endonasal or External. The results are obtained at long term following patients for as long as 16 years.
3. Setting. The patients were institutional and private and the intervention was ambulatory or with 1 day of hospitalization.
4. Patients. A total of 65 patients were examined with photography controls pre and post surgery, for a period of 16 years between 1981-1997. The consultation were to correct the Rhinoplasty iatrogenic secuelaes, as assimetries of the nasal tip, non-definition and non-projection of the nasal tip, pinching, retractions, alar colapsing, hanging columella, anti-aesthetic appeareance, nasal obstruction, etc.
5. Intervention. I show in detail the anterior auricular incision, the exact place ant the way to obtain the autologous conchae cartilage, its sculpturing and how I perform an almost exactly anatomical and physiological structure, as that of the normal nasal lobule, its position and fixation using endonasal or external approach, obtaining support for the nasal tip, natural projection and a normal appearance in patients of severe iatrogenic secuelaes.
6. Main outcome Measure. Analyzis of the improvement of the Aesthetic appeareance in the inferior nasal third, in patients with Nasal Surgery secuelaes.
7. Results. The comparative pre and post operative photograps show the success in the correction of iatrogenic tip nose secuelaes and its permanent good results, by long term follow-ups.
8. Conclusions. This personal technique of Total Reconstruction of the Lobular Nasal Cartilages, including the lateral and media crura in a unique block, with autologous conchae cartilage is recommended for the surgical treatment of severe iatrogenic secuelaes in Tip Nose Rhinoplasties, obtaining excelent results similar to the normal anatomic structure of the nasal tip.
Dynamics and successful technology
for nasal tip surgery
1. Objective. Present a basic and successful personal technique to modify in a conservative way the shape and position of the nasal tip remodeling the cartilages, and using sutures through the domo level to re-distribute the length of the lateral and medial crura, without vertical section of cartilage to conserve its continuity. The purpose of this technique is to narrow, project and rotate the nasal tip. Also to present other complementary techniques to correct additional difficulties as weakened cartilages, thick skin, short collumela, sub-projected and over-projected tip, asymmetric tip, revisional tip, secuelaes of leporine nose, etc.
2. Design. Completion of the expose technique, has been the result of the utilization, analysis and control at long term, in a period of 18 years, with pre, post and inter-surgical photograph and slide studies, and examination of the results of this technique.
3. Setting. Patients were institutional and private, and the surgical interventions ambulatory or with 1 day of hospitalization.
4. Patients. Have been analized and grouped according to the degree of nasal tip problems and difficulties of correction, observing the use of the various techniques and the results in more than 3.000 patients.
5. Intervention. Show in detail the pre and post cartilaginous incisions, the endonasal access way with liberation of lobular cartilages, and the complementary techniques with partial cartilaginous grafting in the columella, in the tip or in the lateral part of the lobule, or with total reconstruction of the lobular cartilages using cartilaginous conchae graft in difficult Revisional Tips.
6. Main outcome measures. Determine the right utilization of the surgical techniques, to correct the shape and position of the nasal tip, based in pre-operative analysis and the determination of the surgical plan by each patient.
7. Results. Comparative pre and post operative photographs show the dynamics and success of the conservative techniques utilized to correct nasal tip deformities, based on the progressive difficulties presented in each case.
8. Conclusions. This personal basic technique for the re-distribution of the lobular cartilages, based on the dynamics of those cartilages and the complementary techniques used in the deformity of the nasal tip of each patient, is a conservative but successful one, recommended to obtain an attractive and natural nasal tip.
The New Domes Technique –
15 years of experience
Nasal tip surgery, which has been considered the most interesting and difficult part of Rhinoplasty, obliges the surgeon to perform a detailed pre-surgical study of each individual patient, analyzing characteristics, skin thickness, cartilage strength and nasal tip shape and position, and requires millimetric precision in the surgical techniques used in order to achieve nasal tip placement in the desired and appropriate position for each patient’s face.
In this presentation, we deal with a patient with a drooping nasal tip whose skin is not very thick and who has good alar cartilage in terms of thickness and consistency. The nasal tip must be projected, rotated and narrowed for aesthetic improvement. We shall clearly describe the post-cartilaginous and pre-cartilaginous incisions, the endonasal approach with cartilage release, and conservational, predictable and stable technique—“the new dome technique”, which places these new domes in a position which is more lateral to the patient’s own domes, and then suturing one to the other, thus forming an aesthetic triangle which results in a natural-looking nasal tip. This technique is generally complemented with the resection of the vestibular skin of the fibrous septum, the resection of the septal caudal edge and, if necessary, the placement of a columellar strut and columellar-septal fixation in order to sustain the results.
The “new domes technique” allows us to obtain a nasal tip which is more projected, cephalically rotated and narrowed natural in appearance, through the use of a procedure which preserves the integrity and continuity of the lower lateral cartilage.
GEORGE FELMAN, M.D.
The Transumbilical Breast Augmentation
The author presents their experience with breast augmentation using endoscopy. They use a transumbilical approach to insert of saline-filled breast implants.
The brief historical reference: For the first time the method of transumbilical breast augmentation was described by Dr. Johnson G.W. in 1993. In 1994 Dr. Abel Chajchir described the endoscopic augmentation mastoplasty using an axillary approach.
A great enthusiast and propagandist of the transumbilical breast augmentation method is Dr. Leonard Grossmann from the New York Plastic Surgery Center owing to whom I had the privilege to study this method and I am greatly appreciate him for this!
The breast augmentation procedures have been performed in my center of Cosmetic Surgery in Tel Aviv over 25 years. The experience accumulated by me during these years and the possible complications feared me and caused some skepticism.
After I have observed one transumbilical breast augmentation procedure by myself I at once became the worshipper of it.
The experience acquired while performing abdomenoplastica and gynecomastia using New Transparent Lipoplastic Cannula with diameter of 8mm provided me the better orientation and surgical skills when transumbilical breast augmentation procedures performing.
The transumbilical breast augmentation procedure has proved save for implants, and most important, safe for patients – provided it is performed properly. In that respect, transumbilical breast augmentation is similar to liposuction in that it is a very safe procedure if performed by a properly trained and qualified surgeon.
Clinical material (preparation): For the 7 past months 32 transumbilical breast augmentation procedures using general anesthesia were performed. No cases of hematoma and infections were observed, 1 implant and 1 expander were damaged. 1 conversion to another incision and 1 implant malposition cases were observed.
The three most critical points are that no sharp instruments are used, the surgeons’ handling of the instrument prevents any long thrusts, and at no time does any instrument point toward the abdominal or thoracic cavity.
What then are the real benefits of the transumbilical breast augmentation method? First, as with the transaxillary method, complete absence of tension on the incision means that large implant sizes can be used without fear of dehiscence or edge necrosis and subsequent infection.
Second, because the pocket is created hydraulically, it conforms to the shape of the implant with no dead space around the periphery of the implant base to harbor infection or hematoma.
Third, the shape of the breast and the position of the implant can be tightly controlled, being monitored directly by the external appearance of the breast very much a what-you-see-is-what-you-get approach that facilitates symmetry.
Fourth, for reasons not fully understood, the prepectoral transumbilical breast augmentation method is, without question, the least painful of any of our augmentation procedures, the patients’ recoveries and return to activities are remarkably fast.
Fifth, as has been documented, the transumbilical breast augmentation procedure has been shown to have the lowest rate of loss of nipple sensibility and the lowest rate of infection or hematoma.
Sixth, absence of scar in the breast area.
Seventh, transumbilical breast augmentation method is successfully applied to women as well as to transsexuals.
Gynecomastia Treatment
Using New Transparent Lipoplastic Cannula
Liposuction is not a new method by treatment of pseudogynecomastia and a true gynecomastia. However in cases of the true gynecomastia a lot of surgeons have to combine liposuction with an inferior periareolar incision for resection of the remaining glandular tissue.
Usual procedures when using the metal cannula can lead to deep skin adherence, depression in the mammary area, or nipple areola complex deformity.
Along with these unsatisfactory results symmetric scars in areola complex remained after the operation cause among patients dissatisfaction with the procedure.
It is not possible for the metal cannula of small diameter with lateral openings to cross through the subareolar glandular mammary tissue because of the its hardness.
As a result of it in true gynecomastia the remaining glandular tissue is surgically removed through a periareolar incision.
In 1996 I suggested a new transparent cannula with an open oblique end and developed a new technique that enables to remove without any additional incisions the excessive adipose tissue as well as glandular tissue in cases of the true gynecomastia.
For the first time after 4 years of serious work I reported about my New Transparent Lipoplastic Cannula on the congress in Tokyo in 2000. Many respectful colleagues, that are now in the hall were present at that congress when I was presenting my cannula and I am sure they are enjoying the good memories until now.
Now I would like to draw your attention to the surgical procedure.
Using general anesthesia (0.25% Lidocain + 1mm Adkenalin) the “tight” infiltration of the removed tissue is performed on the method of Vishnevski. In 10-15 minutes the incision of 1 cm is made at the significant distance from the supposed aspiration place. The New Transparent Lipoplastic Cannula with diameter of 8 mm with an open oblique end is inserted into the incision. After that the adipose tissue and glandular tissue are penetrated with following aspiration. At the opposite side it is necessary to perform an incision at the area that is not symmetric to the previous incision. The operation is completed with putting the two or three stitches. It would be strictly recommended to the patients to wear a rubber belt during 3-4 days after the surgery.
Results
During the period of 1996-2002 132 patient underwent this procedure. Among them:
• 81 patients correction of pseudogynecomastia.
• 51 patients with true gynecomastia.
• It was not made any additional incisions to 127 patients. In 30 cases was observed seroma that was liquidated after some punctures.
• In 5 cases the incisions in the areola area were performed.
• The repeated procedure was made to 8 patients because of asymmetry.
Conclusion:
Applying of New Transparent Lipoplastic Cannula with diameter of 6-8mm for treatment of gynecomastia cases proved to show good results. In majority cases of true gynecomastia it was not necessary to make an additional incision in the areola area.
NTLC has the important advantage: when working with NTLC the plastic surgeon can easily “feel” the penetration of NTLC and control it by “checking hand” that is more safe and secure. ( Remember that some perforations of chest can occur).
Since 1996 any perforations or embolism cases did not occur.
Prof. JULIO FERREIRA, M.D.
Amande peel – new combined almond peeling in treatment of photoaging, dyschromies and acne
Mandelic acid is an alpha-hydroxy acid (AHA) which is derived from an extract of bitter almonds. It has excellent results and its application is useful in hyperpigmentation, acne and photoaged skin. It helps in pre and post laser resurfacing.
It has shown an important antiseptic and despigmentant properties.
Compared with glycolic acid produces less erithema and it can be used in Types I to V (Fitzpatrick) without hyperpigmentation post inflammatory.
It may be used at a peeling agent or combined with other exfoliants.
In this work I will develop the formula, combination with other agents, and its application in cases such as: aging, acne, melasma, lentigeness, photoaged skin, and the obtained results.
Color Peel: New treatment for Stretch Marks
In this work I will present this new method indicated to improve the stretch marks.
As we know the stretch marks are produced due the alteration in collagen and elastic fibers, determined by fibroblast alterations. With the components of the products we are going to activate the production of collagen improving the elasticity and tone of the skin, releasing the area of depressions.
This method is based in the use of two products that are going to be used in the consultancy office by trained hands .
I will show you the steps and the materials that we will need in each session so as the precautions to take into account with the use of the products.
Liposculpture
Since liposculpture appeared until today there have been great modifications in possibilities both for doctors in their own fields and for those results in patients needing changes in the shape of their bodies.
After many years working on liposculpture I named Mixed Lipoesculpture 1 as the combination of different techniques, and its possibility of adaptation for each case , using since 1986 traditional extraction with syringe or suction machines and since 1992 the incorporation of the ultrasonic systems. As cosmetic surgeon and having specialized in liposculpture technique I have been interested in the incorporation of new techniques and solid proof of the preservation of noble structures of the adipose tissue.
This method is the result of the evolution of surgical techniques, instrumentals and equipments and of the investigation and statistic works that promote best results and decrease complications.
I present in this work the scientific basis of the importance of this technique in modelling reshape, pre and post surgical recommendations to achieve better results and a demonstration of different body areas that have undergone Liposculpture and I describe those surgical steps used and the results obtained.
I use in all the cases the tumescent local anaesthesia and without needing neuroleptoanesthetics.
