Transcutaneous Lower Eyelid Blepharoplasty With Fat Excision

OBJECTIVE

To prove through our experience that the use of transcutaneous lower eyelid blepharoplasty results in negligible incidence of unacceptable scar and eyelid malposition and that the overall lower eyelid contour is acceptable. A detailed overview of the lower eyelid anatomy and a discussion of the "aging" eyelid are further discussed.

DESIGN

Retrospective, observational study. The study population comprised 50 patients (100 eyes) seen at the McCollough Plastic Surgery Clinic, Gulf Shores, Ala, between 2002 and 2003 (45 women and 5 men), who had undergone transcutaneous lower eyelid blepharoplasty with fat excision. Lower eyelid blepharoplasty was performed by the senior surgeon (E.G.M.), and the surgical technique was identical in all cases. The patients were followed up for a minimum of 6 months and a maximum of 2 years. Patients were selected on the basis of return visits to record the findings, documented by consecutive digital photos. By comparing standard blepharoplasty digital views, the patients were assessed by 3 independent unbiased plastic surgeons. This study was performed in a private practice setting. The main outcome measure was mean score for the presence of unacceptable scarring, the presence of lower eyelid malposition, and the overall appearance of the eyelid after transcutaneous lower eyelid blepharoplasty, as assessed with the Garcia-McCollough Scale for Lower Eyelid Appearance.

RESULTS

The 50 patients were retrospectively reviewed and analyzed by a group of 3 unbiased plastic surgeons, and there was negligible evidence of lower eyelid contour abnormality, lower eyelid malposition, or easily visible scars.

CONCLUSIONS

Transcutaneous lower eyelid blepharoplasty with fat excision is a time-tested method of correcting the undesirable sequelae of the aging eye. This technique not only is a safe and effective manner to rejuvenate the lower eyelid but also results in virtually nonexistent ill effects.

Cosmetic Lower Eyelid Blepharoplasty With Fat Repositioning via Intra-SOOF Dissection: Surgical Technique and Initial Outcomes

PURPOSE

To describe a novel surgical technique for lower eyelid blepharoplasty with fat repositioning in an intrasuborbicularis oculi fat (intra-SOOF) plane.

METHODS

Description of surgical technique and outcome of a retrospective, interventional case series of 66 consecutive patients who underwent surgery.

RESULTS

Sixty-six patients with an average age of 56 years underwent bilateral transconjunctival lower eyelid blepharoplasty with fat repositioning in an intra-SOOF plane. Surgery was most commonly done in an office-based operating or procedure room under local anesthetic only. Patients were observed for an average of 6 months. Complications and revisions were few. Surgical outcomes and subjective patient satisfaction rate were excellent.

CONCLUSIONS

Lower eyelid fat repositioning blepharoplasty in an intra-SOOF plane is an alternative technique to address the tear trough deformity. This technique provides excellent surgical results and high patient satisfaction. Convenient for both patient and surgeon, this technique is readily performed in an office-based procedure room under local anesthetic. Further follow-up will determine long-term outcomes.

[Cellulite--the greatest skin problem in healthy people? An approach]

Cellulite or so called orange peel skin affects 80-90 % of all females. It is not considered as a pathological condition but as aesthetically disturbing dimpling of the skin seen most commonly on the thighs and buttocks. Despite its high prevalence, there have been only a few scientific investigations into the pathophysiology of cellulite reflected in the medical literature. A lack of knowledge regarding specific aetiopathogenetic factors and pathogenesis at large currently limits treatment options. The preferred hypotheses about the origin of cellulite include: gender specific dimorphic skin architecture, altered connective tissue septae, vascular changes and inflammatory processes. The most widely discussed management options include: attenuation of aggravating factors, physical procedures including laser therapy and application of topical incorporating actives. The latter approach has been evidence-based with respect to caffeine liposomal cream and retinol cream.

Removal of an orbital apex hemangioma using an endoscopic transethmoidal approach: technical note

OBJECTIVE

The posterior orbit contains a number of important and vulnerable structures, including the optic nerve, the ophthalmic artery and vein, and the ocular muscles and their motor nerves, which makes surgical access to the lesion in this region quite difficult. Transfrontal, transfrontal-ethmoidal, and transmaxillary procedures have the disadvantage of possible injuries to a number of nontumor structures, whereas an endoscopic transethmoidal approach is a minimally invasive surgery for the retrobulbar lesions. Retrobulbar cavernous hemangioma was successfully removed by a transethmoidal approach.

METHODS

Tumor removal was performed in a patient with an intraconal cavernous hemangioma of approximately 15 mm in diameter. By a transethmoidal approach, the medial-inferior part of the orbit, as well as the apex of the orbit, were clearly visualized after endonasal ethmoidectomy. After the removal of the medial orbital bone, the orbital periosteum was incised and elevated. By elevating the orbital fat, the tumor could be identified separately from the orbital contents.

RESULTS

Cavernous hemangioma at the orbital apex was removed without complications.

CONCLUSION

An endoscopic transethmoidal approach, which requires no skin incision, is a minimally invasive surgery for retrobulbar orbital tumor, leading to excellent cosmetic results with less bleeding.

Understanding the Finger-Assisted Malar Elevation Technique in Face Lift

BACKGROUND

The finger-assisted malar elevation technique addressing the midface represents one of the new trends in surgical techniques for facial rejuvenation. Although Aston described it in 1996, until now there has been no detailed publication on this technique and its anatomical relations. This study focused on the anatomical structures and layers involved in it.

METHODS

Ten cadavers were dissected from the orbicularis oculi muscle to the base of malar fat pad, which was detached. All visible anatomical structures were described. The finger-assisted malar elevation technique was used in clinical cases and the surgical technique was described.

RESULTS

This digital maneuver is performed in a relatively avascular plane, over the muscles and underneath the malar fat pad. The safety of this technique is also reinforced by the absence of important anatomical structures. Two hundred fifty-three patients underwent this procedure, and minor complications were recorded in six patients.

CONCLUSIONS

The supra-superficial musculoaponeurotic system plane is a safe and natural plane for the finger-assisted malar elevation technique. It also carries the advantage of allowing greater mobilization of the nasolabial fold, the superficial musculoaponeurotic system, and excess skin, although the major advantage is the facility of repositioning the malar fat pad to its original position, over the zygomatic body prominence.

