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The use of XUAL ultrasonic energy to "fractionate" and redistribute facial fat is a valuable adjunct in facial plastic surgery. The 59 patients enrolled in the author's preliminary evaluation of XUAL under the auspices of the American Society of Aesthetic Plastic Surgery Innovative Procedures Committee had in addition to the body liposculpture external ultrasonography application to "superwet" anesthetized face and neck with or without physical removal of fat or skin. When no excisions or liposuctioning were performed, there was visible and photographic improvement in facial contouring. Interview comments ranged from "I can see my cheek bones now" to questions as to whether or not a facelift had indeed been performed. Individuals who had submental resculpturing ("submental tuck") or simple "safe zone" liposuction in the submental area, jowl, and nasolabial zones also showed a remarkable degree of skin tightening and contouring beyond the area of actual fat removal. Those individuals who have been observed closely for more than 12 months still have the improvement. Redistribution of fat and skin tightening initially noted between the second and eighth weeks have persisted unchanged, often in spite of fat accumulation elsewhere from weight gain.

Background: The role of internal ultrasound in liposuction has been debated for approximately 15 years since the preliminary work by Zocchi and colleagues. Objections to the use of internal ultrasound include the added cost, the risk of injury to dermal or nerve elements, the increased incidence of seromas, the increase in operating room time and personnel required by the new technology, and uncertainty regarding ultrasound-assisted lipoplasty (UAL) application times. Anecdotal reports of skin slough, especially when UAL was used in conjunction with abdominoplasty, have caused the introduction of external UAL (XUAL) to be greeted with caution and concern. Objective: At the request of the Innovative Procedures Committee of the American Society for Aesthetic Plastic Surgery, I undertook a study of the effectiveness of XUAL on the extremities and face, as well as in conjunction with abdominoplasty. Methods: Fifty-nine consecutive patients presenting for liposuction or liposuction with abdominoplasty during a 4-month time frame (September 1997 to January 1998) were treated with XUAL, external ultrasound, or XUAL on one side and standard liposuction on the opposite side. Results: Recovery from XUAL was uniformly rapid, with resolution of edema at an average of 3 to 4 weeks compared with 3 to 6 months in comparable non-XUAL patients. Skin shrinkage was most noticeably advantageous in the face, abdomen, and inner thighs, as well as the arms in both small and large upper arm fat deposits. There was no permanent discoloration or dysesthesia noted. Seromas and postoperative hemorrhages observed during the series were directly related to postoperative trauma in three patients. Conclusions: It was apparent in this study that external ultrasound is a valuable adjunct in body and facial sculpture.

Dr. Wilkinson: Dr. Singer, what are the obvious signs of a face lift that are unacceptable by today's standards and need to be addressed in a secondary procedure? Dr. Singer: Crosshatching or poor placement of the scars, tethering or a forward distortion of the axis of the earlobe, flattening or an anterior pull of the tragus, and an excessively high sideburn that's been wiped out are certainly unacceptable results. So are inadequate correction of the neck area, offset of the postauricular hairline, and inadequate correction of the central jowl, as well as the malar area. There may be a lack of harmony because an area such as the neck or forehead wasn't treated or wasn't treated well, or the face may have a “windswept” look from pulling on the skin without correcting the underlying areas. Dr. Wilkinson: Dr. Biggs, which of these issues are most problematic for male patients? Dr. Biggs: The issue of the sideburn is certainly significant. One needs to avoid making it worse in a secondary procedure. It is hoped that newer techniques can be used to correct such problems. Certainly endoscopy has enhanced our ability to lift the forehead. Naturalness is a major issue with men, and this is where the surgeon's artistry is so important. Dr. Barek: I believe one of the biggest mistakes a surgeon can make when performing a face lift on a male patient is the overzealous raising of the brow and excessive removal of the muscle and fat in the upper eyelid. This gives a sculpted look to the lid and a high brow, which has a feminine effect. A little crinkle in the crow's-feet area is fine. Tolbert S. Wilkinson, MD Thomas M. Biggs, MD Dennis Barek, MD Robert Singer, MD Dr. Wilkinson: In our first case, the patient has …

Aesthetic correction of the congenitally short lip and the hooded or heavy upper eyelid will do much to improve the appearance of those afflicted with such defects. Correction of the upper lip can be successfully performed by a technique that differs from the transoral approach, and technical sculpturing of the upper eyelid beyond simple blepharoplasty can do much to alleviate the heavy-lidded appearance.