Filling techniques:
autollogous or heterollogous
We denominate Filling Autollogous Techniques to the technique that uses fat tissue to augment the volume of different body areas.
We use the same fat tissue extracted through Liposculpture Techniques. This tissue will be injected under skin surface. We can apply this technique in facial rejuvenation because it is possible to model the face in volume and to improve depressed areas and improve facial look.
The fat tissue has a filamentose collagen envelope as a soft structure that is in direct contact with the adiposite or adipose cell. With autocollagen technique it is possible to obtain soft structure that will be reinjected in chosen areas.
There will presented different heterollogous substances (natural and synthetics), deep of application and types of needles and materials to be used.
Excellence in cosmetic surgery
Excellence is the maximum efficiency and the maximum effectiveness in the objective chosen, and involves a superior quality. It is not possible to obtain perfection in an imperfect world, but the goal should be to come as close to excellence as possible in performing cosmetic surgery.
Cosmetic surgeons should strive for excellence in their treatment of and attitude toward patients as well as in their capabilities as surgeons. There must be excellence in a private ambulatory surgery suite with up-to-date equipment and well-prepared personnel. There must be a qualified working team with the philosophy of striving for the best of patient care.
I present in this work the definition of the concepts about Excellence and the golden rules to achieve excellence in Cosmetic Surgery.
Complications in liposculpture
This study is a compilation of the work performed at Dr. Julio A. Ferreira’s Surgery Consultancy during seventeen years of work on the liposculpture technique.
In body modelling techniques the doctor’s aim has always been to improve the patients’ appearance. Using modern surgical techniques excellent artistic results may be obtained leaving, in the majority of cases, no scars or visible signs.
Liposculpture, a microsurgery technique, enables us to extract the surplus fatty tissues in an artistic manner and, where necessary, to reuse this tissue in areas that may need be increased in volume or for correction of scars of depressed areas.
Correct use of this technique enables us to perform this work with a minimum degree of risk and with the possibility of post-surgical consequences.
The surgeon should foresee possible complications, many of which, as we see in the study, may be easily avoided.
I will present in this work different types of systemic and local complications, its prevention and treatment.
Golden number in medicine
and cosmetic surgery
I will present in this conference the importance of the consideration of the Divine Proportion or Golden Number to obtain better results in our field, looking for corporal and facial harmony.
As we know this proportion is considered like the most harmonic for human sensitivity and its correspond to the proportions presented by nature.
We can find this relation among the different measures of the face, body, tree branches, mineral crystals, between the minor and mayor axe of the egg, etc.
By this proportion we understood that our perception of beauty depends on measure harmony, and explains that despite of the relative of the concept of “beauty” we can consider that really exists something very near to “perfect beauty”.
I will show with this work how through the centuries, Egyptians, Greeks, Romanians, artists or philosophers trying to understand Universe beauty look for the canons of perfect proportions, measuring and converting in numbers the light equilibrium among parts and all.
We must point out that external and internal perfection create physical and psychic beauty, and humans submit before harmony between them.
Medicine and Cosmetic Surgery can use the knowledge of Proportion Divine to look for its results in shapes harmony, balance and equilibrium.
Gluteolipoplasty
Derived from latin word “culus” and according to the Real Spanish Academy denominate buttocks the area located between the end of the spine and the beginning of the thighs. It is the most important muscular mass of the human anatomy and its functions are as energy deposit, small pillow for sitting, perform the movements of standing up and keeping up, walking and crossing legs, as an important sexual stimulus, used in advertising, as a symbol of beauty and veneration. As we can noticed since long time ago the importance of the area has been shown in art pieces, paintings or statues from the greatest artists. They have different evolution in men or women. In women is rounded, its volume is bigger and it has more adipose tissue, in men its shape is square and it has more muscles. We must point out that the adipose tissue deposited in this region is rebel to local treatments. In this work I will present the develop of the gluteus modelation with the use of liposculpture using microcannulas and taking into account the aesthetic unit of “thigh-gluteus-banana fold, infragluteal fold”.
Introduction in the field of superficial,
medium and deep peelings
Up dating in dyschromias and combined treatmens
The quest for facial rejuvenation and the treatment of the dyschromias has been going on from time immemorial and is buried in obscurity. We do not know when chemical was first used as an exfoliative agent for facial rejuvenation, but the ancient Egyptians and Chinese used different formulas to be applied on the facial treatments. The treatments of the aging face requires an appreciation of skin aging, damage and dyschromias. I will present in this work different kind of substances and peelings (superficial, medium and deep peels) for the treatment of dyschromias and cutaneous aging. Excellent results have been obtained with different types of peelings. In this conference the details of each peel are going to be presented.
Liposculpture of dorsal area and arms
I will present the scheme and routine of the Liposculpture technique used in this non traditional areas.
It will be described marked areas, incisions and different positions of work., pre and post surgical preparation and complementary treatments used to improve the final result.
KIM, ING GON, M.D.
Correction of asymmetric calves
of poliomyelitis patients using calf augmentation and reduction
I have combined augmentation and reduction technique to the patient with poliomyelitis by augmentation of the affected poliomyelitic calf and reduction of the unaffected calf by partially shaving the hypertrophied gastrocnemius muscle thus, setting the patients physical demands as well as psychiatric and social conflicts.
From Jan. 1997 to Jan. 2000, 10 patients(M:F=2:8) with poliomyelitis underwent augmentation and reduction procedures and at least 1 year follow up was obtained. They had thin hypotrophic calf and unaffected leg was hypertrophic and muscular as a result of compensatory mechanism. Insertion of the soft silicon implants subfascially after carving and shaping up to fit the calf contour was performed on the affected calf and partial shaving of the hypertrophied gastrocnemius muscle was performed on unaffected calf.
Mean values of preoperatively measured calf circumference was affected 29.5cm, unaffected 36.3cm and postoperative measurement was 32.5cm and 33.2cm in order. Three months follow up revealed favorable outcome so that patients having symmetrical calves were tolerable to ordinary works. Also Cybex test was performed 1 year postoperatively for the muscle function and power evaluation which presented with favorable results without abnormal findings.
Correction of eyebrow hood
by endoscopically assisted forehead lift
The eyebrows have their own characteristic aesthetic levels and shapes. However, the majority of surgeons dealing with forehead lifts have put too much emphasis on forehead lift and too little on brow lift. Far too often, the eyebrows are elevated excessively in order to “clean up” the upper eyelids.
I performed the correction of eyebrow hood on 352 patients(M:F=85:267) by endoscopically assisted forehead lift from 1994 to 2000 and followed up from 6 months to 2 years. All forehead and brow lifts were performed subperiosteally using an endoscopic guide. Routine corrugator resections and procerus myotomies were performed and seperating the frontalis and orbicularis muscles were carried out. The suspension and fixation were done through 3 slanted cortical tunnels.As one of the results, when scalp was elevated 15mm, the brow was elevated about 4.1mm at the medial part, 5.3mm at the central part and 8.5mm at the lateral part. And I classified my cases into 4 categories according to portions of brow that are mainly corrected:Lift mainly on medial portion, Lift mainly on central portion, Lift mainly on lateral portion and Creation of an ideal arch. Also,I classified my unfavorable results into 4 groups:
• overcorrection,
• undercorrection,
• asymmetry
• no correction.
The endoscopically assisted forehead and brow lift using my method is considered to be best suitable for Asians as they tend to have conspicuous postoperative scars and rigid skin.
Endoscopically assisted subperiosteal face lift in asians for 7 years: problems and solutions
Asians are anatomically distinct from Caucasians and are characterized by a thick dermis, a Mongoloid slant of the palpebral fissure, a relatively prominent zygoma and mandible angle and a relatively flat nose. So, it was believed that the subperiosteal face lift was not suitable for Orientals. However, at my clinic, endoscopically assisted subperiosteal face lifts were performed from May of 1994 to October of 2000 on 352 patients: variable pitfalls, as well as satisfying results, were reported. Patient ages ranged from 29 to 66 years (mean age, 55.2 years), and follow-up ranged from 6 to 44 months (mean follow-up, 23 months). All forehead and brow lifts were performed using an endoscopic guide, and routine corrugator resections and procerus myotomies were performed. Three slanted cortical tunnels were made at the corresponding locations on the outer table of the calvarium, and 1-0 nylon suspension and fixation were performed. Most patients have been satisfied with their postoperative results, but unfavorable results and complications have been reported. There were accentuated Mongoloid slant, insufficient lift, exaggeration of sunken upper eyelids, intermittent headaches, itching sensations, and paresthesia on the scalp. The unfavorable results occurred in the patients who had previously undergone blepharoplasty and in those who had a history of foreign body injections into the face, fatty and thick faces, sunken upper eyelids, Mongoloid slants, and asymmetric facial expressions. Through understanding the anatomic characteristics of the Asians face (i.e., thick dermis, Mongoloid slant of palpebral fissure, prominent zygoma and mandible angle, and flat nose), satisfying results were achieved by appropriate application of the modified procedures.
Experience of Transumbilical Breast Augumentation For 10 years: Modified Method of Mine
The transumbilical breast augmentation(TUBA) has been popular and proven safe and effective. This technique has several advantages over other methods of breast augmentation: Short operation time (less than 30 min.), Unconspicuous operative scar, less postoperative pain, earlier recovery and motion, Low rate of complications, just to mention a few. Nevertheless, the method has often been the subject of a great variety of criticisms.
I have experienced 426 cases of transumbilical breast augmentation for 10 years from 1993 to 2002. At first, I was confronted with several problems but later found out that the problems are from poor and insufficient training without learning curve and inadequate handling of instruments. So, I modified this method to be suitable for each different patient. And I present this modified method of dissecting, adequate handling of instruments, making a pocket level, determining the size of pocket and volume of expansion using sizer, making a choice of final volume, making a beautiful shapes, and finally fixation method and postoperative care.
With my modified method, most difficulties with TUBA can be overcome and the best result can be achieved with few complications.
LINA PEDROZA, M.D.
Fat transplant to buttocks and legs for enhancement and deformities large volumes of fat transplant
Objective: This work was publicized in the book “Autologous fat transplantation”, edited by Melvin A Shiffman, January 2001
Marcel Dekker Inc) and considers the most challenged tips to harvest fat tissue and how to transplant a survival graft. At the present time we have ten years of experience obtaining a tridimentional body contouring of buttocks and legs for enhancement and deformities, the objective was presented because the author has the hyphotesis that a fat graft in cosmetic surgery, responds like other kind of tissue grafts and a result of the author’s search to find a way to avoid the most common applications of having a Buttock or Leg Augmentation done, with the introduction of a silicone prostheses. To find a surgical procedure that was complementary with liposuction, which could give not only the surgeon, but also the patient, less medical and surgical complications, better cosmetic results, more natural cosmetic results, longer lasting results, and an easier surgical technique. Also to find a small surgical procedure to deal with subtle body irregularities that do not justify a big surgical procedure.
Findings: The results are permanent, the recovery faster, no major complications were found and with the fat graft over the Gluteus or over the legs, the patient may have a chance of one single surgery to obtain his desires in body contouring.
Conclusions: This study shows more benefits for Liposuction than the ones made just only by suctioning the Fat Cells. Fat Grafting is a safe procedure and has not only cosmetic results but also Reconstructing for Midfacial Athrophy, Polio Sequelas, and other Desfigurating sindromes where you find Muscular Athrophies or any subcutaneous deformities.
A more effective and conservative
abdominoplasty personal technique - 10 cases report
Objective: Searching for a new technique, a better recovery, an easier recovery, a surgical procedure that will give the patient a less morbid surgery and a better cosmetic result, brought us to find what could be, thanks to modern Lipo-suction the Abdominal Plasty of the XXI Century.
Data collections: Data sources come from a review and also the practice of traditional Abdominal Plasties published in Plastic & Reconstructive Surgery books. Sources come also from the experience of having practiced 2200 Liposculptures from September 1991 to April 2001.
Findings: As Liposuction becomes a more and more popular procedure, we, as others, have noticed that as more Liposuction is done, less need of skin resection of the abdomen is necessary. Only few cases with very specific indications need removal of skin and those few cases are treated specifically with removal of dermis and epidermis after Liposuction of the abdomen, consisting in removing the excess skin and reacommodating the umbilicus to the new flap; which is an advancement flap.