Safe total corporal contouring with large-volume liposuction for the obese patient

The advent of the tumescent technique in 1987 allowed for safe total corporal contouring as an ambulatory, single-session megaliposuction with the patient under regional anesthesia supplemented by local anesthetic only in selected areas. Safety and aesthetic issues define large-volume liposuction as having a 5,000-ml aspirate, mega-volume liposuction as having an 8,000-ml aspirate, and giganto-volume liposuction as having an aspirate of 12,000 ml or more. Clinically, a total volume comprising 5,000 ml of fat and wetting solution aspirated during the procedure qualifies for megaliposuction/large-volume liposuction. Between September 2000 and August 2005, 470 cases of liposuction were managed. In 296 (63%) of the 470 cases, the total volume of aspirate exceeded 5 l (range, 5,000-22,000 ml). Concurrent limited or total-block lipectomy was performed in 70 of 296 cases (23.6%). Regional anesthesia with conscious sedation was preferred, except where liposuction targeted areas above the subcostal region (the upper trunk, lateral chest, gynecomastia, breast, arms, and face), or when the patient so desired. Tumescent infiltration was achieved with hypotonic lactated Ringer's solution, adrenalin, triamcinalone, and hyalase in all cases during the last one year of the series. This approach has clinically shown less tissue edema in the postoperative period than with conventional physiologic saline used in place of the Ringer's lactate solution. The amount injected varied from 1,000 to 8,000 ml depending on the size, site, and area. Local anesthetic was included only for the terminal portion of the tumescent mixture, wherever the subcostal regions were infiltrated. The aspirate was restricted to the unstained white/yellow fat, and the amount of fat aspirated did not have any bearing on the amount of solution infiltrated. There were no major complications, and no blood transfusions were administered. The hospital stay ranged from 8 to 24 h for both liposuction and liposuction with a lipectomy. Serous discharge from access sites and serosanguinous fluid accumulation requiring drainage were necessitated in 32 of 296 cases (10.8%). Minor recontouring touch-ups were requested in 17 of 296 cases (5.7%). Early ambulation was encouraged for mobilization of third-space fluid shifts to expedite recovery and to prevent deep vein thrombosis. Follow-up evaluation ranged from 6 to 52 months, with 38 (12.8%) of 296 patients requesting further sessions for other new areas. Average weight reduction observed was 7 to 11.6 kg (approx. 4 to 10% of pre-operative body weight). Meticulous perioperative monitoring of systemic functions ensures safety in tumescent megaliposuction for the obese, and rewarding results are achieved in a single sitting.

[Bilateral orbital fat prolapse associated with pterygium: case report]

Orbital fat prolapse is an uncommon benign entity that can cause esthetic defects. The authors present a 63-year-old patient with bilateral temporal orbital fat prolapse associated with a bilateral nasal pterygium. Clinical and surgical features are described. The clinical, imaging and histopathological diagnoses are discussed.

Perforator artery based flap debulking: an alternative method

The postoperative bulky appearance of a musculocutaneous flap constitutes aesthetic problems that could necessitate secondary operations. Three patients who were reconstructed with free musculocutaneous flaps were re-operated at the postoperative sixth month. The fasciocutaneous flaps were elevated based on perforator arteries, and the excess skin, dermal, and adipose tissues were excised. There were no complications in the follow-up. This one-staged, perforator artery based flap debulking is proposed as an efficient and alternative method.

Rejuvenation of the aging eyelid

Rejuvenation of the aging eyelid subunit provides a youthful appearance to one of the focal points of the face. As the age of our population increases, these procedures are likely to become increasingly more common. Accurate preoperative examination, assessment, and counseling are imperative to achieve an excellent result. As well, careful selection from the spectrum of available techniques, combined with meticulous surgical precision, will assist the surgeon in rejuvenating the individual patient. Although no one ideal surgical procedure exists, many safe and effective strategies have been developed as we have learned more about the effects of aging. This article aims to provide a history of techniques used in eyelid rejuvenation, as well as an overview of the evaluation process.

An Algorithmic Approach to Upper Arm Contouring

There has been a renewed interest in upper arm contouring given the recent advances and subsequent patient interest in weight loss. Patients undergoing bariatric surgery are often left with a significant amount of redundant skin and laxity of their upper extremity. Some patients within this group have excess fat in their upper arms with relatively good skin tone, while others have a paucity of excess fat with a significant amount of redundant skin. The optimal treatment for each patient can vary. A clinical algorithm is presented that is designed to select the best method for upper arm contouring based on the aesthetic analysis of the upper arm. Case examples are provided demonstrating results that were obtained by following this algorithm.

Is It Safe to Combine Abdominoplasty with Elective Breast Surgery? A Review of 151 Consecutive Cases

BACKGROUND

This study was designed to evaluate and compare the complication rates of patients having abdominoplasty without breast surgery with the rates of those having abdominoplasty with various types of elective breast surgery, including breast augmentation, breast reduction, mastopexy, and mastopexy combined with simultaneous augmentation.

METHODS

The data collected represent a retrospective chart review of consecutive abdominoplasty procedures performed at a single outpatient facility by the senior surgeon (W.G.S.) over a 15-year period (1989 to 2004). Two groups were compared: patients who underwent abdominoplasty without breast surgery and those who had abdominoplasty with breast surgery. The second group was subdivided by the various types of breast procedures noted above. The minor complications assessed included seromas, hematomas, infections, and small (<5 cm) wound breakdowns. Major complications evaluated included large (>5 cm) flap necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. Additional data compiled included age, sex, tobacco use, body mass index, past medical history, American Society of Anesthesiologists physical status level, and operative times.

RESULTS

Of the 415 abdominoplasty procedures, 264 (group 1) did not include simultaneous breast surgery. One hundred fifty-one procedures (group 2) involved simultaneous breast surgery, representing 36 percent of the total. Group 2 was further subdivided into those who had breast augmentation surgery (group 2A, n = 50), those who had breast reduction surgery (group 2B, n = 31), those who had mastopexy surgery (group 2C, n = 28), and those who had simultaneous mastopexy and breast augmentation surgery (group 2D, n = 42). Removal and replacement of implants and capsulectomy/capsulotomy procedures were included in the augmentation group (group 2A). There were no major complications, including flap necrosis (open wound >5 cm), blood transfusions, deep vein thrombosis, pulmonary embolus, myocardial infarction, or death. No patients required hospitalization. No statistically significant associations with complications were noted between groups 1 and 2 (chi-square, 0.0045; p > 0.95, not significant). Furthermore, when subdivided by type of breast surgery, no statistically significant associations were noted among subgroups: group 1 versus 2A (chi-square, 0.96; p > 0.05, not significant), group 1 versus 2B (chi-square, 0.032; p > 0.9, not significant), group 1 versus 2C (chi-square, 0.003; p > 0.975, not significant), and group 1 versus 2D (chi-square, 0.83; p > 0.5, not significant).

