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The transumbilical breast augmentation procedure has proved to be highly effective and safe when performed properly, as outlined herein. In the author's opinion, the popularity of the procedure will continue to increase among both surgeons and patients. This article focuses on the steps necessary to maximize the continuing safety of the procedure. The three most critical points are that no sharp instruments are used, the surgeon's handling of the instrument prevents any long thrusts, and at no time does any instrument point toward the abdominal or thoracic cavity. These and numerous other safety tips are presented here.

Background: Capsular contracture (CC) is a common complication after breast augmentation. Autologous fat grafting may be effective for restoring tissue vascularization and function. Objective: The authors evaluated the efficacy of autologous fat grafting in a porcine model as a treatment for CC after breast augmentation. Methods: This prospective study was performed in 20 female 30-day-old pigs. Each animal was implanted with three 30-cc textured silicone implants (stage 1 of the experiment). Group A served as the untreated control group. To induce CC, 2 mL of autologous fibrin glue was applied to the pericapsular space in group B and C animals at implantation. Three months after implantation (stage 2), the CCs of all groups were assessed by Baker classification and applanation tonometry (AT). Liposuction was performed in group B to harvest fat for these animals. Three months after group B underwent fat grafting, all 3 groups were reevaluated. Reassessments included Baker classification, AT, histologic analysis, and tensiometry (stage 3). Results: The deposition of mature and immature collagen was similar for the 3 groups. The amount of fat remaining around the implanted capsules did not differ significantly between the groups. At stage 3, group B exhibited significantly larger tonometry areas than did group C. The CCs in groups B and C were significantly thicker than those of group A, but the difference between groups B and C was not significant. Capsule rupture forces did not differ significantly between groups A and B but were significantly higher in group C compared with the other groups. Conclusions: Results in this animal model indicate that pericapsular lipoinjection may be a promising treatment for CC in humans.

The authors offer a new technique that provides a better long-term upper pole fullness to the shape of the breasts following reduction mammoplasty, thus creating an overall more satisfactory aesthetic appearance for both breasts.

Background: Efforts to reduce the size or improve the shape of the ptotic breast have resulted in long, obtrusive scars or a shape that lacks upper-pole fullness and projection. Objective: The goal of the present study was to evaluate the short-term and long-term results of a modified procedure that was designed to provide long-lasting upper-pole fullness and reduce visible scarring. Methods: As a result of the use of a shortened oblique incision and the elevation of an inferior chest wall-based flap, divided at its inferior subcutaneous attachment and maintained in the cephalad position by a loop of pectoral muscle, the scar is unobtrusive and the shape is optimal, with lasting fullness in the upper pole. Results: From 1984 to 1998, 1521 women underwent breast reduction or mastopexy. Long-term follow-up (4 years) indicates maintenance of the full upper pole of the breast and satisfaction of nearly all of the patients. All complications, which included steatonecrosis and skin dehiscence below the areola, resolved without additional surgery within 6 months postoperatively. Conclusions: An aesthetically pleasing breast requires a proper shape and adequate skin cover, with a nipple-areola complex at the apex of the mound. The technique presented achieves these goals with an unobtrusive lateral scar that does not extend beyond the anterior axillary line.

The Ultrapulse CO2 laser (Coherent Inc., Palo Alto, CA, USA) was used in 239 patients, from March 1996 to July 1998, for full-face laser resurfacing. In 106 (43%) of these patients rhytidectomy was performed in the same procedure. All patients submitted to laser resurfacing were prepared for 1 to 2 months beforehand with retinoic acid and hydroquinone. The procedures were done under local anesthesia controlled by an anesthesiologist. A clear film dressing impregnated with silicone gel (Silon TSR; Bio-Med Sciences, Bethlehem, PA, USA) was used for 6 to 7 days and complete healing was observed in 7 to 10 days. Complications were exclusively dermatologic, without relation to surgery. No necrosis of the cutaneous flap was observed. Skin biopsies of 10 consecutive patients undergoing the combined procedures revealed no vascular impairment to the dermis. The patients were able to resume their activities 2 weeks after the procedure.

The mastopexy with chest-wall-based flap and pectoralis muscle loop is a maneuver designed to give a better shape to the breast. The technique can be used with different kinds of incisions: standard inverted T, short T, L-shaped incisions, or periareolar vertical incisions. If reduction is necessary, it can easily be carried out in this technique by removing the desired amount either vertically under the breast or from its base. The technique is described.