Iindications: The classification for a new abdominoplasty is: patient in standing position, pendulous skin abdomen and stretch marks. For those patients with a pendulous abdomen in standing position without stretch marks, we prefer to perform liposuction.
Conclusions: Removing only the skin, permits an easier and faster recovery of the patient complications with traditional Abdominalplasties, as excessive bleeding, hematomas, seromas, loss of sensitivity, numness and infection, those disappear with this new safest procedure.
Ultrasonic liposuction- how to do it a study with electronic microscopy to show the efect of ultrasound in fat tissue and fat cells
Objective: Understanding the physic principles of the ultrasound, makes the surgeon be able to use safely the machine in Liposculpture. The experience of others show us cases of burned tissues, cavities, seromas, as complications during liposuction. Knowing what ultrasound is, makes the procedure easy and safer. A serious observation at the electronic microscopy showed us that while we perform internal assisteal liposuction with ultrasound we are obtaining separation of fat cells. The use of ultrasound which is one of the most advanced technologies in medicine permits the surgeon to perform one of the safest procedures in cosmetic surgery, as it is liposuction. The appropiate understanding of ultrasound, the mechanics of action and its effects against fat cells will give every patient a faster recovery, less bleeding, less swelling.
We will be able even to harvest fat cells to be transplanted and grafted over the entire body without disrupting the fat cells membrane.
The ample use of ultrasound in medicine throughout the Ecography- the Magnetic Resonance and the Lithotrity will permit to acknowledge its use in liposulpture.
Silicone prosthesis
a life saving device - 1 case report
Five years ago I had the opportunity to operate a female patient 34 years old, looking for an Augmentation Mammoplasty and a Liposculpture. We performed an Abdominoplasty, Liposculpture and an Axillary approach for Augmentation Mammoplasty. Normal post-op follow-ups were performed for 3 months, and I never saw the patient again. After four years of operation, I received a telephone call from an Emergency Room at a local hospital. I was told that my patient had suffered a life attempt and after a gun shot, the lady had a gun projectile located over the left chest, probably inside a silicone breast implant.
First aid measures after chest X rays were taken and the patient left the hospital two days after her arrival.
Four months after the life attempt, she came back to my office and we found that the gun projectile entered by the lateral face of her left arm, left her body by the inner face of it and entered again through the skin of the lateral pole of her left breast.
Thanks to the presence of a silicone gel filled breast implant, the gun projectile lost velocity and stopped just interiorly to the implant, broke all the implant, and stopped at the level of the fifth rib covered all by silicone gel.
The patient did not suffered any body damage, thanks to the presence of a silicone gel breast implant.
Breast silicone implants, properly used, do not cause harm to the humans health, but can also be a life saving devices.
Endoscopic breast augmentation
axillary approach
The Axillary approach for the Augmentation Mammoplasty, gives an excellent opportunity for the patient to have a surgical procedure that does not leave any scars over the skin of the Breast. It is also the ideal approach for endoscopic breast augmentation
For patients with: (A) Hypoplasia of the Breast tissue, permits the placement of the prosthesis below the Major Pectoralis Muscle using a wide tissue to hidden the implant. It also permits after surgery to take Mammograms visualizing a free Breast tissue which is safe to diagnosis any Pre-malignant or Malignant Pathology of the Breast, and isolating the gland to contact with any strange material.
The approach is the most convenient for the patient, not only Hypoplasic, but also for those patients with: (B) Grade I ptosis with an empty or hypotrophic Breast.
In case (B) the Augmentation Mammoplasty gives two kind of enhancements: (1) Fuller and young appearing breast (2) Pexia of the ptotic grade I Breast without producing any scars over the skin.
Reduction mammoplasty - short scars
We want to present three techniques that help the patient who is looking for a Pexy or a Mammary Reduction, that give them the opportunity to have Short Scars over the Breast Skin.
The first one is the “Daniel Marchac” technique, which resultant scar is an Inverted T where the horizontal line which is covered by the Mammary fold no longer tan 7 cms., versus 20 cms to 28 cms with the traditional reduction Mammoplasties.
The second one using a different movement of the Breast tissue is the “Howard” technique, useful as the last technique in Reductions and Pexies, gives also a little short scar with the inverted T that usually is no longer than 4 to 5 cms.
The third one which is in its full development is the periareolar approach, useful also for Reduction and Pexies for Moderate Hipertrophies and GII ptosis. The fourth technique belongs to “Ermetis de Longis” from Rome. It is an L shaped scar which uses an internal Bra of dermis to lift permanently the Mammary Gland and to avoid late post-op. Ptosis of the lower pole of the Gland.
We are trying to give the best results with less scars possible. Remember that the patient who is looking for an Aesthetic result, wants a surgery that will permit her be more beautiful without been overdressed or maybe using nothing over her skin. Short Scar techniques for Reduction or Pexies, should be the goal of the Third Millennium.
How to use your computer image
for cosmetic surgery
OBJECTIVE: Using your computer Image for Cosmetic Surgery of the Face or Body Contouring, is a helpful device for your records. It’s also a compromising detail which can be used against you if you show the patient a probability of result after surgery. The adequate use of the Computer Image may be helpful if you ask your patient to show you (Doctor) how the patient would expect his result from your surgery. FINDINGS: Asking your patient to show through your computer image how he desires to be after surgery, permits you to realize the normal or abnormal expectations of his patient’s new image. It permits the patient to exercise his mind and place over an image of himself, an requirement to his doctor. It also permits the physician to know specifically what kind of surgery must be done, in order to satisfy his patients desires. In Breast surgery women desire having previously: “A Breast Ptosis and a Glandular Athrophy a Full Breast and a lifted one”. The study shows you what your diagnosisplementary study, to support your surgery plan. It also helps to show to an uncomfortable patient, his results after surgery and how you were approximately to his desires. It also makes the patient how you can improve him but NOT to make him perfect.
GIORGIO FISCHER, M.D.
Facial rejuvination with rice-grain size
microimplants of fat
The results of lipofilling vary widely according to the harvesting, processing and replacements methods.
After fat has been harvested with a 14 GA needle, the curved Fischer’s cannula is attached to a 1ml Luer-Lock syringe, to limit the unnecessary manipulation of the fat which decreases the viability of the fat lobules. Fat is in fact never washed nor centrifugated. The microimplants are carried out with the curved Fischer’s cannula, which has a blunt point and is completely atraumatic for the fat cells.
The microimplants must be of the size of a rice grain, and no more than 5cc should be implanted in half of the face each time. This allows up to 70-80% survival of the implant. In this way, the neovascularization of the lobule is best obtained.
Face rejuvination is obtained by filling the whole face with microimplants of fat in a herringbone fashion. This method ensures a natural appearance of the face and maximum graft viability.
IVAN KRAINIK V., M.D., KRAINIK A.I., M.D.
Ligature lifting of eyebrows.
Eyebrow ptosis is a condition that often needs correction during the rejuvenative operations on face.
Ligature lifting of eyebrows may be an alternative to surgical methods of treatment if patient has high forehead and has no horizontal wrinkle. If we plan a procedure with the help of computer we can determine the height of eyebrow. For doing a procedure special unresolved stitch material is used. Three pairs of ligatures are put symmetrically from every side.
First pair of threads is put outside of a conventional vertical line, which is going through the pupil. On the eyebrow we make two 2 mm long horizontal incisions on the distance of 4-8 mm one from another. Than carry a ligature through a tissue using the incisions. The same incisions are made on vertical lines higher than the line of a hair growth. Ligatures on the eyebrow are immersed under the aponeurosis of forehead and brought out through the incisions in the area of a hair growth. One of the threads in the area of hair growth is immersed in the tissue and carry above aponeurosis under skin. Tying of ligatures is made at the same time on both sides using computer model. A knot is immersed under skin.
Second pair of ligatures is put inside of the conventional vertical line, which is going through the pupil, on the distance of 10-12 mm by the same method. Third pair of threads is used for rising and fixing outside parts of eyebrows. It is the most difficult thread to put because it should both rise outside parts of eyebrows and fix the direction of it. So the fixing of these ligatures must be symmetrical. Usually it is put outside the vertical line of low incisions.
Small injuries disappear in 2-3 days. This method does not need general anesthesia and can be used in ambulance conditions.
Prospects of computer modeling
of plastic operations.
It is very important to give to surgeon and to patient the right idea of a result of the operation. It allows to reach identical understanding of the future result and to create a feeling of belief between surgeon and patient. It is very important psychological factor for both of them. Computer modeling allows patient to decide whether operation is necessary and to choose what he or she wants to get as a result of an operation. For the surgeon computer model is a guiding line during the operation and a standard of its estimation on the whole.
For modeling appearance the program “Plastic Designer” is used. It is 2D program, which was designed for working with photos. This program is easy to use but very accurate, effective and clear for patient. Besides it does not need too much time (and 3D programs do). Furthermore it allows to do long and angular measures of contours and to make numerical control of measured parameters. A base for saving and working up the photos of patients (before the operation, results of modeling and after the operation) gives a possibility to analyze preferences of patients, to compare it and to reveal tendencies of fashion.
Computer modeling most often is used in rhinoplasty. It allows to measure angles (nasolabial, nasofrontal, angle of the nose tip and nosofacial) and to calculate width and length of the nose in different planes. Modeling is effective for calculating heights of forehead and eyebrows, angle of its slope and preferable size of mammary during the reductive mammoplasty. Before the lipospiration surgeon using computer model may decide in what parts body and how much fat he or she should remove. Modeling of lips, cheeks and nosolabial wrinkle gives a possibility to calculate the quantity of gel for correction and to find the best place for its bringing in. The same method can be used in liposculpture. Besides computer can help to choose exact size and shape of implants (diameter, height, etc...) and the place of its installing during endoprotethis of buttocks and shins. During the modeling technical skills of a surgeon and peculiarities of patient’s constitution are taken into consideration. It allows to show patient a possible result of operation. At the same time patient is not given wrong hopes. It is necessary to understand that result of an operation will be only close to the model because afteroperational process can influence the final result.
JONNY DE LA RIVA SALINAS, M.D.
Surgicalcosmetic treatment
axilary hyperhidrosis
The AH. is characterized by marked eccrine hypersecretion,secretion rates
of up to 13ml in 30 minutes from each axilla. Is important study the pathophysiology ,commonly idiopahic Surgical treatment . is for patient fail to respond to the previous types of medical therapy. Before is discribe other surgical methods.Thoracic sympathectomy with high risk, Cryosurgery, electrosurgery, surgical resection of axillary glands
Surgicalcosmetic treatment
Surgicalcosmetic treatment easy procedure,minimize the risk,no necesary drainage,no hematoma formation.notension across the wound,no sutures and total ambulatory. thechnical. local anethetic,no tumescent,litle liposuction with cannula No 2 Mercedes used aperture directed toward the skin surface in a plane just below the dermis. Take aut the glands accrine,apoccrine and hair folicule with pounch N0 1,5 ml. gaze with muperacine for 24 hours.
GEORGE FELMAN, M.D.
The Transumbilical Breast Augmentation
The author presents their experience with breast augmentation using endoscopy. They use a transumbilical approach to insert of saline-filled breast implants.
The brief historical reference: For the first time the method of transumbilical breast augmentation was described by Dr. Johnson G.W. in 1993. In 1994 Dr. Abel Chajchir described the endoscopic augmentation mastoplasty using an axillary approach.
A great enthusiast and propagandist of the transumbilical breast augmentation method is Dr. Leonard Grossmann from the New York Plastic Surgery Center owing to whom I had the privilege to study this method and I am greatly appreciate him for this!
The breast augmentation procedures have been performed in my center of Cosmetic Surgery in Tel Aviv over 25 years. The experience accumulated by me during these years and the possible complications feared me and caused some skepticism.
After I have observed one transumbilical breast augmentation procedure by myself I at once became the worshipper of it.
The experience acquired while performing abdomenoplastica and gynecomastia using New Transparent Lipoplastic Cannula with diameter of 8mm provided me the better orientation and surgical skills when transumbilical breast augmentation procedures performing.
The transumbilical breast augmentation procedure has proved save for implants, and most important, safe for patients – provided it is performed properly. In that respect, transumbilical breast augmentation is similar to liposuction in that it is a very safe procedure if performed by a properly trained and qualified surgeon.
Clinical material (preparation): For the 7 past months 32 transumbilical breast augmentation procedures using general anesthesia were performed. No cases of hematoma and infections were observed, 1 implant and 1 expander were damaged. 1 conversion to another incision and 1 implant malposition cases were observed.