CONCLUSION

The results of this retrospective review indicate that combining elective breast surgery with abdominoplasty does not appear to significantly increase the number of major or minor complications.

Vagal denervation and atrial fibrillation inducibility: Epicardial fat pad ablation does not have long-term effects

BACKGROUND

Major epicardial fat pads contain cardiac ganglionated plexi of the autonomic, predominantly vagal nerves. Vagal denervation may improve the success rate of atrial fibrillation (AF) treatment.

OBJECTIVES

The purpose of this study was to elucidate the long-term effects of fat pad ablation on the electrophysiologic characteristics of the atrium and AF inducibility.

METHODS

Six mongrel dogs were studied. Cervical vagal stimulation was applied to determine effects on the sinus node, AV node, atrial effective refractory period (AERP), and AF inducibility. AERP and AF inducibility were evaluated at both the right atrial and left atrial appendages and at the right atrial and left atrial free walls. Radiofrequency energy was delivered epicardially to the entire areas of two major fat pads: right pulmonary vein fat pad and inferior vena cava-left atrium fat pad. Cervical vagal stimulation then was applied to confirm the acute effects of fat pad ablation. The same evaluation was repeated 4 weeks later.

RESULTS

The effects of vagal stimulation on the sinus node, AV node, and AERP were significantly eliminated immediately after fat pad ablation. However, these denervation effects disappeared after 4 weeks. At baseline, AF inducibility was increased by vagal stimulation (right atrial appendage: 72% +/- 31% vs 4.8% +/- 12%; right atrial free wall: 75% +/- 31% vs 0.0% +/- 0.0%; left atrial appendage: 60% +/- 29% vs 0.0% +/- 0.0%; left atrial free wall: 65% +/- 42% vs 0.0% +/- 0.0%). Fat pad ablation significantly reduced this vagal stimulation effect (8.3% +/- 20%, 10% +/- 22%, 17% +/- 29%, and 25% +/- 29%, respectively). However, similar to baseline, AF inducibility was strongly augmented by vagal stimulation 4 weeks after fat pad ablation (96% +/- 10%, 100% +/- 0.0%, 100% +/- 0.0%, and 95% +/- 11%, respectively).

CONCLUSION

Radiofrequency fat pad ablation may not achieve long-term suppression of AF induction in this canine model.

Strabismus after Deep Lateral Wall Orbital Decompression in Thyroid-Related Orbitopathy Patients Using Automated Hess Screen

PURPOSE

To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS).

DESIGN

Prospective nonrandomized clinical study.

PARTICIPANTS

Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004.

METHODS

Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease.

MAIN OUTCOME MEASURES

Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze.

RESULTS

Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (+/-standard deviation) of 2.7 mm (+/-2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery (P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (delta = 3.7 PD for horizontal deviation and -0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery.

CONCLUSIONS

Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

Mid-Body Contouring in the Post???Bariatric Surgery Patient

BACKGROUND

Obesity has become an increasingly important health care problem. It is estimated that almost 20 percent of the adult U.S. population is obese, including approximately 5 percent of the population considered morbidly obese. Recent advances in bariatric surgery have improved the safety and efficacy of weight-loss operations. As a consequence of the above factors, there has been a 150 percent increase in the number of gastric bypass and vertical banding gastroplasty procedures performed over the past 3 years. Post-bariatric surgery care has become an integral part in the care of these patients, with plastic surgeons playing an important role.

METHODS

The senior author (B.S.) has developed unique variations of the circumferential and near-circumferential abdominoplasty operations to fulfill the needs of these patients. Seventy-five consecutive mid-body lift procedures have been performed over the past 5 years. The basic operation involves circumferential incisions, anterior flap undermining, and simultaneous flap thinning, without resorting to the need for an anterior midline incision.

RESULTS

A dramatic improvement in appearance results from the anterior resection and the lateral thigh and buttock lifts that this procedure affords. More recently, the lower back roll has been removed as well. A cohesive operative sequence that includes optimized patient preparation and positioning, tailoring of flaps for improved contour with avoidance of unnecessary midline scars, a strong superficial fascial system closure, and coordination with the entire operating room team has been developed.

CONCLUSION

The procedure is associated with a low complication rate, a dramatically shortened operative time, and high patient satisfaction.

Massive Panniculectomy after Massive Weight Loss

BACKGROUND

Massive weight loss, defined as loss of 50 percent of excess weight, often results in laxity and redundancy of the abdominal skin, causing disabling rashes, pain, physical limitation, back strain, and cosmetic deformity. The heavier the panniculus, the more marked the symptoms. Panniculectomy can treat these symptoms, but the approach must be customized because of complex medical and surgical histories related to obesity and the size of the panniculus. The aim of this study was to analyze a series of massive panniculectomies greater than 10 pounds following massive weight loss and to investigate the outcomes achieved.

METHODS

All patients undergoing massive abdominal panniculectomy by a single plastic surgeon at an academic hospital from October of 2000 to December of 2003 were retrospectively studied. Seven men and 17 women qualified: one woman had a two-stage abdominal panniculectomy, each time with greater than 10-pound abdominal skin resections. All but one patient had gastric bypass. Average weight loss was 171 pounds, with an average maximum body mass index of 70.5 and a minimum body mass index of 43.7 (morbid obesity is defined as a body mass index greater than 40). Patient presentation was regularly complicated by abdominal scars. Abdominal panniculectomy was performed with conservative undermining. Hernias were repaired at the time of surgery. Routine prophylaxis against thromboembolism was performed.

RESULTS

Average abdominal skin resection was 16.1 pounds, ranging from 10.3 to 49 pounds. Hernia repair was necessary in 13 patients. Additional surgery performed at the time of panniculectomy included skin reduction surgery of the back (40 percent), chest (32 percent), inner thigh (28 percent), and arm (28 percent). Blood transfusion was necessary in five of the cases (20 percent). Length of stay averaged 3 days. Complications included wounds requiring debridement, dressings, vacuum-assisted closure therapy and/or delayed primary closure (20 percent), and seroma requiring drain replacement or dressings (28 percent). Uncomplicated healing occurred in 44 percent of cases.

