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In 1881, Alexander Graham Bell invented what arguably could be called the first metal detector. President James Garfield had been shot. His doctors needed to locate the bullet that was lodged in his chest, but the president already had lost a significant amount of blood. Doctors therefore were reluctant to perform manual exploration. Bell's invention seemed the best hope. What no one realized at the time was that the metal springs in the mattress upon which the president lay would render Bell's metal detector ineffective. Garfield ultimately died from his wounds. The metal detector endured. Through the work of later inventors, it evolved into a device serving a variety of important functions, most notably helping to ensure our safety in public places.1 Many useful inventions originally intended for one purpose end up better serving another. In plastic surgery, such has been the evolution of barbed sutures. In the 1990s, lifting of the brows, midface, and neck using barbed sutures, usually applied subcutaneously with a threading technique, was widely promoted as a safer, quicker, and less invasive alternative to traditional surgical procedures. However, for many surgeons and their patients, both the short- and longer-term results were disappointing. Complications and other adverse events were common. Some problems were undoubtedly technique related, as practitioners with various backgrounds and little hands-on training with barbed sutures aggressively promoted themselves as experts and performed procedures without the requisite experience. Nevertheless, interest in these threading techniques for suspension of facial tissues waned considerably in the plastic surgery community. Subsequently, however, expanded applications for barbed suture technology have evolved. Sutures are essential in almost every procedure that we perform. The choice of suture depends on several variables, including the anatomic site, desired suture characteristics, and surgeon preference. In my practice, barbed sutures have come to play an …

Barbed sutures first received US Food and Drug Administration approval for soft tissue approximation in 2005 and early adopters readily embraced this device to develop new techniques. It has become apparent that the advantages are more than just "skin deep." Superficial and deep fascia, cartilage, tendon, joint capsule, and fibrous periprosthetic capsules can also be manipulated. Barbed sutures have revolutionized our approach to facial rejuvenation and body contouring by enhancing our ability to quilt and powerfully lift tissue. The elimination of surgical drains and shorter surgical times has made this a true boon for plastic surgeons as well as many other surgical specialists. This article summarizes some of the current and evolving applications of this exciting new tool.

The authors present their minimally invasive gluteopexy technique, using polypropylene 2-0 sutures with 10 absorbable polylactic cones in their distal section (Silhouette Lift, Irvine, California) to improve the anteroposterior projection of the gluteal region. Histological study of the reaction of adipose tissue surrounding the cones previously has shown that, 3 months after insertion of the sutures, fibrous scar tissue is sufficiently developed to resist the weight of the tissues. On the basis of this finding, the authors decided to perform the gluteopexy with sutures, in 2 surgical steps. During the first step, the sutures are inserted in the adipose tissue without any proximal fixation. In the second step, performed 3 months after the first procedure when the fibrous reaction is more solid, the sutures are tightened to obtain the gluteopexy. Among the advantages of this technique are its simplicity, the fact that it produces no traumatic effects, and the fact that it can be performed with local anesthetic, reducing surgical time. It is also possible to combine this procedure with lipofilling or liposuction techniques.

Secure closure of wounds is vital to any plastic surgery procedure. Recent developments in suture design have incorporated the creation of small barbs along the suture strand that are intended to engage the surrounding soft tissue and "lock" the suture (and, therefore, the wound closure) into place. Early experience with this type of modified suture has shown promise for a host of wound closure indications, including the closure of skin and fat as well as superficial and deep fascia. Advantages include secure wound closure, elimination of the need for a "third hand," decreased operative time, and an improved appearance in cutaneous scars.

The evolution of barbed suture technologies and their application in the field of plastic surgery is now in its third decade. Much has been learned along the way. Initial excitement was often followed by disappointment as we learned more about the limited longevity of minimally invasive procedures and complications arising from various suture designs of the past. Some of the early designs, developed primarily for use in aesthetic facial procedures, included free-floating, bidirectionally barbed, nonabsorbable sutures; unidirectional barbed, nonabsorbable sutures; anchored, bidirectional, nonabsorbable double-threaded sutures; and a technology combining a nonabsorbable knotted thread and absorbable cones. More recently, a new, absorbable, unidirectional barbed suture design has become available. However, it should be noted that very limited data are available for any of the modified suture designs used in this field, and much of what has been published is based on the experience of a single user. The author has used the bidirectionally barbed Quill Knotless Tissue-Closure Device (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada), the most common barbed suture in both facial and other aesthetic plastic surgery procedures, with considerable success in various open aesthetic facial procedures, including suspension of the brow and midface, platysmaplasty, and lateral neck suspension. It is the author's experience that completion of 1 to 2 cases with this technology is sufficient to achieve competency in the closure techniques discussed in this article and that time savings can be realized using this device in various breast and body contouring procedures, including mastopexy, reduction mammoplasty, abdominoplasty, bodylift, and brachioplasty.

