1. What’s New In PlasticWhat’s New In Plastic
Surgery ?Surgery ?
20102010
Rex Moulton-Barrett, MD
Plastic & Reconstructive Surgery
Alameda and Brentwood Ca
San Leandro Surgery Center

2. Plastic SurgeryPlastic Surgery
• Skin: skin care, fillers, BoTox, lasersSkin: skin care, fillers, BoTox, lasers
• Cosmetic SurgeryCosmetic Surgery
• Reconstructive: Breast, Flaps, BurnsReconstructive: Breast, Flaps, Burns
• Pediatric: Clefts, Hand, Nevi, TumorsPediatric: Clefts, Hand, Nevi, Tumors
• Hand SurgeryHand Surgery
• Head and Neck SurgeryHead and Neck Surgery
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Dr Ralph Millard
1968

3. Paradoxes of ProgressParadoxes of Progress
• Sir Peter MedawarSir Peter Medawar ::
• ““technology and science advance in a sinusoidaltechnology and science advance in a sinusoidal
patternpattern””
• New discoveries arise through necessityNew discoveries arise through necessity
• New discoveries create need for new technologyNew discoveries create need for new technology
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

4. Obaje Nu-Derm System:Obaje Nu-Derm System:
4 components4 components
• Cleaner raises to pH 6Cleaner raises to pH 6
• Toner: restores pH 3.5Toner: restores pH 3.5
• DetergenDetergentt: de-oils: de-oils
• ExfoliantExfoliant:epidermis:epidermis
– 3% Phytic acid or3% Phytic acid or
– 7% Glycolic (1/2) &7% Glycolic (1/2) &
– 7% Lactic acid (1/2)7% Lactic acid (1/2)
• Blends:dermisBlends:dermis
TretinoinTretinoin 0.025-0.1%0.025-0.1%
• BleachBleach
– 4% Hydroquinone4% Hydroquinone
12 weeks Nu-DermMelasma of pregnancy

5. FillersFillers
• Non-permanentNon-permanent:: collagen 2-4 mnscollagen 2-4 mns
hyaluronic acid 3-12 mnshyaluronic acid 3-12 mns
hydroxyappetite 1yrhydroxyappetite 1yr
poly-L-lactic acid 3-5 yrspoly-L-lactic acid 3-5 yrs
• Semi-permanent:Semi-permanent: dermis ( cadaveric )dermis ( cadaveric )
dermisdermis
• Permanent:Permanent: methylmethacrylatemethylmethacrylate
fat ( live )fat ( live )

6. CollagenCollagen
• BovineBovine collagen:collagen: 1972 FDA approved1972 FDA approved:: (4wk allergy test)(4wk allergy test)
• Zyplast 1: 70% H2O/lidocaine, superficialZyplast 1: 70% H2O/lidocaine, superficial
• Zyplast 2: less water and more viscousZyplast 2: less water and more viscous
• Zyderm: thickest, deepest, longest actingZyderm: thickest, deepest, longest acting
• Cultured HumanCultured Human Collagen:Collagen: Cosmoplast/dermCosmoplast/derm
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressoare needed to see this picture.
before after before after
(FDA approved 2003
no allergy test needed)

7. Collagen , cont.Collagen , cont.
• Porcine CollagenPorcine Collagen:: Evolence (R) :Evolence (R) : FDA approved July, 2008FDA approved July, 2008
• Approved for wrinklesApproved for wrinkles
• Moderate to deep wrinklesModerate to deep wrinkles
• such as nasolabial foldssuch as nasolabial folds
• No pretesting requiredNo pretesting required
• LastsLasts 6-24 months6-24 months
• Purported to have less swellingPurported to have less swelling
• Does not absorb water like HA’sDoes not absorb water like HA’s
• Like natural dermis 80% collagenLike natural dermis 80% collagen
• Has a ‘Glymatrix’ formulationHas a ‘Glymatrix’ formulation
• Porcine collagen is cross-linked withPorcine collagen is cross-linked with
• D-RiboseD-Ribose
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.