CONCLUSION

Massive abdominal panniculectomy is challenging to plan, execute, and manage after surgery. The authors present their approach to these patients, with acceptable results.

Liposynovitis prepatellaris in athletic runner (Hoffa's syndrome): case report and review of the literature

A 37-year-old male patient, who is an athletic runner, developed anterior knee pain of acute onset after prolonged running and swelling of his right knee. The patient experiences more pain when he flexes the knee and a sense of catching together with grade 1 effusion. The patient was clinically suspected to have internal derangement and MRI study of his right knee was ordered to exclude such possible diagnosis. The MRI study revealed the following: a hypointense lesion in the infrapatellar pad of fat in T2-weighted images (WI), postcontrast T1 WI with fat saturation demonstrated no enhancement, and STIR sequence showed slightly hyperintense lesion with minimal knee effusion. The MRI findings supported the diagnosis of Hoffa's syndrome, and arthroscopic resection of the fat pad was performed. There was a significant improvement in the symptoms and function after the surgery.

Spontaneous subconjunctival orbital fat prolapse: presentation of four cases

BACKGROUND

Subconjunctival orbital fat prolapse is a benign entity characterized by orbital fat herniation through a dehiscence in Tenon's capsule, usually between the superior and lateral recti muscles. It is often associated with ocular trauma or surgery, although spontaneous cases have also been reported with a predilection for obese individuals.

PATIENTS AND METHODS

A retrospective study of four subconjunctival orbital-fat prolapse cases with no history of ocular surgery or trauma was performed. A trans-conjunctival surgical approach with Tenon's capsule repair was offered to all subjects. Differential diagnosis is discussed.

RESULTS

The diagnosis of subconjunctival orbital fat prolapse was confirmed in all cases by histopathological examination. Functional and aesthetic postoperative results were excellent, with no recurrences during follow-up, for all cases.

CONCLUSIONS

Although rare, subconjunctival orbital fat prolapse should be recognized. Surgical management offers excellent results.

Anatomical localization of the umbilicus: an Indian study

BACKGROUND

The umbilicus is essential to the aesthetic appearance of the abdomen. However, very little has been written about the exact location of the aesthetically pleasing umbilicus as far as the Indian cosmopolitan population is concerned. Although a variety of reconstructive methods are available, no real standards define the location of the umbilicus.

METHODS

In this study, 75 cosmopolitan female volunteers were evaluated in supine position, and the distance of the umbilicus (from central stalk) to fixed bony points over the anterior abdominal wall was measured. These linear measurements were subjected to standard statistical methods.

RESULTS

In this study, the authors observed that the umbilicus is situated around the midline plane such that the ratio of the distance between the xiphisternum and the umbilicus and the distance between the pubic symphysis and the umbilicus is 1.6:1; also, the ratio of the distance between the umbilicus and anterior superior iliac spine and the inter-anterior superior iliac spine is approximately 0.6:1.

CONCLUSIONS

During umbilicoplasty, when each anterior superior iliac spine is taken as a center, and arcs are drawn with a radius 0.6 times that of the inter-anterior superior iliac spine distance, the point of intersection of these arcs is the approximate location of the umbilicus around the midline plane, which should match the ratio of 1.6:1 (i.e., the ratio of the distance from the umbilicus to the xiphisternum and the distance from umbilicus to the pubic symphysis). An effort is made to find and establish the body proportions and symmetry and to determine the critical ratios so as to help the reconstructive surgeon to plan an aesthetically pleasing umbilicus.

Bilateral Lumbar Hip Dermal Fat Rotation Flaps: A Novel Technique for Autologous Augmentation Gluteoplasty

BACKGROUND

The present study reports a novel technique for augmentation and/or correction of deformities in the gluteal region. This technique is applicable to patients with skin excess, skin flaccidity, and/or ptosis, and for redundant skin folds in the lower back region, that often occur following the surgical treatment of morbid obesity.

METHODS

In a retrospective review, nine female patients, aged 27 to 64 years, underwent the bilateral lumbar hip dermal fat rotation flaps procedure for gluteal augmentation. The patients were observed over a period of 3 months to 4 years. Gluteal projection was measured with a standardized computed tomographic scan in two patients. Complications were analyzed.

RESULTS

The postoperative photographs and the measurements taken by computed tomographic scan proved that the gluteal projection had been increased satisfactorily with this innovative procedure. Three complications were observed, the major one being a hematoma that required reoperation.

CONCLUSION

Bilateral lumbar hip dermal fat rotation flaps is an ultimate technique that should be performed in selected patients to create a harmonic autologous augmentation of the buttocks region. Although the complication rate of this technique was high, it was similar to that in some authors' reports for belt lipectomy.

Anatomic and Aesthetic Considerations in Midfacial Rejuvenation

An early sign of the aging process involves changes to the midface. The loss of the lid-cheek continuum begins with underlying laxity in the orbitomalar ligament. As the face continues to age, the malar pad drops inferomedially in position. The approach to the midface has evolved over the past 15 years with the advent of endoscopically assisted techniques of midfacial elevation. Further technology, such as thread-lifting procedures and the Endotine Midfacetrade mark, have supplemented the choices for surgical correction of this facial segment. Descriptions of the different approaches to the aging midface are reviewed.

The S.O.F.T. Cheek method: an approach to lower eyelid and midface rejuvenation

Procedures to rejuvenate the lower eyelids and cheek are amongst the most common aesthetic surgeries performed today. Rejuvenation should be individualized based on the patients concerns, anatomic deformity, and medical condition. A balanced and natural clinical result often requires a combination of techniques designed to address each patient's individual pattern of aging, while maximizing patient safety. We present the S.O.F.T. Cheek method of analysis and treatment, which utilizes well-developed principles and techniques, to consistently maximize clinical results and patient satisfaction.

