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Resolution of the silicone breast implant crisis has been followed by resurgence in the popularity of augmentation mammaplasty. Past concerns over breast implant safety have created a patient population that is more sophisticated, and has access to a greater number of information resources, than the previous generation. These well-informed patients are seeking augmentation that minimizes potential scarring, while delivering a more aesthetic breast contour. Many arrive for consultation aware of their options, and frequently fresh from consultation with other plastic surgeons. They expect to be presented with expertise and experience in all facets of augmentation mammaplasty-including the surgical approach. In this setting, transaxillary subpectoral augmentation mammaplasty, using endoscopic assistance, has emerged as a frontline choice for many patients. It provides a safe and effective route to aesthetic breast augmentation with minimal complications, and a highly acceptable scar location. Mastery of the approach is no longer optional for surgeons who want to offer a full spectrum of services to their patients. The operation, its evolution, and technical details are discussed in detail.

Not all patients presenting for breast reconstruction are candidates for the TRAM flap procedure. Patients requesting autologous reconstruction may have already had an abdominoplasty or TRAM flap and may be unsuitable for an autologous latissimus flap. Many of these women have lipodystrophy of the flank or hip areas, which provide suitable donor tissue for breast reconstruction. Taylor described the iliac crest composite flap for tibial reconstruction two decades ago. Hartrampf described the Rubens flap as a modification of this procedure, which provided a robust skin and fat flap suitable for microsurgical breast reconstruction. The learning curve for this procedure is fairly steep and carries relatively few complications once the pit falls have been mastered. Although experience with this flap has been limited primarily to a few centers, it does provide a very useful alternative to the gluteal free flaps for autologous breast reconstruction. The donor sight is aesthetically pleasing to patients and requires contralateral balancing procedures relatively infrequently.

Reduction of the breast with the vertical technique not only eliminates the inframammary scar but also improvesbreast shape. Elimination of the inframammary scar is a great advantage, especially in those women prone to keloids and hypertrophic scars. Although the ideal candiate for this technique is a nonsmoker, with moderately large breasts and elastic skin, an experienced surgeon may apply this technique to all breast types, regardless of size or skin elasticity. The inconvenience of the unusual early appearance of the breast is far outweighed in terms of final breast shape and scar reduction. Patient satisfaction has been extremely high and complication rates are comparable to those of other techniques. It is my firm belief that short scar techniques, especially the vertical scar technique, will eventually replace those techniques relying on the classical inverted T-incision.

Endoscopic technique may be applicable in selected patients undergoing neck rejuvenation with goals of decreased scar and morbidity. Access incision sites include submental, occipital scalp, and optionally the retroauricular sulcus. No preauricular scars are produced. Endoscopic visualization can assist with broad elevation of the neck skin, control of hemostasis, and lateral plication. While this area is still evolving, present patient selection, instrumentation, and operative technique are described.

Aging in the upper third of the face is often first noted as wrinkling and ptosis of the forehead with deepening frown lines and forehead muscle imbalance. Correcting the ptosis of the forehead and eyebrows and removing or smoothing of the transverse forehead and vertical glabellar frown lines are the primary goals of the forehead lift. The forehead lift has traditionally been performed through an open coronal incision. The endoscopic forehead lift affords corrugator, procerus, and frontalis muscle modification and lateral brow elevation through direct visualization while minimizing the complications associated with a coronal scar.