8. Hyaluronic AcidsHyaluronic Acids
• Restylane,Restylane, FDA approved 2003FDA approved 2003
• Captique,Captique, approved 2004approved 2004
• Juvederm*,Juvederm*, approved 2006approved 2006
• Perlane,Perlane, approved 2007approved 2007
• Elevess*,Elevess*, approved 2007approved 2007
• Hydrelle*,Hydrelle*, approved 2009approved 2009
Features: viscosity related to length of chain
pain = protein antigen, alcohol dilutant, no
lidocaine
duration of action = cross linking
+/- lidocaine = less pain, shorter duration ie
dilute *
QuickTime™ and a
decompressor
are needed to see this picture.

9. Juvederm before and aftersJuvederm before and afters
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

10. Sculptra: Poly-L-Lactic AcidSculptra: Poly-L-Lactic Acid
• FDA approved for facial volume restoration inFDA approved for facial volume restoration in
HIV facial wasting,HIV facial wasting, 20042004
• Not popular in Europe: insufficient dilutionNot popular in Europe: insufficient dilution
• Requires 4-6 injections: expensive $5,000+Requires 4-6 injections: expensive $5,000+
• Injections are spaced at least 6 weeks apartInjections are spaced at least 6 weeks apart
• Lasts 3-5 years, becomes more cost effectiveLasts 3-5 years, becomes more cost effective
for additional injectionsfor additional injections

11. Sculptra Before and AftersSculptra Before and Afters
before first after first after second after third

12. Radiesse: HydroxyappetiteRadiesse: Hydroxyappetite
• FDA approved 2006FDA approved 2006
• Nasolabial foldsNasolabial folds
• Lasts approx 1 yearLasts approx 1 year
• Good for deeperGood for deeper
volume restorationvolume restoration QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

13. ArteFill:ArteFill: 80%80% collagen coated microspherescollagen coated microspheres
&& 20%20% polymethylmethacrylatepolymethylmethacrylate
• FDA approved 2006FDA approved 2006
• Nasolabial folds:Nasolabial folds: immediate and late correctionimmediate and late correction
• 30-50 microns spheres, 3.8% bovine zyplast30-50 microns spheres, 3.8% bovine zyplast
collagen in water/lidocainecollagen in water/lidocaine (allergy testing needed)(allergy testing needed)
• first FDA approved permanent fillerfirst FDA approved permanent filler
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

14. Botulinum ABotulinum A
• BoTox = AllerganBoTox = Allergan
• Dysport / Reloxan = Ipsen Pharm/MedicusDysport / Reloxan = Ipsen Pharm/Medicus
• Mechanism of action: irreversible inhibition ofMechanism of action: irreversible inhibition of
acetyl choline releaseacetyl choline release
from nerve endingfrom nerve ending
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

15. Botulum ToxinBotulum Toxin
• Used since 1980Used since 1980
• FDA approved 2002 frown lines between eyesFDA approved 2002 frown lines between eyes
• FDA approves 2004 for arm pit sweatingFDA approves 2004 for arm pit sweating
• ‘‘Off-label’Off-label’ use since then elsewhere: forehead,use since then elsewhere: forehead,
lateral crows, corner mouth, neck, sweating hands,lateral crows, corner mouth, neck, sweating hands,
neck muscles/tension headachesneck muscles/tension headaches
• Made in the USA bottled in Ireland: 100 U bottleMade in the USA bottled in Ireland: 100 U bottle
• Must be shipped cold in powder formMust be shipped cold in powder form
• Reconstituted in saline: 2-4 mlsReconstituted in saline: 2-4 mls
• Once reconstituted effective: room temp 7 days!Once reconstituted effective: room temp 7 days!

16. What is the End-Point ?:What is the End-Point ?:
No wrinkles at restNo wrinkles at rest oror no lines of facial expression ?no lines of facial expression ?
• No wrinkles at rest:No wrinkles at rest:
• 6 treatments permanent6 treatments permanent
• Must treat every 4 monthsMust treat every 4 months
• No lines of expressionNo lines of expression: requires 2 x more BoTox: requires 2 x more BoTox
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressorare needed to see this picture.