[Lasting treatment of facial HIV and non HIV lipoatrophies through the use of SAM GoreTex malar implants and polyacrylamide hydrogel filler Eutrophill. About 90 consecutive cases]

HIV-related lipoatrophy (HIV LA) stands out with regard to its recent discovery, increasing incidence, multiple etiologies, relatively low morbidity, apparently irreversible effects, and unequivocal clinical features. The underlying cause of HIVLA is still controversial but there is an increasing demand of correction. We describe a technique using soft malar implants and acrylamid gel injections separately or in combination. Expanded polytetrafluoroethylene (Gore SAM) malar implants are used for augmentation of the most sunken areas below the eye; they should be placed subperiostealy and more medially than conventional implants. After trying sheets and custom made implants, preshaped GoreTex) Sam implants are now used systematicaly. Eutrophill) is a 2.5% polyacrylamide hydrogel obtained by polymerization of acrylamide monomers with an official half-life of 5 years. The soluable chains are more or less slowly released by enzymatic degradation and subsequently cleared via interstitial tissue without further metabolism or degradation. Injection should be performed continuously and evenly from one side to the other in the deepest part of the sunken area at the subcutaneous level only. A total of 90 consecutive patients were treated using implants alone in 11 cases, injections alone in 68 cases, and both implants and injections in 11 cases. Drawbacks were very few except three cases of chronic inflammation (dental conflict) with sheets and custom made implants which were never observed since the use of preshaped forms, and some very light bulgings with acrylamid injections which usually desapear in a few months. Mean follow-up was 17 months for injections and 29 for implants.

Effects of different tissue loads on high power ultrasonic surgery scalpel

The objective of this study is to investigate the influence of various tissue loads on the working characteristic of the ultrasonic scalpel, including working frequency, input admittance and reflection factor. Ex vivo animal experiments are carried out and relevant discussions of experimental results are provided. Admittance measurement results show that different tissue loads have different effects on a scalpel's working ability. Soft tissue makes the working frequency decrease and bone tissue makes it increase. Radius of admittance circles and reflection factor are also different. Equivalent circuit model is found and with a least-square parameter identification method, input admittance of ultrasonic scalpel with different tissue loads is solved. Results show that admittance circle radius is determined by the value of R1. Changes in L1 and C1 contribute to the shift of working frequency. This study will help decrease the sensitivity of ultrasonic scalpel to loads and greatly increase surgery efficiency.

Free Microdissected Thin Groin Flap Design with an Extended Vascular Pedicle

BACKGROUND

The senior author has developed a method of microdissection whereby a thin perforator flap can be elevated accurately in a single-stage procedure. Recently, the authors also applied the microdissection technique to the inguinal area and elevated microdissected thin groin flap.

METHODS

In preparation of the flap, the perforator penetrating the fascia of the sartorius muscle is initially detected suprafascially, and then the deep adipose and subfascial layer of the inguinal area is dissected using an operating microscope. After confirming the distribution of the blood vessels in this area, the flap is elevated while dissection is performed between the deep and superficial adipose layers.

RESULTS

Six cases of scar contracture or skin defect by general burn, three cases of other types of traumatic tissue defects, and one case of skin loss at the donor site of an extended wraparound flap were successfully reconstructed with these new flaps.

CONCLUSIONS

The uniform thinness and long vascular pedicle are distinctive characteristics of this flap compared with the traditional groin flap. Moreover, the buried vessels in the deep adipose layer and fascia can be confirmed by microdissection; this enables prediction of the safe area of the flap.

Decrease of Intraocular Pressure After Fat-Removal Orbital Decompression in Graves Disease

PURPOSE

To address the efficacy of fat-removal orbital decompression to reduce intraocular pressure in patients with Graves disease.

METHODS

This cohort study included 64 eyes of 39 patients with Graves disease. Thirteen men and 36 women, with a mean age of 52.5 years (range, 27 to 80 years), underwent fat-removal orbital decompression. Intraocular pressure (applanation) and proptosis (Hertel exophthalmometry) were prospectively investigated before surgery and 1 week and 6 months after surgery.

RESULTS

The volume of resected fat was 6.4+/- 4.5 (3 to 12) ml. The intraocular pressure in primary position decreased from 19.3+/- 4.4 mm Hg to 17.0+/- 2.9 mm Hg at 1 week (p<0.001) and 15.9+/- 3.7 mm Hg at 6 months (p<0.001). Mean proptosis dropped from 24.3+/- 2.5 mm before surgery to 19.9+/-3.0 mm at 1 week (p<0.01), and 19.9+/-3.1 mm at 6 months (p<0.01). Intraocular pressure decrease neither correlated to the volume of resected fat nor to proptosis reduction.

CONCLUSIONS

Fat removal reduces intraocular pressure in patients with Graves disease, with no correlation to the volume of resected fat.

Treatment with ultrasound-assisted liposuction of accessory axillary breast tissues

Supernumerary nipples and breast tissue often are dismissed as cosmetic curiosities. These structures have the potential for pathologic degeneration and may be associated with significant congenital abnormalities. In a prospective comparison of 100 Native American women with 100 non-Native American women, these accessory organs were found much more commonly among Native American women. Careful attention should be given to thorough evaluation and long-term follow-up evaluation of any patient with this anomaly. This study investigated a patient who underwent surgical removal of her axillary breast tissue with ultrasound-assisted liposuction. The advantages of this method include a minimal incision scar from the liposuction cannula and the ability to detect residual axillary breast by ultrasound.

Panniculectomy and the separation-of-parts hernia repair: a solution for the large infraumbilical hernia in the obese patient

BACKGROUND

Infraumbilical hernias in the obese are problematic in terms of achieving adequate exposure and eventual wound healing. Simultaneous panniculectomy with separation-of-parts hernia repair is one approach to this reconstructive issue, but the feasibility of such a combination is untested.

METHODS

Twenty-four simultaneous panniculectomy and separation-of-parts hernia repairs performed by the senior surgeon over a 6-year period are presented. Patients were analyzed by preoperative, intraoperative, and postoperative parameters. Complications were grouped into major and minor categories.

RESULTS

Average patient body mass index was 39 (range, 29 to 57). Twenty of 24 (83 percent) of the hernias were recurrent on initial presentation. Almost one-half of the cases were contaminated (46 percent), marked by the presence of a preoperative wound (29 percent) or concurrent gastrointestinal procedure (17 percent). In 25 percent of cases, a preexisting laparotomy scar necessitated a vertical reopening of the abdominal skin, raising the stakes for postoperative wound breakdown. Despite these findings, major/minor wound complications (12.5 percent/33 percent) and additional surgery rates (17 percent) were relatively low considering this morbidly obese population. Postoperative wound complications, hernia recurrence, and reoperation rates were significantly increased among those patients whose body mass index exceeded 35(p < 0.05). All hernia recurrences (n = 4) were corrected definitively with a secondary direct repair. Mean follow-up was 10 months (range, 3 to 60 months).