Increasing numbers of women are seeking correction of labial hypertrophy for aesthetic and/or functional reasons. It is therefore important for plastic surgeons to become familiar with labioplasty surgical techniques. The authors review the history and current status of labioplasty surgery for practicing plastic surgeons, with particular emphasis on anatomy, diagnosis, indications, and various techniques.

The key points to remember about abobotulinumtoxinA are as follows: BoNTA-ABO (abobotulinumtoxinA [Dysport]; Medicis Aesthetics, Scottsdale, AZ) and BoNTA-ONA (onabotulinumtoxin A [Botox Cosmetic]; Allergan, Irvine, CA) are both derivatives of botulinum toxin A produced from different strains of the bacterium Clostridium botulinum through proprietary manufacturing processes, and both are approved by the US Food and Drug Administration (FDA). BoNTA-ABO and BoNTA-ONA, which are both type A botulinum toxins, should be further differentiated from Myobloc (Solstice Neurosciences, San Francisco, CA), which is the only FDA-approved type B botulinum toxin. BoNTA-ABO, as with other derivatives of botulinum toxin, produces a chemodenervation of the muscle by preventing the release and binding of acetylcholine at the neuromuscular endplate. The paralytic effect of BoNTA-ABO, as with other derivatives of botulinum toxin, produces a relaxation of the underlying muscle with the associated benefit of reducing dynamic rhytids of the overlying skin. BoNTA-ABO units are not interchangeable with BoNTA-ONA units. An understanding of the proper dosing and familiarity with the use of either botulinum toxin in aesthetic applications is required to produce results that are both safe and consistent. Spread of the toxin is dependent on solution volume and injection technique (physically pushing the toxin from the area of injection). Diffusion of the toxin is largely dependent on toxin dose and receptor concentration; unbound toxin moves down a concentration gradient. Beyond the treatment of glabellar rhytids, there are few, if any, randomized, double blind, placebo-controlled studies on the aesthetic uses of BoNTA-ABO. This guide summarizes what is known and serves as a basis for clinical use and continued understanding.

Alan Matarasso, MD Foad Nahai, MD Stanley A. Klatsky, MD G. Patrick Maxwell, MD Dr. Matarasso: The need for secondary breast reduction is an uncommon but vexing problem. Indications for secondary breast reduction may include poor shape from previous surgery, unsightly scars, breast asymmetry, increase in breast volume, need for mastopexy, need to increase breast volume and, occasionally, need for reduction of one breast after having cancer in the opposite side. Our first patient is a 63-year-old woman who had a reduction mammaplasty 12 years ago with an inferior pedicle technique (Figure 1). She gained considerable weight over 10 years and complains that her breasts have become larger. Dr. Klatsky, what would be your treatment approach? Figure 1 This 63-year-old woman had an inferior pedicle reduction mammaplasty 12 years ago. She has gained considerable weight over the past 10 years and complains that her breasts have become larger. Dr. Klatsky: Her nipples seem symmetrical and in good position. At the same time, on the lateral view, it looks as though she may have some pseudoptosis. You indicate she has had an overall weight gain, and she does show lateral fullness of the breasts. Since the nipple-areola position is good, I would consider treating her with lipoplasty to reduce volume, accompanied by a mastopexy to provide better shape. In terms of repeating an inferior pedicle technique, since we know that is what she had, I can feel fairly secure about the perfusion. To determine the operative course, I would first perform the lipoplasty and then intraoperatively perform a “tailor-tack” mastopexy, rather than committing to a pattern for the skin resection. I would like to keep the infraareolar to inframammary distance no greater than 7 cm and, ideally, with her volume, 4.5 to 6 cm from the infraareolar margin. Dr. Matarasso: Dr. Maxwell, would …

The author performs buccal fat pad excision to improve facial contour in some patients with buccal lipodystrophy and to treat buccal fat pad pseudoherniation. He recommends an intraoral approach, taking care not to pull on the fat pad and resecting only that which protrudes easily with gentle pressure.