In the 1960s, carbon dioxide (CO2) laser therapy started to be applied to eliminate wrinkles, actinic scars, and acne because of its capacity of induce intracellular water vaporization. However, recent studies have shown the efficacy of the erbium laser in removing delicate and moderate scars. Furthermore, the postoperative lesions induced by the erbium laser seem to resolve faster and with less erythematous pattern compared with lesions induced by the CO2 laser. The purpose of this study was to determine the immediate pathologic alterations caused by single applications of CO2 and erbium lasers and their association in human skin shreds. Ten white female patients aged 30 to 63 years underwent rhytidectomy, and their respective shreds, which were prepared for excision, were tattooed with the CO2 laser, the erbium laser, or a combination of both in random order and number of applications, before final removal. This project was approved by the local ethical committee. After surgical removal, these tattooed shreds were fixed in 10% buffered formalin and submitted to histopathologic analysis. Morphometric studies demonstrated the normal skin thickness and thickness of the laser-treated area, and their subtraction resulted in the ablation damage values. Residual thermal damage corresponded to the thickness of the affected skin from the most superficial layer of tissue in the laser-treated area down to the deepest dermal area with basophilic degeneration of collagen fibers. Our results showed that two CO2 applications resulted in greater ablation and residual thermal damage when compared with only one CO2 application. The same was true in comparisons of one and two applications of the erbium laser. Both results were statistically significant (p < 0.05). When one isolated erbium and one isolated CO2 application were compared, ablation damage was greater in the former group, although with no statistical significance. One CO2 plus one erbium application compared with one isolated CO2 application showed similar ablation damage but greater residual thermal damage in the latter group (p < 0.05). These observations might contribute to our understanding of the lesions caused in the human skin by erbium and CO2 lasers and eventually help determine the ideal laser combination for the appropriate surgical treatment.

Nowadays, obesity is epidemic all around the world. Statistics of some studies report the prevalence of obesity in more than 1.7 billion people in the world. In the United States, around 5% of people have morbid obesity. This health problem has a lot of causes that include the sedentary life and the foods habits [1]. An important aspect of body contouring after massive weight loss is the reshape of the breast and the upper body. The treatment requires the correct diagnoses and understanding of the anatomy. There are a lot of different types of breast after the patient lost weight. Usually, the ptosis and the laxity of the skin are extensive and is common the decreased inframammary crease in continues with the upper back roll. Some patients have an adequate quantity of fat and glandular tissue to perform the mastopexy. But in general, despite excess skin, the breast lose majority of fat, and has excess of skin and tissue in the lateral aspect of the breast and the back (the upper back roll).

Dr. Colen: The first patient is a 29-year-old woman who underwent a periareolar subpectoral augmentation with a round, smooth saline implant 1 year ago (Figure 1). Dr. Giese, can you describe this patient's problem and how it might have been avoided? Dr. Giese: In this oblique view, it appears that the patient has a double-bubble deformity. In addition, her breast mound and the implant appear unequal; her left breast seems higher on the chest wall than the right. Figure 1 This 29-year-old woman underwent periareolar subpectoral augmentation with a round, smooth saline implant 1 year ago. She does not like the appearance of her breasts. To avoid the occurrence of a double bubble, I would not have chosen to obliterate the natural inframammary fold, if possible. The natural inframammary fold acts as a very strong sling to keep the implants properly positioned on the chest wall. Here, the implant has fallen beyond the natural portion of her breast and into the surgically created inframammary fold pocket. This patient needed an augmentation mastopexy. I like the periareolar approach and the subpectoral position with a round, smooth saline implant, but, again, I would have tried to avoid lowering or changing her natural inframammary folds. Maybe that would have meant using a smaller implant. I do not know what necessitated lowering the folds. Dr. Colen: Dr. Hammond, what would your initial approach to this patient have been? Dr. Hammond: If I felt that she needed a mastopexy, I would have performed a periareolar mastopexy without hesitation. When I am already in the periareolar incision, I use that to gain access to the breast; it is a very nice approach to the lower breast apron. The inframammary-fold incision sometimes masks the location of that fold when the implant is inserted. But from above, through the periareolar …

The authors describe a mastopexy technique that is effective in treating small and mildly ptotic breasts to extremely large breasts and maintains breast shape over time. Tissue that in more traditional procedures has frequently “bottomed out” is moved into the upper pole and supported with a sling of pectoralis muscle.