CONCLUSION

The separation-of-parts hernia repair in combination with pannus resection can be performed safely in obese patients, with complication rates comparable to those reported in the literature. This combined procedure has become the authors' procedure of choice in these difficult clinical situations.

A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale

BACKGROUND

Contour deformities after massive weight loss are diverse and often severe in nature. Current progress has necessitated a valid, accessible, and comprehensive rating system that correlates appearance and appropriate surgical treatment. Presently, no existing rating system addresses the breadth and variety of deformities that can occur or allows for adequate postsurgical evaluation.

METHODS

The authors reviewed full-body photographs of over 300 female patients seen between October of 2002 and May of 2004. The authors targeted body areas most frequently demonstrating skin and soft-tissue laxity and ptosis. A 10-region, four-point grading system was designed to describe the common deformities found in each region of the body. To validate the scale, 12 trained observers applied the rating scale to photographs of 25 patients who showed the 10 regions. Each grading scale ranged from 0, indicating normal, to 3, indicating the most severe deformity. Repeat testing was performed at 2 weeks. Interobserver validity and test-retest reliability were determined using weighted kappa analysis.

RESULTS

In all 10 categories, the kappa value was 0.6 or higher (0.6 = threshold for good validity), with a mean kappa value of 0.68 (range, 0.61 to 0.78) and an overall agreement of 69 percent over two sessions. All 12 observers scored an individual mean kappa value of greater than 0.6, indicating good interobserver validity. A given observer had a mean 67 percent agreement, indicating reasonable test-retest reliability.

CONCLUSIONS

The Pittsburgh Rating Scale is a validated measure of contour deformities after bariatric weight loss. This scale may have applications in preoperative planning and evaluating surgical outcomes.

Submental Nd:Yag laser-assisted liposuction

BACKGROUND

Liposuction of the neck is currently one of the most common cosmetic surgical procedures. In the present study, the author describes his experience with neck and jowl laser-assisted liposuction.

STUDY DESIGN/MATERIALS AND METHODS

In this procedure, submental lipodystrophy is treated with an Nd:YAG laser, at a 1,064 nm wavelength. Over a 5-year-period, 82 subjects were treated using 6-W power, 40-Hz frequency, 150-mJ energy, and 100-microsecond pulse width parameters. Histology was performed on fatty tissue samples.

RESULTS

Submental laser-assisted liposuction resulted in significant cosmetic improvement. Histology revealed a rupture of the adipocyte membrane as well as collagen coagulation and channels along the fatty tissue. Additionally, small blood vessels were coagulated. An adequate skin contraction was observed with an improvement of the cervicofacial region.

CONCLUSIONS

The Nd:YAG laser is a useful tool for the treatment of local lipodistrophy. The laser proved to be effective for cellular lysis and collagen neoformation.

A single center, randomized, comparative, prospective clinical study to determine the efficacy of the VelaSmooth system versus the Triactive system for the treatment of cellulite

BACKGROUND AND OBJECTIVES

One area of cosmetic concern for women of all races is the unsightly appearance of cellulite in the buttocks area and lower extremities. Two modern technological advances claim to improve cellulite and provide reproducible results, TriActive and VelaSmooth. The TriActive laser is intended to reduce the appearance of cellulite through the combination of low-energy diode laser, contact cooling, suction, and massage. The VelaSmooth is based on a combination of two different ranges of electromagnetic energy: infrared light and radio frequency (RF) combined with mechanical manipulation of the skin. This single center study was designed to evaluate the efficacy of the VelaSmooth versus TriActive in the reduction of the appearance of cellulite.

STUDY DESIGN/MATERIALS AND METHODS

Twenty female patients were treated twice a week for 6 weeks with the randomization of TriActive on one side and VelaSmooth on the other side. Patients were evaluated with photographs and circumferential thigh measurements before treatment and after the final treatment.

RESULTS

Although there was improvement in the reduction of cellulite for each device individually, there was no significant difference between VelaSmooth or TriActive devices in the following categories: reduction of thigh circumference, photographic evaluation, and perceived change in before and after photographic grading. There was a statistically significant increase in the incidence of post-treatment bruising with the VelaSmooth compared to TriActive.

CONCLUSIONS

In conclusion, both the TriActive and VelaSmooth provide improvement of cellulite. When comparing differences in efficacy, the average mean percent change calculated was roughly the same for both treatments and showed no statistical difference.

The Plastic Surgeon in the Treatment of Obesity

Obesity is an increasingly common disease, whose complex treatment often terminates with the patient's discontinuation of therapies. The authors suggest how to improve a multidisciplinary approach to the obese, to increase compliance with therapy. A characterization of obesity is a helpful initial step. It consists of an accurate anatomic definition of fat distribution, which can more accurately be performed by imaging (U/S, CT, MRI). The patient's obesity should also be identified based on the physical characteristics that we propose. The plastic surgeon's intervention is often required and beneficial in every type of obesity. Many body areas are appropriate for contouring. Apart from providing a gain in esthetic appearance, plastic surgery also results in several benefits for the patient's general health.

Percutaneous management of Morel-Lavallee lesions

BACKGROUND

Previous recommendations for treatment of Morel-Lavallee soft-tissue degloving lesions have included open débridement with packing or delayed closure. The purpose of this study was to review the use of percutaneous drainage for the initial management of these lesions.

METHODS

Nineteen patients with a Morel-Lavallee lesion were managed with percutaneous drainage and débridement of the lesion within three days after the injury. Drainage was usually completed through two 2-cm incisions: one over the distal aspect of the lesion and one over the most superior and posterior extent of the lesion. A plastic brush was used to débride the injured fatty tissue, which was washed from the wound with pulsed lavage. A medium Hemovac drain was placed within the lesion and was removed when drainage was <30 mL over twenty-four hours.

RESULTS

Fifteen of the nineteen patients had surgery for an associated pelvic or acetabular fracture. Seven of the nine patients in whom a pelvic fracture was treated surgically had percutaneous fixation of the posterior part of the pelvic ring as well as treatment of the Morel-Lavallee lesion during the same operative setting. Fixation of the remaining two pelvic fractures and the six acetabular fractures was deferred until at least twenty-four hours after the drain was removed. Three of sixteen cultures of specimens taken from the wounds were positive. None of the patients with percutaneous fixation of the pelvis had wound complications. One wound required surgical exploration because of persistent drainage, but the culture was negative and the wound healed with no sequelae. No patient required débridement of skin and, at a minimum of six months, no deep infection had occurred.