The three most critical points are that no sharp instruments are used, the surgeons’ handling of the instrument prevents any long thrusts, and at no time does any instrument point toward the abdominal or thoracic cavity.
What then are the real benefits of the transumbilical breast augmentation method? First, as with the transaxillary method, complete absence of tension on the incision means that large implant sizes can be used without fear of dehiscence or edge necrosis and subsequent infection.
Second, because the pocket is created hydraulically, it conforms to the shape of the implant with no dead space around the periphery of the implant base to harbor infection or hematoma.
Third, the shape of the breast and the position of the implant can be tightly controlled, being monitored directly by the external appearance of the breast very much a what-you-see-is-what-you-get approach that facilitates symmetry.
Fourth, for reasons not fully understood, the prepectoral transumbilical breast augmentation method is, without question, the least painful of any of our augmentation procedures, the patients’ recoveries and return to activities are remarkably fast.
Fifth, as has been documented, the transumbilical breast augmentation procedure has been shown to have the lowest rate of loss of nipple sensibility and the lowest rate of infection or hematoma.
Sixth, absence of scar in the breast area.
Seventh, transumbilical breast augmentation method is successfully applied to women as well as to transsexuals.
Gynecomastia Treatment
Using New Transparent Lipoplastic Cannula
Liposuction is not a new method by treatment of pseudogynecomastia and a true gynecomastia. However in cases of the true gynecomastia a lot of surgeons have to combine liposuction with an inferior periareolar incision for resection of the remaining glandular tissue.
Usual procedures when using the metal cannula can lead to deep skin adherence, depression in the mammary area, or nipple areola complex deformity.
Along with these unsatisfactory results symmetric scars in areola complex remained after the operation cause among patients dissatisfaction with the procedure.
It is not possible for the metal cannula of small diameter with lateral openings to cross through the subareolar glandular mammary tissue because of the its hardness.
As a result of it in true gynecomastia the remaining glandular tissue is surgically removed through a periareolar incision.
In 1996 I suggested a new transparent cannula with an open oblique end and developed a new technique that enables to remove without any additional incisions the excessive adipose tissue as well as glandular tissue in cases of the true gynecomastia.
For the first time after 4 years of serious work I reported about my New Transparent Lipoplastic Cannula on the congress in Tokyo in 2000. Many respectful colleagues, that are now in the hall were present at that congress when I was presenting my cannula and I am sure they are enjoying the good memories until now.
Now I would like to draw your attention to the surgical procedure.
Using general anesthesia (0.25% Lidocain + 1mm Adkenalin) the “tight” infiltration of the removed tissue is performed on the method of Vishnevski. In 10-15 minutes the incision of 1 cm is made at the significant distance from the supposed aspiration place. The New Transparent Lipoplastic Cannula with diameter of 8 mm with an open oblique end is inserted into the incision. After that the adipose tissue and glandular tissue are penetrated with following aspiration. At the opposite side it is necessary to perform an incision at the area that is not symmetric to the previous incision. The operation is completed with putting the two or three stitches. It would be strictly recommended to the patients to wear a rubber belt during 3-4 days after the surgery.
Results
During the period of 1996-2002 132 patient underwent this procedure. Among them:
• 81 patients correction of pseudogynecomastia.
• 51 patients with true gynecomastia.
• It was not made any additional incisions to 127 patients. In 30 cases was observed seroma that was liquidated after some punctures.
• In 5 cases the incisions in the areola area were performed.
• The repeated procedure was made to 8 patients because of asymmetry.
Conclusion:
Applying of New Transparent Lipoplastic Cannula with diameter of 6-8mm for treatment of gynecomastia cases proved to show good results. In majority cases of true gynecomastia it was not necessary to make an additional incision in the areola area.
NTLC has the important advantage: when working with NTLC the plastic surgeon can easily “feel” the penetration of NTLC and control it by “checking hand” that is more safe and secure. ( Remember that some perforations of chest can occur).
Since 1996 any perforations or embolism cases did not occur.
Prof. JULIO FERREIRA, M.D.
Amande peel – new combined almond peeling in treatment of photoaging, dyschromies and acne
Mandelic acid is an alpha-hydroxy acid (AHA) which is derived from an extract of bitter almonds. It has excellent results and its application is useful in hyperpigmentation, acne and photoaged skin. It helps in pre and post laser resurfacing.
It has shown an important antiseptic and despigmentant properties.
Compared with glycolic acid produces less erithema and it can be used in Types I to V (Fitzpatrick) without hyperpigmentation post inflammatory.
It may be used at a peeling agent or combined with other exfoliants.
In this work I will develop the formula, combination with other agents, and its application in cases such as: aging, acne, melasma, lentigeness, photoaged skin, and the obtained results.
Color Peel: New treatment for Stretch Marks
In this work I will present this new method indicated to improve the stretch marks.
As we know the stretch marks are produced due the alteration in collagen and elastic fibers, determined by fibroblast alterations. With the components of the products we are going to activate the production of collagen improving the elasticity and tone of the skin, releasing the area of depressions.
This method is based in the use of two products that are going to be used in the consultancy office by trained hands .
I will show you the steps and the materials that we will need in each session so as the precautions to take into account with the use of the products.
Liposculpture
Since liposculpture appeared until today there have been great modifications in possibilities both for doctors in their own fields and for those results in patients needing changes in the shape of their bodies.
After many years working on liposculpture I named Mixed Lipoesculpture 1 as the combination of different techniques, and its possibility of adaptation for each case , using since 1986 traditional extraction with syringe or suction machines and since 1992 the incorporation of the ultrasonic systems. As cosmetic surgeon and having specialized in liposculpture technique I have been interested in the incorporation of new techniques and solid proof of the preservation of noble structures of the adipose tissue.
This method is the result of the evolution of surgical techniques, instrumentals and equipments and of the investigation and statistic works that promote best results and decrease complications.
I present in this work the scientific basis of the importance of this technique in modelling reshape, pre and post surgical recommendations to achieve better results and a demonstration of different body areas that have undergone Liposculpture and I describe those surgical steps used and the results obtained.
I use in all the cases the tumescent local anaesthesia and without needing neuroleptoanesthetics.
Filling techniques:
autollogous or heterollogous
We denominate Filling Autollogous Techniques to the technique that uses fat tissue to augment the volume of different body areas.
We use the same fat tissue extracted through Liposculpture Techniques. This tissue will be injected under skin surface. We can apply this technique in facial rejuvenation because it is possible to model the face in volume and to improve depressed areas and improve facial look.
The fat tissue has a filamentose collagen envelope as a soft structure that is in direct contact with the adiposite or adipose cell. With autocollagen technique it is possible to obtain soft structure that will be reinjected in chosen areas.
There will presented different heterollogous substances (natural and synthetics), deep of application and types of needles and materials to be used.
Excellence in cosmetic surgery
Excellence is the maximum efficiency and the maximum effectiveness in the objective chosen, and involves a superior quality. It is not possible to obtain perfection in an imperfect world, but the goal should be to come as close to excellence as possible in performing cosmetic surgery.
Cosmetic surgeons should strive for excellence in their treatment of and attitude toward patients as well as in their capabilities as surgeons. There must be excellence in a private ambulatory surgery suite with up-to-date equipment and well-prepared personnel. There must be a qualified working team with the philosophy of striving for the best of patient care.
I present in this work the definition of the concepts about Excellence and the golden rules to achieve excellence in Cosmetic Surgery.
Complications in liposculpture
This study is a compilation of the work performed at Dr. Julio A. Ferreira’s Surgery Consultancy during seventeen years of work on the liposculpture technique.
In body modelling techniques the doctor’s aim has always been to improve the patients’ appearance. Using modern surgical techniques excellent artistic results may be obtained leaving, in the majority of cases, no scars or visible signs.
Liposculpture, a microsurgery technique, enables us to extract the surplus fatty tissues in an artistic manner and, where necessary, to reuse this tissue in areas that may need be increased in volume or for correction of scars of depressed areas.
Correct use of this technique enables us to perform this work with a minimum degree of risk and with the possibility of post-surgical consequences.
The surgeon should foresee possible complications, many of which, as we see in the study, may be easily avoided.
I will present in this work different types of systemic and local complications, its prevention and treatment.
Golden number in medicine
and cosmetic surgery
I will present in this conference the importance of the consideration of the Divine Proportion or Golden Number to obtain better results in our field, looking for corporal and facial harmony.
As we know this proportion is considered like the most harmonic for human sensitivity and its correspond to the proportions presented by nature.
We can find this relation among the different measures of the face, body, tree branches, mineral crystals, between the minor and mayor axe of the egg, etc.
By this proportion we understood that our perception of beauty depends on measure harmony, and explains that despite of the relative of the concept of “beauty” we can consider that really exists something very near to “perfect beauty”.
I will show with this work how through the centuries, Egyptians, Greeks, Romanians, artists or philosophers trying to understand Universe beauty look for the canons of perfect proportions, measuring and converting in numbers the light equilibrium among parts and all.
We must point out that external and internal perfection create physical and psychic beauty, and humans submit before harmony between them.
Medicine and Cosmetic Surgery can use the knowledge of Proportion Divine to look for its results in shapes harmony, balance and equilibrium.
Gluteolipoplasty
Derived from latin word “culus” and according to the Real Spanish Academy denominate buttocks the area located between the end of the spine and the beginning of the thighs. It is the most important muscular mass of the human anatomy and its functions are as energy deposit, small pillow for sitting, perform the movements of standing up and keeping up, walking and crossing legs, as an important sexual stimulus, used in advertising, as a symbol of beauty and veneration. As we can noticed since long time ago the importance of the area has been shown in art pieces, paintings or statues from the greatest artists. They have different evolution in men or women. In women is rounded, its volume is bigger and it has more adipose tissue, in men its shape is square and it has more muscles. We must point out that the adipose tissue deposited in this region is rebel to local treatments. In this work I will present the develop of the gluteus modelation with the use of liposculpture using microcannulas and taking into account the aesthetic unit of “thigh-gluteus-banana fold, infragluteal fold”.
Introduction in the field of superficial,
medium and deep peelings
Up dating in dyschromias and combined treatmens
The quest for facial rejuvenation and the treatment of the dyschromias has been going on from time immemorial and is buried in obscurity. We do not know when chemical was first used as an exfoliative agent for facial rejuvenation, but the ancient Egyptians and Chinese used different formulas to be applied on the facial treatments. The treatments of the aging face requires an appreciation of skin aging, damage and dyschromias. I will present in this work different kind of substances and peelings (superficial, medium and deep peels) for the treatment of dyschromias and cutaneous aging. Excellent results have been obtained with different types of peelings. In this conference the details of each peel are going to be presented.
Liposculpture of dorsal area and arms
I will present the scheme and routine of the Liposculpture technique used in this non traditional areas.
It will be described marked areas, incisions and different positions of work., pre and post surgical preparation and complementary treatments used to improve the final result.
KIM, ING GON, M.D.
Correction of asymmetric calves
of poliomyelitis patients using calf augmentation and reduction
I have combined augmentation and reduction technique to the patient with poliomyelitis by augmentation of the affected poliomyelitic calf and reduction of the unaffected calf by partially shaving the hypertrophied gastrocnemius muscle thus, setting the patients physical demands as well as psychiatric and social conflicts.
From Jan. 1997 to Jan. 2000, 10 patients(M:F=2:8) with poliomyelitis underwent augmentation and reduction procedures and at least 1 year follow up was obtained. They had thin hypotrophic calf and unaffected leg was hypertrophic and muscular as a result of compensatory mechanism. Insertion of the soft silicon implants subfascially after carving and shaping up to fit the calf contour was performed on the affected calf and partial shaving of the hypertrophied gastrocnemius muscle was performed on unaffected calf.
Mean values of preoperatively measured calf circumference was affected 29.5cm, unaffected 36.3cm and postoperative measurement was 32.5cm and 33.2cm in order. Three months follow up revealed favorable outcome so that patients having symmetrical calves were tolerable to ordinary works. Also Cybex test was performed 1 year postoperatively for the muscle function and power evaluation which presented with favorable results without abnormal findings.
Correction of eyebrow hood
by endoscopically assisted forehead lift
The eyebrows have their own characteristic aesthetic levels and shapes. However, the majority of surgeons dealing with forehead lifts have put too much emphasis on forehead lift and too little on brow lift. Far too often, the eyebrows are elevated excessively in order to “clean up” the upper eyelids.