Ever since Poland described a group of anomalies with absence of the pectoralis major and minor muscles and syndactyly of the ipsilateral hand, many variations of this condition have been reported in the literature. Thomson, in 1895, added other features, including the absence of ribs, chest wall depression, amastia with or without athelia, the absence of axillary hair, and limited subcutaneous fat. Other authors have described the syndrome by many names, including subclavian artery supply disruption sequence, hand and ipsilateral thorax syndrome, fissura thoracis lateralis, acro-pectoral-renal field defect, pectoral-aplasia-dysdactylia syndrome, and unilateral chest–hand deformity. Goals of surgical repair of these anomalies are twofold: to correct any functional deficits and to create a cosmetically acceptable result. A variety of surgical procedures are available to treat the various deformities.

Women are concerned about breast size and breast contour when requesting breast augmentation. Different techniques have been developed to offer a better result concerning scar position and natural contour of the breast. The major advantage of transaxillary breast augmentation is to not place a scar in the breast unit. The disadvantages of submuscular placement include a more invasive procedure, increased postoperative discomfort, and visible flattening or distortion of the breast when the pectoral muscle is contracted. If the muscle is released inadequately medially, the implant may ride too high, or if the muscle is released excessively, the implant may be displaced inferiorly and laterally. The position of an implant in the subglandular space has significant disadvantages if the soft tissue cover is inadequate. In addition to implant palpability and visibility, the rates of fibrous capsular contracture, rippling, and nipple sensation alteration, such as numbness, are higher. The subfascial plane is well recognized and widely used among plastic surgeons to improve the results in breast augmentation.

The quest for better results in the midface after a face lift has led to the repositioning of a structure called the malar fat pad. Finger-assisted malar elevation (FAME) consists of detaching the malar fat pad from the underlying SMAS, which allows for the elevation of this structure. Two hundred five patients (189 females and 16 males) from January 2002 to August 2007 underwent a facial rejuvenation procedure comprising short-scar rhytidoplasty, SMASectomy, and FAME, with or without a simultaneous endobrow, blepharoplasty, and lipofilling. The midface fixation technique consisted of a stitch from the malar fat pad and SMAS flap to the periosteum at the zygomatic arch which was performed in every case. Elevation of the midface and improvement of the nasolabial fold and the mandible contour were obtained in all cases. Facial aging should be evaluated as a global process instead of a segmented one. Aging occurs in every structure of the face in different ways, depending on the vector of descent, thereby treatment must be individualized. We have observed improvement of the midface when using the FAME procedure in a rhytidoplasty with SMASectomy with deep fixation.

Background: Endoscopic brow lift has become widely accepted as a method for rejuvenation of the upper third of the face, mainly to achieve eyebrow elevation. In this study, the authors quantified eyebrow elevation after videoendoscopic subperiosteal technique and followed up the heights of the eyebrows at different postoperative intervals. Methods: Seventy-two patients were submitted to endoscopic subperiosteal brow lift, and photographic evaluation was performed preoperatively and at different intervals postoperatively. From an interpupillary line, three different measurements on each side were obtained up to the superior border of both eyebrows. The distance between the medial eyebrows was also measured. Results were analyzed statistically by using the t test. Results: Comparing preoperative values and those obtained at 5 months postoperatively, significant augmentation in medial, central, and lateral height of both eyebrows was noted (p < 0.05). Analyzing a group of 38 patients with mean postoperative times of 8.5 and 3.5 months, it was noted that there is spontaneous and significant augmentation in the medial height of both eyebrows (p < 0.05). A third group (24 patients) was analyzed at mean postoperative times of 3.5 and 24 months. The later follow-up showed continuous and significant elevation of the medial, central, and lateral height of both eyebrows (p < 0.05). The distance between medial eyebrows did not show any statistical difference. Conclusion: Subperiosteal endoscopic brow lift showed clinical and statistical effectiveness in correcting eyebrow ptosis, promoting also a spontaneous and progressive elevation of eyebrows, without enlarging the interbrow distance.

Wound contractures can cause severe deformities and disabilities. Recent studies have suggested that leukotriene receptor antagonists have an inhibitory effect on the healing contraction process. This study aimed to evaluate the influence of the leukotriene inhibitor montelukast on the cutaneous healing process and the wound contraction phenomenon in rats.For this study, 60 male rats were randomly divided into four groups (MK-7d, SF-7d, MK-14d, and SF-14d) according to the drug given through a rigid orogastric tube (MK group: montelukast 10 mg/kg/day; SF group: normal saline solution) and the day the animals were killed (7d: postoperative day 7; 14d: postoperative day 14). An excisional wound (2 x 2 cm) was created on the dorsum of each rat. The wounds were left open to heal spontaneously and documented by standard digital photographs on different postoperative days. Wound contraction rates were calculated with specific software, and specimens were histologically evaluated using picrosirius red stain. Results were analyzed using the Aspin-Welch, Mann-Whitney, and t tests, assuming a significance level of 5%.The wound contraction rates were similar between the control and study groups (p0.05). On postoperative day 7, the wounds showed a marginally significant reduction in collagen maturation in the study group (40.1% +/- 6.88% vs 61.2% +/- 8.02%; p = 0.0607). On postoperative day 14, this reduction was statistically significant in the MK group (26% +/- 5.66% vs 68.3% +/- 7.76%; p = 0.0001).Montelukast does not alter the contraction rate of excisional wounds in rats but has a significant and progressive inhibitory effect on collagen maturation.