17. Rex Moulton-Barrett, MDRex Moulton-Barrett, MD
ScitonSciton ProfileProfile
Broad Band Light: BBLBroad Band Light: BBL

18. BBL Interchangeable FiltersBBL Interchangeable Filters
7 Filters (nm)7 Filters (nm)
– 420 - Blue light420 - Blue light
– 515 - Pigment515 - Pigment
– 560 -560 - VascularVascular & Pigment& Pigment
– 590 -590 - VascularVascular && HairHair
– 640 -640 - VascularVascular && HairHair
– 695 -695 - HairHair
– STST -- Collagen RemodelCollagen Remodel

19. BBL: Controlled CoolingBBL: Controlled Cooling
• Sapphire crystal contact coolingSapphire crystal contact cooling
• Provides timed before, during and after contact coolingProvides timed before, during and after contact cooling
• System sets skin temperature accurately from 0ºC to 30ºCSystem sets skin temperature accurately from 0ºC to 30ºC
• Includes 15 x 45, 15 x 15 or round 10 mm treatment areaIncludes 15 x 45, 15 x 15 or round 10 mm treatment area

20. Epidermis
Dermis
SkinTyte elevates subsurface temperature.A subsurface layer is briefly heated.Then is cooled.
Sciton SkinTyteSciton SkinTyte
Chilled Sapphire Plate
12°C
55°C

21. Epidermis
Dermis
• Denatures collagen causing immediate contraction
• Activates collagen generating fibroblasts leading to
long-term remodeling
Sciton SkinTyte

22. SkinTyte treatment of the neck
Before Immediately After

23. Modern Philosophy PlasticModern Philosophy Plastic SurgerySurgery::
‘‘MMuullttiimodality’modality’
• RenewRenew elasticityelasticity & tighten dermis:& tighten dermis: skin careskin care // laser: BBL/MLPlaser: BBL/MLP
• Correct hyperCorrect hyperpigmentpigmentation:ation: skin careskin care//peelpeel//laserlaser
• RestoreRestore volume:volume: surgerysurgery // fillerfiller
• CorrectCorrect positionposition:: surgery /surgery / thread lifts
• Correct excessiveCorrect excessive tonetone & tension:& tension: BoTox // surgerysurgery
• CorrectCorrect laxitylaxity:: fillerfiller // surgerysurgery // thread lifts

24. Plastic Surgery: What’s NewPlastic Surgery: What’s New
• New Types of Lipolysis a.c.t.mechanical liposuctionNew Types of Lipolysis a.c.t.mechanical liposuction
• Lipostructure: fat graftingLipostructure: fat grafting
• Thread LiftsThread Lifts
• New Facelift: volume restoration & relocationNew Facelift: volume restoration & relocation
• Breast Augmentation: Silicone FDA approvedBreast Augmentation: Silicone FDA approved
• Mastopexy/AugmentationMastopexy/Augmentation
• Breast ReductionBreast Reduction
• Abdominoplasty: leads to weight lossAbdominoplasty: leads to weight loss
• Post-Bariatric SurgeryPost-Bariatric Surgery

25. Current Techniques of LipolysisCurrent Techniques of Lipolysis
• Topical anti-cellulite creamsTopical anti-cellulite creams
• Oral anti-cellulite medicationOral anti-cellulite medication
• Trans-cutaneous laser lipolysisTrans-cutaneous laser lipolysis
• ultrasonic lipolysisultrasonic lipolysis
• Sub-cutaneous injection lipolysisSub-cutaneous injection lipolysis
• Subcutaneous ‘mechanical’ lipolysis aka liposuctionSubcutaneous ‘mechanical’ lipolysis aka liposuction
• Subcutaneous Liposuction with:Subcutaneous Liposuction with: UltrasonicUltrasonic lipolysislipolysis
VibrationVibration lipolysislipolysis
HydroHydro lipolysislipolysis
RadiofrequencyRadiofrequency lipolysislipolysis
LaserLaser lipolysislipolysis

26. Most Popular Surgical Procedure ByMost Popular Surgical Procedure By
AgeAge
Age *ASAPS
1977-2005
Procedures
18
Rhinoplasty
174,851
Breast
Augmentation
2.7 Million
19-34 35-50 51-64 65+
Liposuction
5.3 Million
Eyelid
Surgery
2.7 Million
Eyelid
Surgery
530,139