Owing to the increasing popularity of the circumareolar technique for a variety of problems, I was asked to chair a panel at the 1994 annual meeting of the American Society for Aesthetic Plastic Surgery. It is evident that a number of surgeons take moderately different approaches to the technique, beginning with Ulrich Hinderer, and continuing through the excellent video tape in 1993 by Larry Schlesinger. The only consensus is that the deepithelialized circle has been reduced by all authors and that a variety of methods are used to reduce tension to avoid spreading of the areola. The only radical departure is that of Cardoso de Castro, who has resumed the once discredited approach of circumferential freeing of skin from the breast and removing the wedge of tissue for reduction on the superior aspect.

As is emphasized repeatedly throughout this book, markings on the skin are not as important as the creation of the subcutaneous breast shape. Nevertheless, if an excess of skin is left in place, we cannot expect sufficient shrinkage to the new subcutaneous cone. On the other hand, the larger the circle of skin that is removed or deepi-thelialized, the more likely there is to be long- term wrinkling in the closure, and the greater the possibility that the surgeon will choose a “lollipop” vertical midline excision. In this book we assume that patient selection precludes the lollipop excision, and will demonstrate to you the technical maneuvers that virtually eliminate areolar spread and reduce the length of time in which the circumferential rippling is visible. In my technique, undermining is limited to the lower half or two thirds of the breast. Other authors have no hesitation in undermining all of the breast skin, which diminishes blood supply.

There are two additional advantages to the circumareolar approach for mastopexy or reduction. The first is the enhanced access to the interior of the breast for palpation and possible biopsy, and a more efficient expansion and break-up of the fibrocystic component. Because the incidence of breast cancer is neither increased nor decreased in patients with mastopexy, reduction, or breast implants, the addition of a breast prosthesis for creation of the fullness preferred by most American mastopexy candidates is in this respect an additional plus, because the patient can do a more efficient self-examination: small breast lesions are more easily palpated with the fingertip technique in implant patients than in those without implants. In fact, a certain degree of capsular contracture makes breast examination easier.

Adapting the circumareolar principles for repair of the distorted or stretched breast is valuable for the practicing surgeon. Either from low placement of a breast prosthesis, or from stretching due to gravitational or muscular factors, a number of patients are presenting us with the problem of ballooning of the lower half of the breast with or without areolar descent. The principles of “subcutaneous mastopexy” are used to recreate the original shape of the breast with restoration of the inframammary fold position and with the reinforcement of the thinned parenchyma. The cross-over procedure is a deterrent to future ptosis of this area, and the entire repair is performed by way of the original short periareolar augmentation incision. The idea of repositioning the nipple-areolar complex without a vertical or horizontal scar was intriguing enough for many of us to try this operation for patients who needed reparative surgery. The patient in Figure 10.1 A was one of these cases. She had requested a small breast augmentation in 1979 to fill out the upper quadrant. By 1992 the lower half of her breasts had stretched, and the nipples had dropped to a lower position as well.

I proposed a classification for breast augmentation candidates that was published in 1978,6 1983,7 and 19898; the classification system was designed to indicate which patients suffered ptosis as an effect of the ageing process in subsequent years, and what should be offered: simple breast augmentation versus the lifting of the areola, or mastopexy. No mention was made of the circumareolar technique in this earlier text.

If the only problems with the circumareolar reduction/mastopexy/repair surgeries were the occasional stitch granuloma, as illustrated in Figure 12.1, there would be no question that the procedure is vastly superior to standard surgeries. As readers know, patients gain and lose weight, the breast stretches or contracts, fibrocystic disease interferes with prostheses, and scars often behave erratically. The same psychological problems are seen. Patients whose breasts are reduced often have a change of heart and ask for further enlargement. Those who have implants removed are sometimes no longer content with the breast size that is achieved by utilizing all of their remaining breast tissue. These problems are independent of the surgical procedure and are not always avoided by extensive preoperative counseling. The problem of capsular contracture has become less of a concern with the advent of textured prostheses and improvement in control of bacterial overgrowth.

Studies published in the American Journal of Psychiatry are of interest to plastic surgeons. The following is an excerpt of my communications with Kenneth Nakdimen of New York, who summarized many of the current concepts of sexual stereotyping and their relation to physical features and clothing.