Aesthetic improvements of the upper third of the face have been a challenge for nearly a century. Brow ptosis management has undergone evolutionary changes from the classic coronal open brow and anterior hairline techniques to the more recently described less-invasive techniques such as minimal incision lateral brow lift and endoscopic brow lift [2].

The literature reports many variations of Poland’s syndrome. This article describes 18 cases of Poland’s syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques. This study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple–areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case. For the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple–areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap. This study demonstrated several breast reconstruction options for patients with Poland’s syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.

Abdominal compartment syndrome is directly related to an increase in intraabdominal pressure (IAP), which can lead in severe cases to serious clinical consequences. Routine measurement of IAP in specific cases has been advocated by some surgical specialties. However, few studies in plastic surgery have focused on the use of IAP. The authors review the literature and describe a method of IAP analysis used for 12 patients who underwent abdominoplasty.

INTRODUÇÃO: Diferente do lifting, cuja tração mecânica é a responsável pelo efeito clínico de rejuvenescimento sobre rugas profundas, a fibroplasia (ou neocolagenização) é a responsável direta pelo resultado final da ação do laser sobre a pele com rugas superficiais, conferindo-lhe aparência mais jovem. O uso combinado dessas duas técnicas pode ser vantajoso, pois permite um resultado estético melhor com um único procedimento anestésico e cirúrgico em um curto período de recuperação. OBJETIVOS: O presente estudo morfométrico se propõe a avaliar se ocorre alguma alteração na espessura da fibroplasia induzida pelo resurfacing a laser erbium:YAG quando este se associa ao lifting cutâneo. MÉTODO: Foram utilizados 50 ratos da linhagem Wistar, divididos em dois grupos de 25, sendo que o primeiro grupo foi submetido à aplicação exclusiva de laser erbium:YAG no dorso de cada animal e o outro sofreu a aplicação de laser Erbium: YAG combinada ao lifting, o qual foi representado, no animal de experimentação, por retalho cutâneo dorsal pediculado. A fibroplasia foi avaliada nos dois grupos com medidas morfométricas lineares realizadas após o sacrifício dos animais nos dias 14, 28, 56, 84 e 112 do pós-operatório. RESULTADO: Foi observado aumento da fibroplasia em ambos os grupos estudados, porém o crescimento do colágeno foi superior no grupo submetido à terapia isolada com laser Erbium: YAG. CONCLUSÃO: A espessura da fibroplasia induzida pelo resurfacing a laser Erbium: YAG foi influenciada pela associação de um segundo procedimento cirúrgico no mesmo tempo operatório, neste caso, o lifting cutâneo.

The early experiences using ultrasound-assisted liposuction in treating difficult fibrous cases, such as gynecomastia, have led to the evolution and improvement of ultrasound-assisted liposuction techniques. This prospective study examined 348 consecutive patients treated with ultrasound-assisted liposuction over two and a half years, from October of 1998 to July of 2001. We use a three-stage technique consisting of infiltration, ultrasound-assisted sculpturing, and suction-assisted liposuction. This technique has improved our final outcome, with better skin contraction, shorter operative time, and minimization of complications, resulting in the optimization of liposuction as a safe procedure.