I performed the correction of eyebrow hood on 352 patients(M:F=85:267) by endoscopically assisted forehead lift from 1994 to 2000 and followed up from 6 months to 2 years. All forehead and brow lifts were performed subperiosteally using an endoscopic guide. Routine corrugator resections and procerus myotomies were performed and seperating the frontalis and orbicularis muscles were carried out. The suspension and fixation were done through 3 slanted cortical tunnels.As one of the results, when scalp was elevated 15mm, the brow was elevated about 4.1mm at the medial part, 5.3mm at the central part and 8.5mm at the lateral part. And I classified my cases into 4 categories according to portions of brow that are mainly corrected:Lift mainly on medial portion, Lift mainly on central portion, Lift mainly on lateral portion and Creation of an ideal arch. Also,I classified my unfavorable results into 4 groups:
• overcorrection,
• undercorrection,
• asymmetry
• no correction.
The endoscopically assisted forehead and brow lift using my method is considered to be best suitable for Asians as they tend to have conspicuous postoperative scars and rigid skin.
Endoscopically assisted subperiosteal face lift in asians for 7 years: problems and solutions
Asians are anatomically distinct from Caucasians and are characterized by a thick dermis, a Mongoloid slant of the palpebral fissure, a relatively prominent zygoma and mandible angle and a relatively flat nose. So, it was believed that the subperiosteal face lift was not suitable for Orientals. However, at my clinic, endoscopically assisted subperiosteal face lifts were performed from May of 1994 to October of 2000 on 352 patients: variable pitfalls, as well as satisfying results, were reported. Patient ages ranged from 29 to 66 years (mean age, 55.2 years), and follow-up ranged from 6 to 44 months (mean follow-up, 23 months). All forehead and brow lifts were performed using an endoscopic guide, and routine corrugator resections and procerus myotomies were performed. Three slanted cortical tunnels were made at the corresponding locations on the outer table of the calvarium, and 1-0 nylon suspension and fixation were performed. Most patients have been satisfied with their postoperative results, but unfavorable results and complications have been reported. There were accentuated Mongoloid slant, insufficient lift, exaggeration of sunken upper eyelids, intermittent headaches, itching sensations, and paresthesia on the scalp. The unfavorable results occurred in the patients who had previously undergone blepharoplasty and in those who had a history of foreign body injections into the face, fatty and thick faces, sunken upper eyelids, Mongoloid slants, and asymmetric facial expressions. Through understanding the anatomic characteristics of the Asians face (i.e., thick dermis, Mongoloid slant of palpebral fissure, prominent zygoma and mandible angle, and flat nose), satisfying results were achieved by appropriate application of the modified procedures.
Experience of Transumbilical Breast Augumentation For 10 years: Modified Method of Mine
The transumbilical breast augmentation(TUBA) has been popular and proven safe and effective. This technique has several advantages over other methods of breast augmentation: Short operation time (less than 30 min.), Unconspicuous operative scar, less postoperative pain, earlier recovery and motion, Low rate of complications, just to mention a few. Nevertheless, the method has often been the subject of a great variety of criticisms.
I have experienced 426 cases of transumbilical breast augmentation for 10 years from 1993 to 2002. At first, I was confronted with several problems but later found out that the problems are from poor and insufficient training without learning curve and inadequate handling of instruments. So, I modified this method to be suitable for each different patient. And I present this modified method of dissecting, adequate handling of instruments, making a pocket level, determining the size of pocket and volume of expansion using sizer, making a choice of final volume, making a beautiful shapes, and finally fixation method and postoperative care.
With my modified method, most difficulties with TUBA can be overcome and the best result can be achieved with few complications.
LINA PEDROZA, M.D.
Fat transplant to buttocks and legs for enhancement and deformities large volumes of fat transplant
Objective: This work was publicized in the book “Autologous fat transplantation”, edited by Melvin A Shiffman, January 2001
Marcel Dekker Inc) and considers the most challenged tips to harvest fat tissue and how to transplant a survival graft. At the present time we have ten years of experience obtaining a tridimentional body contouring of buttocks and legs for enhancement and deformities, the objective was presented because the author has the hyphotesis that a fat graft in cosmetic surgery, responds like other kind of tissue grafts and a result of the author’s search to find a way to avoid the most common applications of having a Buttock or Leg Augmentation done, with the introduction of a silicone prostheses. To find a surgical procedure that was complementary with liposuction, which could give not only the surgeon, but also the patient, less medical and surgical complications, better cosmetic results, more natural cosmetic results, longer lasting results, and an easier surgical technique. Also to find a small surgical procedure to deal with subtle body irregularities that do not justify a big surgical procedure.
Findings: The results are permanent, the recovery faster, no major complications were found and with the fat graft over the Gluteus or over the legs, the patient may have a chance of one single surgery to obtain his desires in body contouring.
Conclusions: This study shows more benefits for Liposuction than the ones made just only by suctioning the Fat Cells. Fat Grafting is a safe procedure and has not only cosmetic results but also Reconstructing for Midfacial Athrophy, Polio Sequelas, and other Desfigurating sindromes where you find Muscular Athrophies or any subcutaneous deformities.
A more effective and conservative
abdominoplasty personal technique - 10 cases report
Objective: Searching for a new technique, a better recovery, an easier recovery, a surgical procedure that will give the patient a less morbid surgery and a better cosmetic result, brought us to find what could be, thanks to modern Lipo-suction the Abdominal Plasty of the XXI Century.
Data collections: Data sources come from a review and also the practice of traditional Abdominal Plasties published in Plastic & Reconstructive Surgery books. Sources come also from the experience of having practiced 2200 Liposculptures from September 1991 to April 2001.
Findings: As Liposuction becomes a more and more popular procedure, we, as others, have noticed that as more Liposuction is done, less need of skin resection of the abdomen is necessary. Only few cases with very specific indications need removal of skin and those few cases are treated specifically with removal of dermis and epidermis after Liposuction of the abdomen, consisting in removing the excess skin and reacommodating the umbilicus to the new flap; which is an advancement flap.
Iindications: The classification for a new abdominoplasty is: patient in standing position, pendulous skin abdomen and stretch marks. For those patients with a pendulous abdomen in standing position without stretch marks, we prefer to perform liposuction.
Conclusions: Removing only the skin, permits an easier and faster recovery of the patient complications with traditional Abdominalplasties, as excessive bleeding, hematomas, seromas, loss of sensitivity, numness and infection, those disappear with this new safest procedure.
Ultrasonic liposuction- how to do it a study with electronic microscopy to show the efect of ultrasound in fat tissue and fat cells
Objective: Understanding the physic principles of the ultrasound, makes the surgeon be able to use safely the machine in Liposculpture. The experience of others show us cases of burned tissues, cavities, seromas, as complications during liposuction. Knowing what ultrasound is, makes the procedure easy and safer. A serious observation at the electronic microscopy showed us that while we perform internal assisteal liposuction with ultrasound we are obtaining separation of fat cells. The use of ultrasound which is one of the most advanced technologies in medicine permits the surgeon to perform one of the safest procedures in cosmetic surgery, as it is liposuction. The appropiate understanding of ultrasound, the mechanics of action and its effects against fat cells will give every patient a faster recovery, less bleeding, less swelling.
We will be able even to harvest fat cells to be transplanted and grafted over the entire body without disrupting the fat cells membrane.
The ample use of ultrasound in medicine throughout the Ecography- the Magnetic Resonance and the Lithotrity will permit to acknowledge its use in liposulpture.
Silicone prosthesis
a life saving device - 1 case report
Five years ago I had the opportunity to operate a female patient 34 years old, looking for an Augmentation Mammoplasty and a Liposculpture. We performed an Abdominoplasty, Liposculpture and an Axillary approach for Augmentation Mammoplasty. Normal post-op follow-ups were performed for 3 months, and I never saw the patient again. After four years of operation, I received a telephone call from an Emergency Room at a local hospital. I was told that my patient had suffered a life attempt and after a gun shot, the lady had a gun projectile located over the left chest, probably inside a silicone breast implant.
First aid measures after chest X rays were taken and the patient left the hospital two days after her arrival.
Four months after the life attempt, she came back to my office and we found that the gun projectile entered by the lateral face of her left arm, left her body by the inner face of it and entered again through the skin of the lateral pole of her left breast.
Thanks to the presence of a silicone gel filled breast implant, the gun projectile lost velocity and stopped just interiorly to the implant, broke all the implant, and stopped at the level of the fifth rib covered all by silicone gel.
The patient did not suffered any body damage, thanks to the presence of a silicone gel breast implant.
Breast silicone implants, properly used, do not cause harm to the humans health, but can also be a life saving devices.
Endoscopic breast augmentation
axillary approach
The Axillary approach for the Augmentation Mammoplasty, gives an excellent opportunity for the patient to have a surgical procedure that does not leave any scars over the skin of the Breast. It is also the ideal approach for endoscopic breast augmentation
For patients with: (A) Hypoplasia of the Breast tissue, permits the placement of the prosthesis below the Major Pectoralis Muscle using a wide tissue to hidden the implant. It also permits after surgery to take Mammograms visualizing a free Breast tissue which is safe to diagnosis any Pre-malignant or Malignant Pathology of the Breast, and isolating the gland to contact with any strange material.
The approach is the most convenient for the patient, not only Hypoplasic, but also for those patients with: (B) Grade I ptosis with an empty or hypotrophic Breast.
In case (B) the Augmentation Mammoplasty gives two kind of enhancements: (1) Fuller and young appearing breast (2) Pexia of the ptotic grade I Breast without producing any scars over the skin.
Reduction mammoplasty - short scars
We want to present three techniques that help the patient who is looking for a Pexy or a Mammary Reduction, that give them the opportunity to have Short Scars over the Breast Skin.
The first one is the “Daniel Marchac” technique, which resultant scar is an Inverted T where the horizontal line which is covered by the Mammary fold no longer tan 7 cms., versus 20 cms to 28 cms with the traditional reduction Mammoplasties.
The second one using a different movement of the Breast tissue is the “Howard” technique, useful as the last technique in Reductions and Pexies, gives also a little short scar with the inverted T that usually is no longer than 4 to 5 cms.
The third one which is in its full development is the periareolar approach, useful also for Reduction and Pexies for Moderate Hipertrophies and GII ptosis. The fourth technique belongs to “Ermetis de Longis” from Rome. It is an L shaped scar which uses an internal Bra of dermis to lift permanently the Mammary Gland and to avoid late post-op. Ptosis of the lower pole of the Gland.
We are trying to give the best results with less scars possible. Remember that the patient who is looking for an Aesthetic result, wants a surgery that will permit her be more beautiful without been overdressed or maybe using nothing over her skin. Short Scar techniques for Reduction or Pexies, should be the goal of the Third Millennium.
How to use your computer image
for cosmetic surgery
OBJECTIVE: Using your computer Image for Cosmetic Surgery of the Face or Body Contouring, is a helpful device for your records. It’s also a compromising detail which can be used against you if you show the patient a probability of result after surgery. The adequate use of the Computer Image may be helpful if you ask your patient to show you (Doctor) how the patient would expect his result from your surgery. FINDINGS: Asking your patient to show through your computer image how he desires to be after surgery, permits you to realize the normal or abnormal expectations of his patient’s new image. It permits the patient to exercise his mind and place over an image of himself, an requirement to his doctor. It also permits the physician to know specifically what kind of surgery must be done, in order to satisfy his patients desires. In Breast surgery women desire having previously: “A Breast Ptosis and a Glandular Athrophy a Full Breast and a lifted one”. The study shows you what your diagnosisplementary study, to support your surgery plan. It also helps to show to an uncomfortable patient, his results after surgery and how you were approximately to his desires. It also makes the patient how you can improve him but NOT to make him perfect.
MARINA LANDAU, M.D.
Long-term follow up results of patients
after deep chemical peel
Chemical peeling has been used for over half a century and has gained widespread use over the past decade. Overall, the best results are obtained by deep peeling using phenol-containing solutions.
We report our experience with a modified phenol-based formula (Exoderm peel) and a long-term (3-10 years) follow up results.