27. Sub-cutaneousSub-cutaneous Laser & Liposuction:Laser & Liposuction: 88 companiescompanies
From 2006-2009
Name Wavelength
(nm)
Pulse Freq Pulse
Power
Max
power
output
Fiber
size
Pulse
width/duration
Simultaneous
or staged lipo
Date FDA
cleared
Osyris
‘LipoControl’
980nm
diode laser
staged 2009
pending
CoolTouch ‘Cool-
Lipo’
1320
Nd:YAG
20-50 Hz 15 Watts .32 –
2mm
100 micsec simultaneous January
2008
Eleme
‘SmoothLipo’
980nm continuous
Cynosure ‘Smart-
Lipo’,MTX,
Triplex
1064,1320,
1444Nd:YAG
40 Hz (aiming
beam-
3mW)
6, 12, 18
watt
.35mm
.4 mm,
.6mm
150,200, 250
mic sec
staged November
2006
Palomar
‘SlimLipo’
924 & 975
diode laser
continuous N/A 15-25
Watt
& 40
watt.
1.5
mm
100
microsecond-
‘continuous
wave’
staged April 2008
Sciton ‘ProLipo’ 1064 & 1319
Nd:YAG
1-50Hz 5-10
kilowatts
5-25
Watts
0.6 and
1 mm
10-100
microsec
staged July 2007
Lutronic
‘AccuSculpt’
1444nm
Nd:Yag
40 Hz 175 mJ 7 W 0.6mm 100-150 micsec staged November
2008
Syneron
‘LipoLite’
1064
Nd:YAG
50Hz 800mJ
2 pulsed
energy
levels
12 Watts .550
mm
100-800 micsec staged May 2008

28. Lutronic AccuSculpt 1444nm Laser Assisted LiposuctionLutronic AccuSculpt 1444nm Laser Assisted Liposuction
• Purported to be the greatest fat absorption coefficient of laser assisted devices: “ > 8 xPurported to be the greatest fat absorption coefficient of laser assisted devices: “ > 8 x
absorption 1064 and 1320nm”absorption 1064 and 1320nm”
• Relies on photo-acoustic properties & less photo-thermic action for lipolysisRelies on photo-acoustic properties & less photo-thermic action for lipolysis
• Because of this requires less power and therefore less thermal damageBecause of this requires less power and therefore less thermal damage
• Theoretically, should have high photo-thermic injuryTheoretically, should have high photo-thermic injury, purported opposite, purported opposite
• Competing chromophores: ieCompeting chromophores: ie dermal waterdermal water should limit power usedshould limit power used

29. SmartlipoSmartlipo

30. SmartLipo 1064nm Nd:YagSmartLipo 1064nm Nd:Yag
SmartLipo MPX: 1064+1320nmSmartLipo MPX: 1064+1320nm
SmartLipo Triplex:1064+1320+1444SmartLipo Triplex:1064+1320+1444
Laser Assisted LiposuctionLaser Assisted Liposuction
• Originally Italian ‘Deka’ company: termed ‘lipolysis’, designed for up to 500ccOriginally Italian ‘Deka’ company: termed ‘lipolysis’, designed for up to 500cc
• FDA approved 2006 CynosureFDA approved 2006 Cynosure
• 1, 734 pts Brazil: 1 burn, 1 seroma, all < 500 mls, 300micron fiber, 1mm1, 734 pts Brazil: 1 burn, 1 seroma, all < 500 mls, 300micron fiber, 1mm
metal cannulae, tumescent technique ( Goldman, 2002)metal cannulae, tumescent technique ( Goldman, 2002)
• Commonest complaintCommonest complaint undercorrectionundercorrection especially larger treatment areasespecially larger treatment areas
• 82 pts Brazil: submental area:82 pts Brazil: submental area: similar overall results with traditionalsimilar overall results with traditional
liposuction except he noted less postoperative bleedingliposuction except he noted less postoperative bleeding ( Goldman, 2006)( Goldman, 2006)
• New 1mm fiber and hand-piece measures tip temperature and regulatesNew 1mm fiber and hand-piece measures tip temperature and regulates
energy provided to avoid overheating and skin injuryenergy provided to avoid overheating and skin injury
• Maximum power MPX up to 30 Watts 1064nm, 16 Watts 1320nmMaximum power MPX up to 30 Watts 1064nm, 16 Watts 1320nm