CONCLUSIONS

Early percutaneous drainage with débridement, irrigation, and suction drainage for the treatment of Morel-Lavallee lesions appears to be safe and effective. Percutaneous procedures for pelvic fixation were well tolerated by the small number of patients in this series, and open procedures appeared to be safe when performed in a delayed fashion.

What causes eyelid bags? Analysis of 114 consecutive patients

BACKGROUND

The purpose of this study was to identify the anatomical basis for perception of lower eyelid bags in patients seeking aesthetic surgery and to evaluate the cumulative contribution of different anatomic characteristics before surgery.

METHODS

The histories and photographs of patients whose motivation for aesthetic consultation was lower eyelid bags were analyzed. Six categories of anatomic basis for the lower eyelid bags were identified. For each patient, a score from 0 to 4 was given in each category. The cumulative contribution score for each category was calculated as total points for that category for all patients, divided by the 456 total available points. The authors also developed a "uniqueness score" to reflect the percentage contribution of the worst identified anatomic problem compared with the other problems. This was calculated for each patient as the maximum score in one category, divided by total points for that patient.

RESULTS

A total of 114 consecutive cases were evaluated (67 men and 47 women; mean age, 52 +/- 11 years; age range, 23 to 76 years). The cumulative contribution score for each anatomic variable was as follows: cheek descent and hollow tear trough, 52 percent; prolapse of orbital fat, 48; skin laxity and sun damage, 35; eyelid fluid, 32; orbicularis hyperactivity, 20; and triangular cheek festoon, 13. Prolapsed orbital fat and tear trough deformity both received the higher score and were more common in men as compared with women. The average uniqueness score was 38 percent, with a range of 20 to 75 percent. No one category played a dominant role for most patients. Tear trough depression, skin laxity, and triangular malar mound were significantly more common in patients older than 50 years. Linear regression analysis showed that recommendation for surgery is based on the extent of fat prolapse, skin elasticity, and midface descent. Significant positive correlations were found in all six categories and in uniqueness scores calculated by different observers (r values ranged from 0.31 to 0.73; p < 0.001, Pearson correlation), with the highest score in agreement with the contribution of eyelids fat (r = 0.73) and skin laxity (r = 0.66); the uniqueness score correlation was r = 0.45 (p < 0.001).

CONCLUSIONS

Eyelid bags do not have a single anatomic basis. For different anatomic problems, different treatments are recommended.

Minimally Invasive Orbital Decompression

OBJECTIVE

To investigate the safety and efficacy of a conservative orbital decompression using sharp-curette bony decompression and intraconal fat debulking through a transconjunctival incision in patients with thyroid-related orbitopathy and mild to moderate proptosis.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS AND METHODS

Data from all patients undergoing minimal orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, over a period of 4(1/4) years were collected and analyzed. Data included visual acuity, exophthalmometry measurements, intraocular pressure, complete slitlamp examination results, ocular ductions, new-onset primary or downgaze diplopia, and patient satisfaction. Conservative decompression was performed through a transconjunctival incision using a manual curette and by removing cortical bone from the zygomatic marrow space on the anterior rim of the inferior orbital fissure; intraconal fat was bluntly dissected and excised or suctioned with a Frasier tip aspirator.

MAIN OUTCOME MEASURES

Patient perception of pressure pain and ocular discomfort, proptosis, visual acuity, intraocular pressure, postoperative complications, and new-onset primary or downgaze diplopia.

RESULTS

Eighty minimally invasive orbital decompression surgeries were performed in 48 patients (6 male, 42 female). Six surgeries (4 patients) were performed for prominent globes with relative proptosis and no thyroid-related orbitopathy (non-Graves proptosis). All patients had improvement in congestive orbitopathy and pressure pain associated with thyroid-related orbitopathy. Exophthalmos decreased by a mean +/- SD of 2.4 +/- 2.6 mm from 22.7 +/- 2.5 mm (range, 17-29 mm) to 20.3 +/- 2.3 mm (range, 14-25 mm) (P<.001 [95% confidence interval, 1.8-3.0]). Mean visual acuity improved after surgery (P = .02). One patient (2.1%) developed postoperative primary or downgaze diplopia; he underwent successful eye muscle surgery at a later stage. No complications were associated with orbital decompression.

CONCLUSIONS

Minimally invasive orbital decompression surgery with intraconal fat debulking in this group of patients was effective in proptosis reduction; improvement in subjective pressure pain and high patient satisfaction were noticed. Surgery was associated with a low rate (2.1%) of new-onset primary or downgaze diplopia. Proptosis reduction using a graded approach accounting for 4 mm of retrodisplacement was achieved.

Hoffa's fat pad resection in total knee arthroplasty

The authors have studied the consequences of resection of Hoffa's fat pad during total knee arthroplasty (TKA). Sixty eight patients undergoing primary TKA were randomised to have Hoffa's fat pad either resected or preserved. Biopsy specimens of Hoffa's fat pad were taken for pathological study in all patients. Radiological, functional and clinical evaluation was made after surgery, before discharge from hospital, after one month and after six months. Thirty six percent of the patients were found to present inflammatory infiltration of Hoffa's fat pad, and severe fibrosis was found in 33 %. A progressive decrease in postoperative anterior knee pain was found in 95% of the patients in both groups. Hoffa's fat pad resection did not appear to result in a change in patellar tendon length during the first six months after TKA. Preoperative fibrosis of Hoffa's fat pad may play a role in postoperative pain and range of motion.

[Transconjunctival inferior blepharoplasty]

The transconjunctival approach is the appropriate standard for lower eyelid blepharoplasty in patients presenting with lower eyelid herniated fat without excess skin. A transconjunctival incision is made approximately 2 mm below the tarsal border and extended inferiorly following a plane posterior to the orbital septum. No conjunctival suture is necessary. Although transconjunctival blepharoplasty diminishes the occurrence of postoperative complications when compared to the transcutaneous method and constitutes a more comfortable option for the patient, we always recommend a preoperative test of the eyes. Patients must be informed of the risk of amaurosis.