O presente estudo tem como objetivo analisar, do ponto de vista anatomopatológico, os efeitos térmicos encontrados na pele de ratos wistar após a aplicação do laser de CO2 e do laser erbium. Utilizaram-se oito ratos submetidos a tricotomia em toda a região toracodorsal. Selecionaram-se duas áreas separadas, as quais receberam a aplicação do laser. Na primeira foram realizadas duas passadas do laser de CO2 e na segunda, duas passadas do laser erbium. A área-controle correspondeu àquela imediatamente adjacente à área submetida ao laser. A análise microscópica da lesão causada pelo laser de CO2 revela lesão em forma de U, com ablação completa da epiderme em toda a sua extensão. A derme superficial apresenta degeneração do colágeno, correspondendo ao dano térmico residual, e a transição deste para a derme normal é bem demarcada. Na pele lesada com laser erbium observa-se também extensa área de pele lesada em forma de platô, com algumas pequenas áreas de pele não-lesada. Pode-se observar, ainda, dano do colágeno na derme superficial, porém mais discreto que aquele causado pelo CO2. The aim of this paper is to analyses the histopathology of the termal effects on the skin of Wistar rats after the application of CO2 and erbium laser. Eight rats had their flanks shaved and two areas were selected for the use of the laser. The first area received two applications of CO2 laser, and the second area two applications of the erbium laser. The skin adjacent to the laser application site was used as a control area. The microscopic analysis of the injury caused by CO2 laser revealed a complete ablation of epidermis and an injury that looked like an "U" in shape. The superficial dermis presented a degeneration of the collagen that corresponded to the residual thermal injury, to normal dermis was sharply demarcated. The injury caused by erbium laser was observed as a plateau injured area with a few small normal areas. The collagen of the superficial dermis was also injured, however to a lesser degree as compared to CO2 laser effect.

Video endoscopy for breast hypoplasia and glabellar frown lines has been used since 1996 at our private clinic. Breast augmentation with an S-shape incision for transaxillary access is utilized to introduce the implant, in a submuscular or subglandular and, recently (since October 1998), in a subfascial location. From August 1998 through January 1999, 62 patients underwent endoscopic surgeries; 49 were submuscular, 5 subglandular, and 8 subfascial. McGhan 410, anatomical biodimensional implants 155 to 235 g, were used. We observed three cases of complications, two of them malpositioning (rotation), needing reoperation, and one hematoma, treated with drainage. Patient satisfaction was high, especially regarding the axillary incision. There have been no capsular contractions to date.

Corduff and Taylor [1] from Australia reported on their technique for vertical mastopexy with the use of a large vascularized flap rotated to fill the upper pole of the breast. They present 25 patients, over 2 years, who have undergone the procedure; 18 were primary mastopexies and 7 were mastopexies after implant removal. The authors were very clear when they declared that ‘‘the goals of a mastopexy are to restore shape and volume,’’ but the biggest difficulty is to maintain this shape for long-term follow-up. If we do not use an implant, the goal is to remove the tissue from the inferior pole to avoid an earlier bottoming out. The challenge is how to do it. The authors rotate a flap from the lower breast gland as a medial pedicle flap into a pocket beneath the upper pole. They describe the anatomy and explain the technique very well. However, I did not see differences between their technique and Hall-Findlay’s technique [2]. Hall-Findlay uses a medial pedicle flap to move and fill the upper pole, but she does not undermine the upper pole as the authors do. Maybe this is the only difference between the two techniques. The authors wrote in the Introduction: ‘‘Techniques have been described using small glandular flaps transposed to increase projection [2–7], but these do not adequately fill out the upper pole.’’ Therefore, the authors’ ideas conflict with the already established technique, as Hall-Findlay (ref. 6 in Corduff and Taylor) and Graf and Biggs (ref. 2 in Corduff and Taylor) [3] described, in which they rotate flaps from the middle and inferior pole of the breast, respectively, to fill the upper pole. Regarding Graf’s technique, the main goal is upper-pole fullness, where a chest wall-based flap is moved superiorly, passing under a loop of the pectoralis muscle flap, and is fixed to the upper pole reaching the second intercostal space. This provides a long-lasting result with upper-pole fullness. We can add new techniques and new approaches but never try to decrease the merits of the already described techniques. In breast mastopexy, no one is perfect because the breast is a not a fixed organ and changes with the aging process. Every technique seeks to maintain the results for long-term follow-up, but only a few have reached these goals. We can observe in this paper (Figs. 7–10) that the postoperative results are similar to many techniques with the upper pole not completely full as the authors try to show. When we have so many different techniques to fix one problem, it means that no one is perfect; as Tom Biggs always says: ‘‘No key fits every lock.’’ We have to analyze every case and try to use the best for each case. One of the important aspects is the skin quality of the patients. It sometimes guides the final result regardless of the technique used. I agree with some of the authors’ points regarding attempts to improve upper-pole fullness in mastopexy by using well-vascularized flaps when the patient has enough breast tissue to use. I congratulate the authors for embracing this challenge, treating breast ptosis with the patient’s own tissues to obtain a successful result with mastopexy. Certainly there is no one right way to do this. It will depend upon the experience and preference of the surgeon and on each individual pattern of the breast. R. M. Graf (&) Division of Plastic Surgery, Hospital de Clinicas, School of Medicine, Federal University of Parana, Rua Solimoes 1175 Merces, Curitiba, PR 80810-070, Brazil e-mail: ruthgraf@bighost.com.br