Between May 1998 and May 2000 102 patients were treated. All patients were females, with an average age of 54 years, ranging between 20 and 87 years. Most patients had Fitzpatrick skin type 2 or 3. 13 of the 102 females had previously undergone surgical face- and/or neck-lifting. 86 patients had multiple wrinkles in various areas of the face, pigmentary changes were found in 87 patients, acne scars with or without associated wrinkles in 19 patients, precancerous lesions like solar keratosis or superficial basal-cell carcinoma were seen in 5 females. Based on a scale of 1 (disappointment) to 10 (high degree of satisfaction), patients were asked to express their degree of satisfaction 12 to 20 weeks after the procedure.
We were also able to examine the results and the satisfaction level in 29 patients, being treated up to 10 years earlier.
Results: In general the procedure was well tolerated by the patients and the immediate recovery time was 8 days. No permanent complications, such as scars, have been observed. Homogenous lightening of the skin color, however, was frequently seen and was well accepted and tolerated by the patients. Transient complications included asymptomatic sinus tachycardia, pruritus, milia, accentuation of the nevi, demarcation line between the submandibular zone and the neck region, transient hyperpigmentation, rare persistent erythema, localized herpes simplex labialis eruption. There were no bacterial infections in any of the treated patient.
The average score was 8.6. In approximately 20% of patients, a local touch-up was performed.
A long term follow up demonstrated reasonable perseverance of the results with gradual deterioration after 5-8 years. All the patients maintained a better quality of the skin even 10 years after the peeling.
Chemical peelings and combination procedures – submental liposuction, botulinum toxin injections
and fillers
Chemical peelings have been used for over half a century and have gained popularity over the past decade. The results of the procedure depend on a multitude of factors, including the chemical used, the skin complex of a patient and a combination with additional esthetic modalities.
The topic of this presentation is to expose the possibilities of combination of chemical peels with other complimentary non surgical methods.
The major disadvantage of deep chemical peels is their inadequacy to be used on the neck skin. This skin, which is almost devoid of the follicular adnexae, has limited ability to regenerate following chemical peels. Therefore, following deep peel a fully rejuvenated facial skin is always in disagreement with the aged neck complexion. In recent years we have introduced medium depth peel or neck liposuction as a complimentary method for facial phenol-based peels.
Botulinum toxin A has been introduced recently to the esthetic use, mainly for muscular hyperactivity-induced wrinkles. A combination of chemical peels with Botulinum toxin A injections provides a synergistic improvement achieved by each technique separately.
Fillers are sometimes combined with chemical peels to further improve the results or as a beautification procedure.
We present our experience with the combination procedures.
MAURIZIO CECCARELLI, M.D., B.SC., F.PATH.
Treatment with aminoacidic-diet in
preparation to liposuction
The treatment of the localized adipose excesses needs a local intervention because the mobilization of these districts is conditioned from the sexual hormones.
The intervention more used is the liposuction.
A medical preparation to this intervention can be an amino acidic diet that improves the final result.
This treatment allows to decrease the fat from the zones of localized adiposity because it increases the values of the Growth hormon and it stops the construction of the fat: the unbalance between lipolisis /liposyntesis to the lipolisis. The effect of this medical preparation allows a diminution of volume of the adipose cells with an increase of the result, to parity of drawn out volume with the liposuction.
We present the scheme of the amino acidic treatment and the clinical results.
The medical treatment of the cutaneous aging:
biostimulation
The results of a surgical intervention effected on the skin depend both from the ability of the operator, and from the quality of the field on which he intervenes.
The treatment of biostimolazione represents an useful medical intervention to the optimisation of the functions of the skin.
The stimulus effected with this treatment determines an activation of the functions of the fibroblast with increase of the formation of collagen, of elastina and of jaluronico acid.
It achieves an improvement of the biological state of the useful skin to the optimisation of it both of the interventions of traction and of the cicatrizial answer.
The treatment is described in its technique and proposed in preparation to all the surgical interventions of the face.
The Life Quality Medical Program
The Physiological Medicine has a very important role in the modern society: to improve not just the duration of the life but his quality. From here the demand to study a program aimed to get the psychophysics comfort of the person.
This program is effected in the Life Quality Medical Centre, a mark of quality of which the medical centres can be decorated if they operate according to international scientific protocols within the prevention of the aging. Born from the scientific collaboration among the Ae.Phy.Med. Centre in Rome and the Spanish Society of Medicine and Aesthetical Surgery and the South American Academy of Cosmetic Surgery has been proposed in Italy, Spain, South America (Argentina and Brazil) and now widened to the rest of the world.
The mark is attributed to the medical centres that apply the protocols of the Physiological Medicine: medical jaw that also operates for the health of the patient with interventions of medicine and aesthetical surgery according to the concepts of the P.N.E.I. (psycho neuro endocrine immunology), that explains how the improvement of the aesthetical harmony helps to balance the nervous, endocrine and immune functions of the subject.
To learn the Life Quality Medical Program courses of formation are organized for the physicians.
MELVIN SHIFFMAN, M.D.
Complications of Facial Cosmetic Surgery
Cosmetic surgery of the face has a multitude of potential risks and complications. Many of these are associated with laser and chemical peels. The complications will be discussed with methods of prevention and treatment.
Autologous Fat Transfer
Filling defects can be accomplished by a variety of fillers. Autologous fat is an excellent and inexpensive means of accomplishing this. The technique is operator dependent and can be extremely successful if properly applied. The technique of fat transfer will be discussed with its possible risks and complications.
Mastopexy Technique
Mastopexy or breast lift is performed for significant ptosis. There are a variety of techniques and each has its own deficits. In order to get a significant lift for moderate or severe ptosis, the author uses a modified Aries-Pitanguy technique. The procedure will be described and possible complications discussed.
Complications of Abdominoplasty
The abdominoplasty procedure has a variety of risks and complications that should be discussed with the patient prior to surgery. Some of these complications will be described with a discussion on the cause and treatment of the complication. The smoker is a major contributor to postoperative skin necrosis and care must be taken that the patient stops smoking at least 2 weeks before and 2 weeks after surgery.
Complications of Breast Augmentation
The technique of breast augmentation appears to be relatively simple but the presence of a large prosthesis in the body is fraught with a variety of possible risks and complications. The surgeon should discuss these complications with the patient prior to surgery and discuss the different placement of incisions and the types of implants available. Anyone performing cosmetic surgery of the breast should know how to avoid and treat complications and some of these problems will be discussed.
MOHAMED M. GHOZ, M.D.-FCDS
Lasers in oral surgery
The advantages of laser soft tissue interaction and the application of the laser to treatment of mucosal lesions in the oral cavity has only been recently described in the oral and periodontal surgery literature.
Different modalities of lasers are used for different mucosal lesions in the field of dermatology that can be added to our strategic weapons fighting against a large scale of disorders whether congenital, inflammatory or tumorous in origin.
Indications, pre- and post-operative management, complications and case presentations for laser surgery in the oral cavity will be presented by slide and video demonstration.
NIKOLAY SERDEV, M.D., Ph.D.
Scarless brow lift using a “Serdev suture”
A special technique is described by the author for fixation of the brows to the frontal muscle. The technique is ambulatory, under local anesthesia. In the early postop period a limited swelling could appear. In our patients no swelling of the upper lid, no haematomas and seromas were observed. The operation is easy and makes patients feel comfortable after it. Mimics are not disturbed.
The operation is ambulatory. It belongs to the so called “weekend operations”. Patients stay at home for a day or two because of the swelling that is very limited and localized in the area of the operation. No incisions are made and no visible scars are left.
Chin augmentation using a “Serdev suture”
The aesthetic positioning of the chin is a part of the beautification process in the Aesthetic Cosmetic Surgery. Chin augmentation could be done by several types of surgery: bone surgery, implantations and injections etc.
The author is presenting his technique using a simple suture of the chin soft tissue, using it’s volume to give projection of the chin, or to correct deformities and to equalize left and right half of the face .
Definition: suturing of loose chin soft tissue to obtain volume, projection and straight profile
Anatomy approach: chin soft tissue:
Surgical approach: skin punctures to insert the needle and to make the suture
Surgical technique: skin punctures only, 1 or more sutures of the soft tissue
This method has some priorities:
• it is an ambulatory procedure,
• there is no dermal closure,
• no bandages are necessary,
• next day facial wash is possible
• immediate return to work is possible
Scarless brow lift using a “Serdev suture”
A special technique is described by the author for fixation of the brows to the frontal muscle. The technique is ambulatory, under local anesthesia. In the early postop period a limited swelling could appear. In our patients no swelling of the upper lid, no haematomas and seromas were observed. The operation is easy and makes patients feel comfortable after it. Mimics are not disturbed.
The operation is ambulatory. It belongs to the so called “weekend operations”. Patients stay at home for a day or two because of the swelling that is very limited and localized in the area of the operation. No incisions are made and no visible scars are left.
“Serdev suture” for scarless buttock lift
and ultrasonic liposculpture of the buttocks
The author presents a new technique for higher fixation of the buttock soft tissue to the gluteus maximus fascia without visible scars. The new instrumentation is presented. The procedure is ambulatory, under local anesthesia. The results are very satisfactory and pleasant especially for ladies. It elongates visually the legs. One and two year results are present.
The operation is usually combined with ultrasonic liposculpture of the buttocks that reduces the buttock volume and heaviness, in order to be lifted by suture after that.
To make the suture, the author uses the present punctures used for the ultrasonic liposculpture. There are no incisions and scars left. The procedure is ambulatory. Some pain is presented for one or two weeks in sitting position.
Columella sliding – a personal technique (+ video)
The aesthetic positioning of the tip of the nose is a part of the beautification process in the Aesthetic Cosmetic Surgery. Tip projection could be done by several types of surgery, described by several authors.
The author is presenting his technique using a simple excision of 3 triangles: one columellar, and two lateral in the soft tissue of the nostrils. The excision can include septal excision as well as excision of the cephalic parts of the major alar cartilages or the distal parts of the lateral nasal cartilages. The precise excision is made at once assuring a triple triangle of soft tissue scrap, leaving only the cutis in that region. Transfixion of the tip (columella to septum suture) follows. Depending to what we aim with the suture, we can slide the tip forwards or backwards, obtaining a change in its projection, or refine the tip, or correct deformities and equalize left and right volume excising different amount of tissue in the left and the right alar area.
This method has some priorities:
• it is a short ambulatory procedure with excellent results,
• no important bleeding can be observed,
• there is no post op swelling in the lower lids,
• no bandages are necessary,
• next day cleaning of the crusts and facial wash are obvious,
• immediate return to work is possible
Goretex string for lip augmentation
A technique is described by the author to project and augment the labial borders using GoreTex strings. The technique is ambulatory, under local anesthesia. We place 6.0 stitches to close the 1mm perforation points at the both ends of the lips. The operation is easy and makes patients feel comfortable after it. Mimics are not disturbed. Most of the patients are working and having social contacts after one or two days.
In the early postop period a limited swelling could appear. In our patients no haematomas and seromas were observed. One infection due to the special profession of the lady was observed 6 days after surgery. The string was removed and the lip healed in 4 days.
The operation It belongs to the so called “weekend operations”. Patients stay at home for a day or two. No visible scars are left.
Minimum trauma beautification rhinoplasty (videos)
The aesthetic proportions of the nose are a basic part of the total face beautification process in the Aesthetic Cosmetic Surgery. Hump removal, shortening of the length of the nose, tip projection, alar refinement are the most asked changes in the ethnic Balkan society. Surgeons use several different methods for these procedures in their combinations.
The author is presenting his own techniques. The whole operation does not last longer than 10 to 15 min in order to be atraumatic and bloodless. Touch of cartilages should not be repeated. Triple triangle excision of the distal part of the nose pyramid, medial osteotomies, lateral osteotomies or digital fractures, as well as final sutures and transfixions have been done via endonasal contralateral approach. Repetitions of any of these precise gestures are usually followed by progressive bleeding and have to be avoided.
Depending on the specific personal face, the aim of beautification rhinoplasty is to obtain:
• Golden dividing of the face length in equal three parts. The nose is the medial third,
• 90degrees angle of the tip profile and 110 degrees of the naso-labial angle,
• 30 degrees of the nostrils at the tip,
• 30 degrees angle of the lateral nasal pyramidal structure to the septal line.
Author’s operation techniques give excellent results and have some priorities:
• it is a short atraumatic ambulatory procedure, preferred by patients,
• bleeding is insignificant,
• atraumatic touch to nasal structures saves the normal vascularisation especially of important nasal cartilages,
• a sticky tape (Micropore) is used for 3 days to minimise the haematoma and the swelling.