[Facial surgery for rejuvenation]

Aging brings about anatomical changes that are undesirable. Senescence is consequently one of the most powerful stimuli for aesthetic surgery. The face, responsible for the myriad expressions of human experience, is constantly subject to exposure and also suffers from the perennial action of environmental factors and gravity. Frequently, the face is the main focus of anxiety in individuals who have attained a certain age, presenting skin flaccidity and loss of tone, marked lines of expression and fat deposits. Expectations of both the patient and the surgeon, regarding facial aesthetic surgery, have increased considerably over the last two decades with the advent of newer procedures and equipment. While experience allows the surgeon a better selection of techniques, at the same time he must be knowledgeable in details of different surgical approaches and variations to attain the best result for each individual case. The anatomy of the aging face should be examined carefully for a personalized treatment plan. Currently, a satisfactory result of an aesthetic facial procedure is obtained when signs of an operation are undetectable and no anatomical landmarks have been altered. The bond created between the patient and surgeon will be frustrated if there remain signs that reveal the "secret" that surgery was performed.

[A comparative study between the results of antro-ethmoidal orbital decompression isolated and associated with orbital fat removal]

PURPOSE

To compare the results of isolated antral-ethmoidal orbital decompression and that associated with orbital fat removal in patients with dysthyroid orbitopathy.

METHODS

Nineteen isolated antral-ethmoidal orbital decompressions were performed in a group of 12 patients (19 orbits) with the diagnosis of dysthyroid ophthalmopathy in the quiescent stage. The same procedure, but in association with orbital fat removal, were performed in another group of 8 patients (10 orbits) also with the diagnosis of dysthyroid ophthalmopathy in the quiescent stage. The results of both groups were compared.

RESULTS

In the first group the amount of retroplacement of the globe achieved 1-5 mm (mean 3.68+/-1.10 mm) and in the second group it achieved 1-5 mm (mean 3.25+/-1.36 mm).

CONCLUSIONS

There was no significant difference between the results of the isolated antral-ethmoidal orbital decompression and that associated with orbital fat removal. The removal of 1 ml of seems not to improve the retroplacement of the globe as an association with a 2-wall orbital decompression. However, many conditions must be considered to conclude any comparison between the two orbital decompression techniques, such as orbital soft tissue compliance, amount of fat removal and size of bone opening.

Revised Uvulopalatopharyngoplasty with Uvula Preservation and Its Clinical Study

OBJECTIVES

A revised uvulopalatopharyngoplasty (UPPP) is reported for reducing the surgical complications without compromising the response.

METHODS AND MATERIALS

A new method of performing UPPP was designed, in which the uvula is preserved, but a larger portion of the soft palate is removed. This new procedure is called the 'revised UPPP with uvula preservation' (Han's UPPP or H-UPPP), the characteristics of which are as follows: complete preservation of the uvula; larger portion of the soft palate resected (with the levator palati and tensor palati remaining intact); the adipose tissue in the space of the velum palati is removed; the preserved uvula will become a 'normal' one by the contraction of scar tissue on both sides of the musculus palato-uvularis and the lower margin of the tensor palati. 68 cases of obstructive sleep apnea/hypopnea syndrome had been treated with H-UPPP between September 1998 and May 2001.

RESULTS

Polysomnography was performed for all 68 cases 6 months postoperatively with a surgical response of 69.12%, defined as a >50% reduction of the apnea-hypopnea index and <20 apneic pauses/h; no palatopharyngeal incompetency or palatopharyngeal stenosis. Anatomic measurements showed that the preserved uvula in H-UPPP begins to retract 2 weeks postoperatively, and the preserved uvula becomes 'normal' in 3-6 months.

CONCLUSIONS

These results suggest that H-UPPP is an effective surgery and produces fewer complications compared with the classic UPPP.

Plasma lidocaine levels and risks after liposuction with tumescent anaesthesia

BACKGROUND

It is common today to use tumescent anaesthesia with large doses of lidocaine for liposuction. The purpose of the present study was to evaluate lidocaine plasma levels and objective and subjective symptoms during 20 h after tumescent anaesthesia with approximately 35 mg per kg bodyweight of lidocaine for abdominal liposuction.

METHODS

Three litres of buffered solution of 0.08% lidocaine with epinephrine was infiltrated subcutaneously over the abdomen in eight female patients during monitored intravenous (i.v.) light sedation. Plasma levels of lidocaine and signs of subjective and objective symptoms were recorded every 3 h for 20 h after liposuction.

RESULTS

Lidocaine 33.2 +/- 1.8 mg/kg was given at a rate of 116 +/- 11 ml/min. Peak plasma levels (2.3 +/- 0.63 microg/ml) of lidocaine occurred after 5-17 h. No correlation was found between peak levels and dose per kg bodyweight or total amount of lidocaine infiltrated. One patient experienced tinnitus after 14 h when a plasma level of 3.3 microg/ml was recorded.

CONCLUSION

Doses of lidocaine up to 35 mg/kg were sufficient for abdominal liposuction using the tumescent technique and gave no fluid overload or toxic symptoms in eight patients, but with this dose there is still a risk of subjective symptoms in association with the peak level of lidocaine that may appear after discharge.

Influence of fat pad removal on patellar tendon length during growth

During various knee operations, the changes caused by the surgical invasion to the infrapatellar fat pad (IPF) is still unknown. If any changes exist, it will have great influence especially on growing generations. Eighty-four Japanese white rabbits (6-month-old) were divided into three groups: the resection group involving resection of the IPF, the graft group involving resection and reimplantation of the IPF, and the no-surgery group. All these surgical procedures were done in right knees. In all left knees, only arthrotomy was performed, serving as the sham side. After 3, 6, 12, and 24 weeks of the operation, the rabbits were killed. Lengths of the patellar tendon and patellar were measured in lateral X-ray. In order to eliminate individual differences in the patellar height, we defined a new index as percent patellar height (PPH) which indicated the percentage of the patellar height of surgery side compared with that of the sham side. The PPH was 90.6% (3 weeks), 83.0% (6 weeks), 73.6% (12 weeks), and 74.7% (24 weeks) in the resection group, while it was 88.4% (6 weeks), and 88.9% (24 weeks) in the graft group. Postsurgical scar tissue formation occurring where the IPF was removed prevented the normal growth of the patellar tendon. Reimplantation of the IPF lessened the adhesion of the patellar tendon to the surrounding tissue, and better growth of the tendon. These results showed that preservation of the IPF in young individuals could be crucial for the normal growth of the patellar tendon, and critical as well for the prevention of the degeneration of the articular surface.

Lower Blepharoplasty: Transconjunctival Fat Repositioning

Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear-trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.