Background: Statistics published by The American Society for Aesthetic Plastic Surgery report a 48% increase in cosmetic procedures for 2000-2001 and a 14% increase for rhytidectomies alone. Patients aged 35 to 50 account for 30.2% of all rhytidectomies performed. Many of these patients undergo secondary rhytidectomy. Objective: We investigated differences between patients undergoing secondary rhytidectomy and those undergoing a primary rhytidectomy, and between older (more than 60 years) and younger (60 years or less) patients undergoing secondary rhytidectomy. Methods: A retrospective descriptive research design with the computer cross-filing system of the senior author (A.M.) was reviewed for patients undergoing secondary or more (ie, tertiary, quaternary, etc) rhytidectomy. A total of 113 consecutive patients were identified; charts from 98 female patients and 3 male patients, were available for review. Ages at the time of surgery ranged from 40 to 81 years, with an average of 60. Results: Among patients older than 60 undergoing secondary face lift, 41 of 53 patients (77%) had combined procedures with their most recent face lift; 39 of 53 (74%) of these patients had at least one comorbid medical condition. Among patients aged 60 or younger undergoing secondary face lift, 37 of 48 patients (77%) underwent multiple procedures along with their most recent face lift, and 16 of 48 patients (33%) had at least one comorbid medical condition. The overall complication rate was 2/101 (2%). Conclusions: There is a statistically significant increase in the number of comorbid medical conditions in older patients. The overall complication rate in patients undergoing secondary rhytidectomy compares favorably to that traditionally quoted for patients undergoing primary rhytidectomy, who on average are younger at the time of surgery. This suggests that in properly screened patients, even in older patients with combined ancillary procedures, secondary face lifting is both common and safe. (Aesthetic Surg J 2002;22:526-530.)

Nuvaring (Organon Kenilworth NJ) is a vaginal contraception ring inserted by the patient. It was approved by the Food and Drug Administration in 2001 for the prevention of pregnancy. The intent of this paper is to increase the awareness of Nuvaring among plastic surgeons and to explore the risks associated with its use. We report the cases of two cosmetic surgery patients. These patients developed deep venous thrombosis and pulmonary emboli in the postoperative period while using Nuvaring. The very advantages of the Nuvaring-the ease of use the avoidance of daily administration and the insertion and removal of the device by the patient-may lead to the failure of patients to recollect being on a vaginal ring for contraception. LEVEL OF EVIDENCE: 4 Risk. (c) 2015 The American Society for Aesthetic Plastic Surgery Inc. Reprints and permission: journals.permissions@oup.com.

Dr. Miller: The first patient is a 40-year-old woman with pale, translucent skin. She is concerned about vertically oriented wrinkle lines in the glabellar area (Figure 1, A ). Dr. Klein, how would you approach this patient? Dr. Klein: If this patient chooses injectables alone and still wishes to have full functioning of the corrugators, my choice would be Zyderm 1 bovine collagen 35 mg per cc (McGhan Pharmaceuticals, Santa Barbara, CA). There is also Zyderm 2, which is administered at 65 mg per cc. To greatly reduce the chance of an adverse reaction, I would perform a skin test initially and again in a month, and then treat her at 6 weeks. I would begin injecting where the lines intersect with the brows and the upper part of the procerus. I would then flow collagen into these areas in a wide, yellowish mass, avoiding any irregularity. When one becomes adept at injecting it, Zyderm 1 produces the best cosmetic result. I frequently get overcorrection in that area when I use Zyderm 2. Timothy A. Miller, MD Val S. Lambros, MD Arnold W. Klein, MD Seth Matarasso, MD Dr. Miller: Are there any technical considerations that you advise when injecting the Zyderm? Dr. Klein: It is important to hold the surface that you are injecting taut. For Zyderm 1, I use a 32-gauge metal needle rather than the 30-gauge needle that comes with it. The injection should create a yellowish color that can be seen beneath the skin. One should not see a residual whiteness upon completion. I inject in a continuous stream, keeping the material flowing from the advancing border after each injection. Dr. Miller: Why do you use a 32-gauge rather than a 30-gauge needle? Dr. Klein: The 32-gauge needle produces less trauma. I don't get the bruising …