• there is insignificant bruising or swelling in the lower lids,
• next day cleaning of the crusts and facial wash are obvious,
• after removal of the tape on the 3rd day, make up is possible to cover yellow-green rests of bruising,
• return to work is possible after 3 to 5 days
Temporal, supra-temporal, medial and lower smas lift
A special technique is described by the author for lifting and higher fixation of the temporal, supra-temporal, para-zygomatic and lower SMAS including platysma muscle to the underlying temporal fascia and to the mastoid. The technique is ambulatory, under local anesthesia. In the early post op period a limited swelling could appear. In our patients bruising, seromas, swelling of the lower lid, were observed in a very low percentage. One unilateral hematoma occurred in a patient with a lower SMAS lift. In a case of upper lid ptosis during the operation, an immediate release of the suture was performed and the result was an immediate improvement. A new suture was placed with success.
The operation is easy and makes patients feel comfortable after it. Mimics are not disturbed even in the early post op period.
These operations are ambulatory. They belong to the so called “weekend operations”. Patients stay at home for a day or two, because of a very limited swelling, localized in the areas of the operations. No visible scars are left.
Implantation ot biocompatible hair “Biofibre”
Serdev N., M.D., Mironov E., M.D.
In this presentation we offer you our two-years experience with implantation of biocompatible artificial hair “Biofibre” (Medicap, Italy) in 20 patients. The method is an excellent alternative in initial and advanced hair loss (Alopecia androgenica and areata), and the only possibility in failures after autogenous transplantation as well as in cases of bum, trauma and jatrogenic scars in the capillitium. Preoperative preparations of the seborrheic skin are required. The immediate result allows the patient to leave the clinic with the desired hair length and style. Post implantation hair care is relatively easy, done mostly by the patient himself and includes obligatory regular check-up. The average loss of biofibre implants is insignificant, furthermore the method permits additional implantation for thickening. In two cases of infection, we extracted the amount of affected biofibres, that was followed by healing of the skin and preservation of the rest of implants.
Fotoepilation with “Spa touch” –
3 years experience
Serdev. N., M.D., Miladinova E., M.D., Polomska D., M.D.,
HaJiolova R., M.D.
The authors share their experience in usage of “Spa touch” system for progressive permanent epilation. Spa touch is much more efficient, much faster and much less expensive then any previous known methods. It is based on a visible pulse light emission , absorbable for melanocytes in the hair bulb. The method is painless and easy to work for the operator.
NGUYEN XUAN AI, M.D., FEACS., AACS., ASLSS.
Liposuction assisted face lift
Purpose: The areas where excess fat may deposited in the face are parotid, preantral (lateral to the nasolabial groove) malar and jowl. The nasolabial groove is resistant to ccorrection by face lift or soft tissue fillers. It is thought that this groove forms through repeated contraction of the levator labil superiors, levator agulioris and zygomaticus major, which insert the perioral rregion contraction of these muscles displaces the fat lateral to the developing fold superficially, further accentuating fold. The use of liposuctioo in conjunction with face lift allow for smooth defating with decreased bleeding and less risk of damaging nerves. To upgrade results in face lift operation we sometimes combine this with liposuction of the face (jowl) and neck.
Technique: After infiltration tumescent solution as local an esthetic, the suction needle or curve canula a point just beneath the ear lobe to remove buccal fat and fat in the neck in less than 5 minutes,, the entire fat in the check and the neck can be treated.
Nowadays, the chin fat in best remove by liposuction to improve Chin-Neck profile. After liposuction of the check and the neck, we use canula for liposuction to dissect and separate the skin and fat tissue, then remove the excessive skin to correct of the fundamental manifestation of aging in the face and neck, cutaneo-musculo-aponeurotic ptosis in face lift procedure.
Conclusion:Under local an aesthetic by tumescent solution, liposuction assisted face lift is a safe procedure. It is less traumatic with less bruising.
In five years, we had performed 500 cases of liposuction in our Clinic. Excess, facial fat was removed and muscles was tightened depending on the extend of surgery. swelling and bruising decreased in some days after operation. These procedures demonstrated liposuction assisted face lift permits much better results and obtains a more harmonious and youthful face. Liposuction is a great complement to esthetic surgery in creating the ultimate in facial esthetic treatmentInternational Board of Cosmetic Surgery
How to create dimple?
Introduction: A dimple in formed in one or both cheeks in some people naturally when they smile. It presents an area of muscle weakness with a consequent concave dimpling of skin (a depression on the cheek due to the adherent of the skin and muscle). Dimples are considered a sign of beauty of many young girls in Eastern Asian Countries.
Making out the dimples: On the face, a vertical line is draw from the lateral angle of the eye down-ward to the middle ear tragus . The point of insertion marked as the side of the dimple.
Technique: Dimple is a depression on the cheek when we smile due to the adherent ot the skin and the muscle in the cheek.
To perform dimple the surgeon has to dissect and separate the skin and the cheek muscle by different techniques under local anesthesia, then anchor the skin and the cheek muscle by a suture with catgut 2.0. This suture is left in place to dissolve.
Conclusion: Every year, in Asia Aesthetic Surgery Clinic we had performed 600 cases of dimples ,under local anesthetic with best result We will demonstrate our technique by video presentation.
Facial rejuvenation surgery by liposuction
Purpose: Facial aging presents the manifestation of prominent nasolabial folds, jowls and double chin.
On the face, the jowl fat responds very favorably to liposuction. With aging, the facial muscles atrophy and the cheeks sag. creating the jowl deformity. This consists mainly of buccal fat which can be easily suctioned out to flatten and obliterate the deformity. Sometime, younger patients request the flattening of this area of the check due to extensive fat disposition.
The chin fat, nowadays, is best removed by liposuction to improve the chin neck profile.
Technique: After infiltration tumescent solution as local an aesthetic:
• 8.4% sodium bicarbonate 4ml
• 1 % lidocaine in 1:100,000 epinephrirne 40ml
• Physiologic Saline Solution120%
• 0.25% lidocaine with 1:400,000 epinephrine 164ml
The suction needle or curved canula will be introduced at a point just beneath the ear lobe to remove buccal fat and fat in the neck in less than 5 minutes, the entire fat in the cheek and the neck can be treated.
During ten years we had used liposuction as a very useful adjunct in facial rejuvenation surgery. We will illustrate cases where liposuction was used:
• Alone for lipodystrophy of lower face and neck.
• Use of liposuction in treating submental lipodystrophy,
• Use of liposuction in culturing a face with generalized fullness.
• Liposuction in conjunction with a chin implant.
• Liposuction assisted facelift.
• Liposuction as an adjunct in facelift surgery for correction of the heavy and difficult neck problems.
• Use of liposuction in dealing with deep nasolabial folds.
Conclusion: Under local an aesthetic by tumescent solution, liposuction of the face and neck without facelift or assisted facelift is a very useful adjunct in facial rejuvenation surgery.
It is a safe procedure and less traumatic with less bruising.
In five years, we had performed 500 cases of liposuction for facial rejuvenation without complication.
Excess facial fat was removed, swelling and bruising decreased w some days after operation.
Liposuction is a great complement to esthetic surgery in creating the ultimate in facial esthetic treatment.
PLAMEN NEDEV, M.D., MARIO MILKOV, M.D.
External and endonasal approach in septorhinoplasty - comparative evaluation
The purpose of our research was to compare the traditional endonasal ( subcutaneous) approach with the external approach in rhinoseptoplasty and to evaluate there advantages and disadvantages.
The object of our research were 97 patients operated by us using rhinoseptoplasty. External approach was applied in 45,4% of cases and endonasal approach in 54,6%.
On the basis of our surgical experience we reached the following conclusions:
• Septorhinoplasty with external approach is easier to perform
• External approach is reccomended on “difficult noses” -with serious traumatic deformities and reoperations
• Rhinoseptoplasty with endonasal approach is still important and is a routine method for correction of the external nose.
SHIGEMI SAKAI, M.D., KAZUMASA ANDO, M.D.
New approach for a correcting of
intractable inverted nipple (Sakai methods)
Some severe cases of the inverted nipple cannot be corrected by simple method, especially if the nipple never comes up from the areolar level by manipulation. For these cases we contrive a new method.
To avoid the recurrence of nipple retraction and to keep the
lactiferous function, we perform a surgical procedure in which an incision made on the nipple is deepened vertically to free the lactiferous ducts from the contracted tissues surrounding them. After extension or resection of the restricting tissues, the nipple is raised. Then, protrusion of the nipple is produced by gathering it with inside sutures, which are fastened without damaging any of the lactiferous ducts. Because the narrowed base of the nipple is still loose at this stage, a z-plasty is added to each end of the incision.
A situation which is not amenable to treatment by method I, method II should be used. In method II, the nipple is raised as described above and fixed with dermal flaps that form a structure like a suspension bridge at the base of the nipple which were used z-plasty of method.
This procedure preserves the breast-feeding function and prevents the recurrence of inversion.
SUSANNA A. NIKITINA, M.D.
Advantages of electrocoagulation resurfacing,
24 years experience
Much is said about different techniques in Facial Rejuvenation. Among many other methods of Resurfacing Electrocoagulation Resurfacing has been wildly used in Leningrad since 1932. More than 60 years of experience on tens of thousands of patients has shown that it is an excellent method for treating the most problematic cases such as deep wrinkles and deep atrophic scars while the others methods such as laser resurfacing, dermabrasion, or different peelings are helpless.
The results are evaluated from 24 years of my experience performing about 11000 procedures of Electrocoagulation Resurfacing. No patients had any serious complications such as scarring or infection. There were five patients with reactivation of herpes labialis after resurfacing upper lips and occasional patients with temporary hyperpigmentation.. Electrocoagulation Resurfacing can be wildly used in Dermatological surgery.
Particular advantages include small size of equipment — which makes it portable and easy used at any place — and relatively low cost.
Prof. TETSUO SHU, M.D.
The techniques of breast augmentation procedures
Purpose: There are various types of implants utilized in breast augmentation, the author prefers to perform axillary approach with infra-mammary insertion, and it is considered the most suitable for the Orientals. How to prevent the problems attributed to breast implants like capsular contracture, malposition etc. will be described. The author has advocated the use of autologous fat transplantation for breast augmentation to provide a more acceptable alternative since 1983.
Materials & Methods: There are 5 methods in performing Augmentation Mammoplasty: (1) Trans-axillary insertion of implant in the subglandular area; (2) Trans-axillary insertion of implant in the submuscular area; (3) Trans-axillary insertion of implant in the subglandular area with autologous fat transplantation;(4) Trans-axillary insertion of implant in the submuscular area with autologous fat transplantation; and (5) use of Autologous fat transplantation alone.
Results: We have performed at least 1300 cases of Augmentation Mammoplasty by using implants and Lipo-transplantation since 1983. The percentage of post-operative capsular contracture in this series of cases is around 10% for breast augmentation using implants. With long-term clinical experiences backed by numerous histological studies and routine radiographic examinations, autologous fat transplantation procedure has proven to be a useful method of breast augmentation.
Summary: Capsular contracture in breast implants is greatly influenced by the surgical technique, hematoma formation, and the time and period of massage. The results of fat transplants on the other hand are dependent on the quality of harvested fat and the basic condition of the breast of the patient, as well as, the experience and techniques of the surgeon. The average volume that remains after fat transplantation in our clinic is about 50%, in which case a second or a third procedure may be necessary to achieve a more desirable final outcome. Employing the proper techniques and handling of fat tissues may prevent post-operative complications, such as necrosis, macro-cyst formation and calcification.
TOMA T. MUGEA, M.D., Ph.D.
TTM® chart and breast aesthetic surgery
According to TTM® chart, we studied 380 female subjects, with normal chest and no bone or spine deformities, aged 15 - 65 yrs. At the end, all collected data was introduced in a computer program, designed to compare different dimensions and to establish connections and significant parameters between them. All subjects are Caucasians, with a wide ethnic mixture.
Nipple position related to the “inverted triangles” show that, in normal cases there is a downward gliding of this, on the external margins of the triangles, starting from a high position in young teenager.