The techniques of umbilical stalk separation, closure of the umbilical site in the midline, and short upturned incision lines define the operation described as limited abdominoplasty. The operation has evolved over the past 17 years into a procedure which is applicable in the majority of patients who have suffered distortion of the entire abdominal wall, with panniculus formation and fatty deposition. The use of liposuction is an essential part of "limited" abdominoplasty and of "complete" abdominoplasty. To protect the flap, techniques once applied only in the lesser procedures are now used for patients requiring a repair of the abdominal wall from the xiphoid to the pubis. These techniques also include advancement of the incision line to the "French line" position for aesthetic reasons. A description of the technical maneuvers required as well as the objectives for correction of the deformity in patients of all abdominoplasty types is presented. Patient selection is no longer an absolute criterion for the type of abdominoplasty repair that is selected.

IN THIS CHAPTER WE DISCUSS THE TECHNIQUES USED TO AVOID the horizontal scar that may plague breast surgery. At times the standard T incision must be used, and some patients require a free nipple transplant, but I do not like to perform this surgery. Following are the major points to consider for mastopexy and reduction.

Subcutaneous mastectomy is a compromise surgical procedure for the precancerous breast. We do not think that total mastectomy is indicated in such patients. The effect of the small cuff of tissue beneath the areola more than compensates for the minimal additional risk by leaving a more attractive and eminently more acceptable breast. In the past six years, in more than 150 patients, use of the fanned muscle flap has not only restored warmth and thickness to the thin breast envelope but provided additional suture-line protection. The layered closure has prevented implant exposure even with traumatic or seromatous skin separation on several occasions. Placement of the incision lateral to the areola or entirely above the areola prevents unnecessary visible scarring with most clothing and provides additional protection for the incision line since it overlies the muscle flap. With increasing experience using this procedure, we now attempt to limit all our incisions to the supraareolar hemicircle. Neither incision limits visualization of the axilla or of the inevitable bleeding in this area.

Eight patients in whom heminasal reconstruction was aided by a modified septal chondromucosal flap are presented. The technique involves support of the new ala and additional lining by the hinge flap; continuity of the septum is restored by reapproximation of the ipsilateral mucosa.

Stretching of the abdominal wall and skin following pregnancy or excessive weight gain may be limited to the infraumbilical area. In these patients, abdominal repair may be accomplished with a shorter incision and without the necessity for relocating the umbilicus with its attendant visible scar. Forty patients are presented in whom excellent aesthetic repairs were effected through short curvilinear, low abdominal incisions with removal of a modest amount of excess skin. Fascial plication from pubis to umbilicus or above is facilitated by buried figure-of-eight sutures. Suction-assisted lipectomy may be employed as an adjunct. Recovery is facilitated by the reduced incision line length, reduced undermined area, and absence of tension in the midline skin incision, such as may occur in a standard abdominoplasty in which large amounts of panniculus and skin are removed with a complete repair of the abdominal wall. The limited abdominoplasty may be safely performed with ketamine-diazepam anesthesia in an office surgical center. Major complications are few and generally reflect the unpredictable nature of the elasticity of the abdominal skin.

Platysma surgery should not be confined to rhytidectomy of the older face. Patients of any age benefit from lessons learned in dealing with the aging face. Cervical facial contour deformities in the young adult are defined and the various problems discussed.

The results of a survey of 450 plastic surgeons regarding the practice of operating on their staff members is presented. An overwhelming majority (85 percent) of responding surgeons do operate on their staff. Whether surgery is a "right" of employment or a "reward" for service was addressed. Seventy-two percent felt surgery was a "reward," while only 8 percent felt it was a "right." The results found complications to be relatively minor but numerous (23.5 percent). The need for an office policy is stressed to help eliminate misunderstandings with other employees, and a model office policy is presented and endorsed.

The complications of malar augmentation with prosthetic materials are few. The majority are related to incorrect choice of prosthesis size or position. No complications of tissue damage have occurred, but the two instances representing delayed infection may have been a result of seeding of the capsular space from the structures in the oral cavity abetted by what appeared in one case to be the remnant of an old hematoma. Preventable complications include the use of posterior Dacron fixation for gel prostheses, since the elongated or extended malar prosthesis may not resist the forces of capsular contracture in all instances. Patient acceptance has been extremely high in 35 cases, and removal has been requested in only one instance, reflecting the value of preoperative counseling with diagrams, photographs, and drawings.