Superwet anesthesia is a method of regional anesthesia for liposuction surgery that uses an evenly distributed, rapidly infused solution under pressure, until tissue blanching and moderate tension are achieved, in a ratio of 0.5 to 1.5 ml per milliliter of injectate to lipoaspirate. It is accompanied by systemic anesthesia and supplemented with intravenous hydration. The efficacy of superwet formulation for regional anesthesia was evaluated in a consecutive series of 20 patients who underwent large-volume (>1500 ml) liposuction. The average volume of injectate was 2285 ml and fat aspirate was 2437.5 ml. The average fluid volume fractionated from the aspirate infranatant was 507.5 ml, and the amount of injectate absorbed was 1775.5 ml. The mean “pure fat” fractionation was 1930 ml. Approximately 21% to 22% of injected fluid is not absorbed, so the ratio of fat removed to fluid absorbed by hypodermoclysis is in the range of 11. Consequently, this requires an alteration in traditional fluid replacement levels. This also alters the threshold of what has been traditionally considered “large”-volume liposuction so that the traditional 1500 ml defining large-volume aspirate may no longer be applicable. To achieve consistency in reporting, all liposuction data should be standardized to routinely include the volumes of injectate, aspirate, and infranatant fluid fractionation.

Ligatures have been used for millennia to close wounds. Sterilization and synthetic polymers that degrade in a commensurate fashion with wound healing have been the most significant improvements in these age-old devices. However, the constricting loop of a traditional suture and subsequent ischemia ("approximate, don't strangulate") still account for the most common cause of wound dehiscence-necrosis. Inspired by the quill of the North American porcupine, I envisioned a bidirectional array of barbs that could secure tissue without relying on constricting loops. One set of barbs could anchor the other. In this article, I document the development process of these barbed sutures from concept to patent to manufacture and US Food and Drug Administration approval. Knotless, strong, and easy to place, barbed sutures could foreseeably supplant conventional sutures, particularly as endoscopic procedures become more common. They also offer the intriguing potential to suspend ptotic tissues without surgical intervention.

Background: Body contouring operations are concluded with suture closure of long incisions under tension. While an expeditious and secure repair without complications is the objective, wound closure typically consumes a substantial percentage of the operative time and too often leads to delayed wound healing and other problems. Objectives: The authors evaluate suture-line wound healing for body contouring operations with barbed suture wound closure compared with absorbable running suture closure. Methods: In this retrospective study, wound-healing complications for a 228 consecutive-patient cohort with barbed sutures over a period of 4 years were compared with those for a prior 132 consecutive-patient cohort with absorbable running sutures over a period of 2 years. Complications were classified according to severity: grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The preferred suture techniques for the closure of either thick or thin subcutaneous tissue under tension are described. The authors’ clinical impressions are also presented. Results: Patients whose wounds were closed with absorbable running sutures had a significantly greater incidence of complications at all severity grades of severity than did those with barbed suture closures, with the exception of grade 3 (severe) complications in thighplasty. Logistical regression was

Wound-closing technology continues to evolve with the advent of barbed sutures, which appear to address some of the limitations of traditional sutures (numerous knots and time-consuming insertion, among other things). Advantages of knotless suture devices, specifically in body contouring, have been discussed in the literature over the past decade, with a recent increase over the past several years due to the US Food and Drug Administration (FDA) approval of unidirectional V-Loc (Covidien, Mansfield, Massachusetts) and bidirectional Quill (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada) barbed sutures for soft tissue approximation. A thorough review of the existing literature and evaluation of the author's personal experience are presented in this article. As with any new surgical device, a learning curve is present that needs to be overcome to realize the full benefits of utilizing barbed sutures in body surgery while minimizing their complications.

The authors discuss why Botox is their preferred nonsurgical treatment for lateral canthal rhytids, or crow's-feet. Three or 4 injections are spaced at 1.0- to 1.5-cm intervals beginning immediately beneath the lateral edge of the eyebrow and extending down to the lateral infraorbital rim. Complications are infrequent and can usually be avoided with the injection techniques described.

As aesthetic surgeons, we have an interest not only in the appearance of our patients but also in their general health. Obesity undeniably has a great impact on both. As radical but effective procedures to treat obesity become more common, as is happening now, our surgical expertise in treating the after-effects of massive weight loss will be in greater demand. This is likely to foster the development of what might be dubbed the “new” field of bariatric plastic surgery . The twin epidemics of obesity and diabetes continue to spread unchecked in the United States. The facts about obesity are alarming and their implications profound. A study by the Centers for Disease Control and Prevention, published in the Journal of the American Medical Association ,1 reported that in 1991, 21% of the population — more than 44 million people — were obese (body-mass index > 30), 60% were overweight or obese, and 6 million were morbidly obese. Eight percent of …

Injectable synthetic hyaluronic acid is biodegradable and biocompatible with human hyaluronic acid. Soft tissue augmentation with this product does not require prior skin testing and provides robust augmentation. Its ability to attract and maintain significant amounts of water accounts for the volume and duration of correction that persists until the stabilized gel is completely metabolized.