The outcome of the statistical analysis, in the aesthetic breast, shows a strong connection between noted dimensions and the Ni-Infra distance. This is why we call Ni-Infra, the “K” number, or the key of the breast. “K” number can be found as the media between k1, k2 and k3 numbers, obtained dividing Mn-Pb distance by 8 (k1), Ac-Ac at 6 (k2) and Sp-Sp by 4 (k3). These numbers (8, 6 and 4), result from our computer analysis and show the relation between breast and trunk dimensions. Because there are different constitutional types of women, it is necessary to have a media between k1, k2 and k3, to have a closer relation with that specific subject!
Concerning the relations between K and other distances we find:
• K is similar to Ni-Infra
• 2 x K – 10% = breast diameter
• 3 x K = inframammary fold length,
• 3 x K = breast circumference,
• 3 x K = Ideal Triangle (Mn - Ni, Ni – Ni)
• Infra length : 2 = Ax-Ni
• Infra length : 2 = St-Ni
• Infra length : 2 – 10% = Breast Projection (Ni - Ant. Axilary Line)
• Cocktail view = Breast projection : 3
With TTM® chart, including precise measurements of the trunk and the breast, our work is much easyer. This chart is wery useful in documentation of preoperative and postoperative situation in breast surgery. It allow us to make an accurate planing of the operation, taking account that we can change everything on the breast, except the length of the inframamary fold. In breast reduction this is the key to estimate the future length of Mn-Ni and Ni-Infra distances, to obtain at the end an aesthetic breast for that specific case.
Subfascial breast implant -
a new concept for breast augmentation
The development of the subfascial technique brings a new concept in shaping the breast for a more natural appearance. Subfascial disection plane for breast augmentation has been described by R.M.Graf in 2000. From march 2002 we used this technique in our clinique for 42 breast augmentation, with excellent results. In October 2002, at the workshop held before the IV th International Congress of Romanian Aesthetic Surgery Society, we had a videopresentation with this technique, for Mentor implants selected by TTM chart. The main reason for using the implant in the subfascial space of pectoralis muscle is that allows soft-tissue coverage of the superior pole of the implant, without the downside of rising the muscle. All the disadvantages of retromuscular placement are avoided but the good shape, and natural looking are better than in the subglandular plasement. We reccomand these technique for its logique, simplicity and results.
Non fatty areas - ideal donor sites in autologous
fat transplantation
In practice we find that many patients are looking for a liposuction, and ask the surgeon to do in the same time a fat transplant, just “to take two rabits with one shot”. So, usually transplanted fat came from fatty areas as hipogastric area, latheral thie, flanks and buttoks, the surgeon sinking also that in this area thereis a low vascularisation and the adipocites are well trained to survive.
Clinically, we discovered that the fatty tissue in the epigastric area has better take as a fat transplant than other donor sites. To prove our clinical observations, in more than 30 cases, we performed histological studies in the same patient, harvesting the fat from epigastric, hipogastric, flanks, latherothoracic and inner knee areas.
The fat was harvested under local anesthesia with Klein solution by low power aspiration technique, using 2 mm cannula and a small syringe. We do not wash the fat before injection and so we have a minimum fat manipulation.
Histologicaly we found:
• the fat tissue from the epigastric area has a well organized lobular structure, equal cell dimensions and a small vascular network
• in the flanks, the fat tissue presents large and medium size adipocytes and rare connective tissue and vascular network
• latherothoracic areas have mediumsize adipocytes, well defined reticulinic fibers, and a poorly represented vascular nerwork
• hipogastric areas present different cell dimensions with irregular contour (mainly samll cells), and a strong conective tissue and vascular network
• inner kne areas have dominant medium size adiposytes and a moderate hiperplasia of reticuluic fibers.
According to our findings in fatty areas we have in fact adipocolagen, and if we wash and centrifuge the fragments extracted by liposuction, the result will be a high concentration of colagen, suitable for small volumes corections.
The fat harvested from non fatty areas, contain mainly adipocites and is suitable for fat transplant.
Using this technique, we have good experience with the fat transplant in more than two years with second “touch” procedure in only 10% of cases.
Breast reduction with short inverted T scar -
our technique
In breast aesthetic surgery there are many techniques and procedures, some of them with more or less specific indicationes. We must understand that there is not a perfect procedure suitable for all situations. In our current practice we use the following techniques:
• Roobin technique for gigantomastia
• TTM technique for medium breast reduction and mastopexia
• Bennely technique in small skin excision for mastopexia.
Our technique is based on an inferior pedicle. The point is to minimise the horisontal line and to perform an accurate skin and tissue excision.
• Areola diameter 5-7 cm, suitable to the breast volume
• Ni - infra distance = Inframammary fold length : 3
• MB and LC distances = Inframammary fold length : 2 (AM and AL distances)
• ATB and ATC triangles are equal and isoscele, designed to minimise the dog ear appearance
• TAT represent the base of the flap, equal with the length of the horisontal line.
The right assesment of breast problem with TTM chart and the accurate planning of the operation allow us to obtain very good predictable results in breast surgery.
TOMA T. MUGEA, M.D., Ph.D.
TTM® chart and breast aesthetic surgery
According to TTM® chart, we studied 380 female subjects, with normal chest and no bone or spine deformities, aged 15 - 65 yrs. At the end, all collected data was introduced in a computer program, designed to compare different dimensions and to establish connections and significant parameters between them. All subjects are Caucasians, with a wide ethnic mixture.
Nipple position related to the “inverted triangles” show that, in normal cases there is a downward gliding of this, on the external margins of the triangles, starting from a high position in young teenager.
The outcome of the statistical analysis, in the aesthetic breast, shows a strong connection between noted dimensions and the Ni-Infra distance. This is why we call Ni-Infra, the “K” number, or the key of the breast. “K” number can be found as the media between k1, k2 and k3 numbers, obtained dividing Mn-Pb distance by 8 (k1), Ac-Ac at 6 (k2) and Sp-Sp by 4 (k3). These numbers (8, 6 and 4), result from our computer analysis and show the relation between breast and trunk dimensions. Because there are different constitutional types of women, it is necessary to have a media between k1, k2 and k3, to have a closer relation with that specific subject!
Concerning the relations between K and other distances we find:
• K is similar to Ni-Infra
• 2 x K – 10% = breast diameter
• 3 x K = inframammary fold length,
• 3 x K = breast circumference,
• 3 x K = Ideal Triangle (Mn - Ni, Ni – Ni)
• Infra length : 2 = Ax-Ni
• Infra length : 2 = St-Ni
• Infra length : 2 – 10% = Breast Projection (Ni - Ant. Axilary Line)
• Cocktail view = Breast projection : 3
With TTM® chart, including precise measurements of the trunk and the breast, our work is much easyer. This chart is wery useful in documentation of preoperative and postoperative situation in breast surgery. It allow us to make an accurate planing of the operation, taking account that we can change everything on the breast, except the length of the inframamary fold. In breast reduction this is the key to estimate the future length of Mn-Ni and Ni-Infra distances, to obtain at the end an aesthetic breast for that specific case.
Subfascial breast implant -
a new concept for breast augmentation
The development of the subfascial technique brings a new concept in shaping the breast for a more natural appearance. Subfascial disection plane for breast augmentation has been described by R.M.Graf in 2000. From march 2002 we used this technique in our clinique for 42 breast augmentation, with excellent results. In October 2002, at the workshop held before the IV th International Congress of Romanian Aesthetic Surgery Society, we had a videopresentation with this technique, for Mentor implants selected by TTM chart. The main reason for using the implant in the subfascial space of pectoralis muscle is that allows soft-tissue coverage of the superior pole of the implant, without the downside of rising the muscle. All the disadvantages of retromuscular placement are avoided but the good shape, and natural looking are better than in the subglandular plasement. We reccomand these technique for its logique, simplicity and results.
Non fatty areas - ideal donor sites in autologous
fat transplantation
In practice we find that many patients are looking for a liposuction, and ask the surgeon to do in the same time a fat transplant, just “to take two rabits with one shot”. So, usually transplanted fat came from fatty areas as hipogastric area, latheral thie, flanks and buttoks, the surgeon sinking also that in this area thereis a low vascularisation and the adipocites are well trained to survive.
Clinically, we discovered that the fatty tissue in the epigastric area has better take as a fat transplant than other donor sites. To prove our clinical observations, in more than 30 cases, we performed histological studies in the same patient, harvesting the fat from epigastric, hipogastric, flanks, latherothoracic and inner knee areas.
The fat was harvested under local anesthesia with Klein solution by low power aspiration technique, using 2 mm cannula and a small syringe. We do not wash the fat before injection and so we have a minimum fat manipulation.
Histologicaly we found:
• the fat tissue from the epigastric area has a well organized lobular structure, equal cell dimensions and a small vascular network
• in the flanks, the fat tissue presents large and medium size adipocytes and rare connective tissue and vascular network
• latherothoracic areas have mediumsize adipocytes, well defined reticulinic fibers, and a poorly represented vascular nerwork
• hipogastric areas present different cell dimensions with irregular contour (mainly samll cells), and a strong conective tissue and vascular network
• inner kne areas have dominant medium size adiposytes and a moderate hiperplasia of reticuluic fibers.
According to our findings in fatty areas we have in fact adipocolagen, and if we wash and centrifuge the fragments extracted by liposuction, the result will be a high concentration of colagen, suitable for small volumes corections.
The fat harvested from non fatty areas, contain mainly adipocites and is suitable for fat transplant.
Using this technique, we have good experience with the fat transplant in more than two years with second “touch” procedure in only 10% of cases.
Breast reduction with short inverted T scar -
our technique
In breast aesthetic surgery there are many techniques and procedures, some of them with more or less specific indicationes. We must understand that there is not a perfect procedure suitable for all situations. In our current practice we use the following techniques:
• Roobin technique for gigantomastia
• TTM technique for medium breast reduction and mastopexia
• Bennely technique in small skin excision for mastopexia.
Our technique is based on an inferior pedicle. The point is to minimise the horisontal line and to perform an accurate skin and tissue excision.
• Areola diameter 5-7 cm, suitable to the breast volume
• Ni - infra distance = Inframammary fold length : 3
• MB and LC distances = Inframammary fold length : 2 (AM and AL distances)
• ATB and ATC triangles are equal and isoscele, designed to minimise the dog ear appearance
• TAT represent the base of the flap, equal with the length of the horisontal line.
The right assesment of breast problem with TTM chart and the accurate planning of the operation allow us to obtain very good predictable results in breast surgery.
VLADIMIR DRAGAN, M.D.
A Short Height is as Social-Conditioned Indication
for Orthopedic Correction of the Length
of Lower Limbs
Nowadays there is an uncertainty in a choice of indications to the surgical height correction of healthy people. Absence of direct medical indications to operative intervention in patients of short height who have no disorders of extremities’ functions, makes difficult to treat the diagnosis. Definition of such operations as only cosmetic and carried on the patient initiative, unwarrantedly narrows the understanding of the given problem and infringe on interests of the most part of a society. The task of the given research is an attempt to show on the example of the interrogation of 30 patients, who had the height correction by internal lengthening method, that indications to many surgical operations which change human appearance are socially-caused and demand more detailed discussion and precise definition.
WANG, ZHIJUN, M.D.
The technique of autologous fat transplantation for face and breasts
Fat transplantation for face and breast is one of the most advanced cosmetic procedures nowadays, the reason is that the materials has not an odd body, therefore, there has no rejection to our body.
The aspirated granular fat tissues by liposuction are reused after washing out the blood and has carefully selected before injecting to the face and to the breast. In order to prevent the reduction of the size in the post-transplanted fat cells, it is necessary to select the fat tissue carefully and treat the aspirated fat strictly, so as the infection and the necrosis could be completely inhibited. The size of the fat cell should be decreased, and most of the size of fat cells will be fixed within 2-3 months, finally, the volume of the fat tissue will be kept between 50%-80% that is depending on the quality of fat cells.
Abdomen, hips and thighs is usually selected as the donor site for autologous fat transplantation.
For the patient who is too skinny, and difficult too harvest the enough fat to achieve the satisfaction in one procedure, may be repeated fat transplantation will be considered.
The instrument for liposuction will advise using a small diameter cannula, and in order to decrease the injury to the fat cells, a low negative pressure instrument is also advised.
The harvested granular fat tissue is irrigated repeatedly by using the normal saline, and the treated fat tissue should not expose too long in the air.
While injecting the fat tissue to the face and breast, we are using a syringe connected with a small cannula, the fat should be injected evenly like a noodle but not like a lake.
The massage right after the fat injection is very important to improve the union of injected fat with facial and breast tissues.
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