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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.)

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.

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.

We appreciate the opportunity to respond to the letter from Dr Rodriguez Muniz. I suspect that Dr Daher et al, who Dr Muniz credit with being …

As aesthetic surgeons and medical practitioners, we always welcome the opportunity to offer patients new treatment options that have been tested for safety and efficacy. The approval of a new formulation of botulinum neurotoxin type A (BoNTA-ABO; Dysport [abobotulinumtoxinA], Medicis Aesthetics, Scottsdale, AZ) by the US Food and Drug Administration (FDA) offers aesthetic specialists in the United States just such an opportunity. FDA approval of BoNTA-ABO is for treatment of cervical dystonia in adults and for temporary improvement in the appearance of moderate to severe glabellar lines in adults under 65 years of age. Back in the 1980s, it would have been difficult (if not impossible) to predict that within 20 years, nonsurgical rejuvenation would be the fastest growing segment of most cosmetic practices. I am well aware that the 1980s may seem like ancient history to some readers of Aesthetic Surgery Journal . In fact, in the ‘80s—when I was a medical student, house officer, and junior attending—if a senior surgeon referred to “how we did it back in the ‘60s,” I would listen politely but usually considered the information largely irrelevant. Like many young surgeons, I held the belief that the world was different then. Today, that's probably more true than ever, but to understand how we arrived at the point where an entire supplement of the world's leading journal of cosmetic surgery is devoted …

Alan Matarasso, MD, is a Senior Scientific Editor of Aesthetic Surgery Journal. The number of bariatric surgery procedures performed in the United States has leapt from approximately 13,000 in 1998 to potentially just under 200,000 in 2006. A key reason for this increase is the recognition that bariatric surgery is an effective, and perhaps the most effective, treatment for morbid obesity. This understanding prompted Medicare to announce earlier this year that it would cover the cost of bariatric surgery, provided that it was performed in a designated center of excellence. Although bariatric surgery has now won acceptance as a treatment for morbid obesity, surgeons continue to focus on issues of safety and outcomes data. Although the reported incidence of complications associated with the procedure is high, bariatric surgeons argue that complications are significantly reduced when surgery is performed in a center of excellence and/or using …

By early afternoon on September 11, New York was a different city than it had been just hours before, and lower Manhattan was a different world. A thick cloud of smoke from the devastation at the World Trade Center filled the sky and could be seen from almost every corner of the city. Sidewalks were filled with stunned throngs of people who had been directed to walk north. The shrill sirens of fire trucks and ambulances could be heard blaring as they raced in the opposite direction. Lines formed around hospitals and other facilities where blood donations were being collected, and rescue volunteers assembled in front of armories where armed guards in full combat gear were stationed. For me, the day had started out like most others. I had planned on a full schedule of elective surgery in the morning, new patients …

No matter what your political views, the paradox of the lifestyle and finances of Bill Clinton is noteworthy. In spite of room, board, a jet plane, and numerous other perks, Clinton's salary is still only $200,000—a lot of money, but after taxes, probably closer to $100,000. So when I learned that his recent peccadilloes had resulted in legal bills of more than $4 million (and he hasn't even gone to court), causing him to resort to calling on friends to donate money (and, on top of that, think what the special prosecutor will cost taxpayers—the gross national product of a developing country), I got to thinking. What the President needs is national legal insurance. Here's how it would work: For a monthly premium …

Alan Matarasso, MD , is Senior Scientific Editor of Aesthetic Surgery Journal. There was a time when referrals were relatively uncomplicated. The mother who called the pediatrician when her child fractured a bone was referred directly to the orthopedist, and the gynecologist who was asked about a breast lift referred that patient unconditionally to a plastic surgeon. There was no need to worry that the mother's mention of her child's allergy shots might prompt the orthopedist to volunteer to do them, or that the gynecologist would have racks of literature on liposuction and …