The disease entity known as venous thromboembolism (deep vein thrombosis and pulmonary embolism [DVT/PE]) continues to be a public health hazard, with an estimated 600,000 annual cases. It carries a morbidity of up to one third of cases and represents a significant disability in those patients who have postphlebitic syndrome or other disease sequelae. In 1860, Virchow described a triad of conditions that remain valid predictors of throm-boembolic disease today. Numerous risk factors, including age over 40 years, pregnancy, female gender, supplemental hormone therapy (eg, birth control pills), obesity, heart-related conditions, cancer, a personal or familial history, genetic factors, smoking, multiple trauma fractures, certain surgical procedures, and all surgery longer than 30 minutes or involving general anesthesia, predispose individuals to venous thromboembolism. With continuing progress in science and technology, additional risk factors will undoubtedly be identified. In 1954, a report appeared in the New England Journal of Medicine describing DVT related to air travel. Two British researchers, followed by Cruickshank, introduced the term … Reprint requests: Alan Matarasso, MD,1009 Park Avenue, New York, NY 10028.

Ostensibly, role models are chosen because they embody important and uncommon characteristics that may affect the way we view our lives—and the way we live them. When emulated, they can serve as mentors who provide guidance and influence our career choices. When I reflect on my own career, it is enlightening to realize how many plastic surgeons have been role models who not only directly or indirectly influenced me but also had an impact on current American aesthetic surgery practice as a whole. Alan Matarasso, MD , is Senior Scientific Editor of Aesthetic Surgery Journal. Consequently, I am struck by the fact that many of the role models for our profession are no longer visible; many nationally recognized giants of plastic surgery are semiretired or “slowing down,” while numerous other, locally recognized plastic …

Background: Many patients who seek “abdominal” contour surgery also desire improvement of areas of the torso adjacent to the abdomen, such as the flanks and back rolls. Objective: We propose a classification of the abdomen into distinct aesthetic units and report on a series of cases in which this classification was used, with special emphasis on one such unit, the mons pubis. Methods: A series of 400 consecutive patients were evaluated according the proposed designation of aesthetic units. Lipoplasty was performed as described in previous studies. A subset of 6 patients who specifically desired improvement of the mons pubis were treated by lipoplasty and/or horizontal or vertical wedge incision. Results: Most patients who received treatment according to aesthetic unit were satisfied with their outcomes. Two of the patients who sought improvement of the mons pubis specifically requested additional procedures. Conclusions: An approach to abdominal contour surgery that includes consideration of all related aesthetic units can achieve more proportional, harmonious results and increase patient satisfaction.

A little more than 20 years ago, Dr. D. Ralph Millard walked into my medical school class on the mechanism of disease at the University of Miami's Rosenstiel fourth-floor auditorium and demonstrated a tubed pedicle being waltzed up a postmastectomy chest. Within the space of a few months, my life changed forever. There was no question of what type of physician I intended to become. I never considered anything else, and I never looked back. As a third-year medical student, I read Plastic and Reconstructive Surgery, subscribed to the first issue of the Annals of Plastic Surgery, and studied in the Gillies Memorial Library. By my senior year I had already memorized the “Principles” of plastic surgery (Gillies H, Millard, DR Jr. The Principles and Art of Plastic Surgery. Boston: Little, Brown, 1957;1:1-317; 11:318-652) and spent half of my fourth year rotating on the plastic surgery service. In the ensuing years we have witnessed an incredible explosion in the …

After an intensive, industry-financed lobbying and publicity campaign, Congress approved the Dietary Supplement Health and Education Act in 1994. This law stipulates that, to remove a product from the market, usually as a result of consumer harm or injury, the Food and Drug Administration (FDA) has to prove it unsafe. Moreover, the product can remain available until the FDA finishes its testing and proves its allegations in court. Often the process of removing a product is hastened only after significant adverse publicity and complications cause a drop in sales (as in the case of L-tryptophan). It is estimated that approximately 60% to 80% of the American population has taken or would take herbs, nutritional supplements, or vitamins (dietary supplements). Annual sales of these over-the-counter products now represent a $12 billion industry. There are …