31. Smartlipo
Effect on the adipocytes

32. ProLipo EquipmentProLipo Equipment
• liposuction cannulaeliposuction cannulae
• fiber and handlefiber and handle

33. The Results Case Studies
Before After 6 monthsBefore After 3 months

34. ‘‘Lipostructure’Lipostructure’: Fat Grafting: Fat Grafting
• Volume restoration with fatVolume restoration with fat
• Each graft:Each graft: 0.03 ml droplet0.03 ml droplet
• Requires harvesting, centrifugeRequires harvesting, centrifuge
• Multiple ports to injectMultiple ports to inject
• If too close to skin: lumpyIf too close to skin: lumpy
• May get 100% survivalMay get 100% survival
• Hard to remove lumpsHard to remove lumps
• Excellent for cheeksExcellent for cheeks
• Time consuming=expensiveTime consuming=expensive
QuickTime™ and a
TIFF (Uncompressed) decomp
are needed to see this picture
QuickTime™ and a
TIFF (Uncompressed) decomp
are needed to see this picture
QuickTime™ and a
TIFF (Uncompressed) decomp
are needed to see this picture
Sydney Coleman
QuickTime™ and adecompressor
are needed to see this picture.

35. Example: cheek and lower lidExample: cheek and lower lid

36. Thread LiftsThread Lifts
• Contour Thread Lift:Contour Thread Lift: proleneprolene
• Aptos/Feather LiftAptos/Feather Lift FDA approved 2004FDA approved 2004
• Quill:Quill: PDO absorbable suturePDO absorbable suture
• Covidien:Covidien: V Lock 180 polyglyconateV Lock 180 polyglyconate
Not FDA approvedNot FDA approved
• Russian Silk LiftRussian Silk Lift
• Golden ThreadsGolden Threads
• Euro/SilhouetteEuro/Silhouette
a. 3 .0 polypropylenea. 3 .0 polypropylene
b. absorbable cones 8-10 monthsb. absorbable cones 8-10 months
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

37. Endotine Forehead LiftEndotine Forehead Lift
• FDA approved 2006FDA approved 2006
• AbsorbableAbsorbable
• 82/18 Poly: Llactide/glycolide82/18 Poly: Llactide/glycolide
• Screw to skull and 5 posts fix to scalpScrew to skull and 5 posts fix to scalp
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

38. Transconjunctival BrowpexyTransconjunctival Browpexy
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Courtesy of Mary Szatkowski, MD

39. FaceliftFacelift
Aging face:Aging face:
• >25% facial fat loss>25% facial fat loss
• Accumulation of neck fatAccumulation of neck fat
• Loss of muscular attachments: neck muscle bowstringingLoss of muscular attachments: neck muscle bowstringing
• Descent of cheek fat padsDescent of cheek fat pads
• Persistent nasolabial/orbital rim attachmentsPersistent nasolabial/orbital rim attachments
• Laxity of orbital septumLaxity of orbital septum
• Looseness and loss of elasticity of skinLooseness and loss of elasticity of skin
QuickTime™ and a
TIFF (Uncompressed) decompres
are needed to see this picture.

40. FaceliftFacelift
Correction:Correction:
• Remove all fat below mandibleRemove all fat below mandible
• Divide bowstringing musclesDivide bowstringing muscles
• Tighten muscles: create sling under mandibleTighten muscles: create sling under mandible
• Suspend fat in face on tightened musclesSuspend fat in face on tightened muscles
• Suspend lateral brow on underlying tissueSuspend lateral brow on underlying tissue
• Remove excess skin and use dermal sutures toRemove excess skin and use dermal sutures to
avoid scarringavoid scarring

41. Examples: facelift with brow liftExamples: facelift with brow lift
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompresso
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompresso
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

42. Breast AugmentationBreast Augmentation
• Choices:Choices:
• Under/over muscleUnder/over muscle
• Incision siteIncision site
• Smooth/texturedSmooth/textured
• Tear drop/roundTear drop/round
• Wide or narrow profileWide or narrow profile
• Silicone gel/salineSilicone gel/saline
• Lift or no liftLift or no lift
• Allergan or MentorAllergan or Mentor

43. Breast AugmentationBreast Augmentation
• 365,000 woman 2005 in USA365,000 woman 2005 in USA
• FDA approved siliconeFDA approved silicone Nov 2006Nov 2006
• saline versus siliconesaline versus silicone
• Incision 1 inch 3 inchesIncision 1 inch 3 inches
• Deflation rateDeflation rate 5%5% <1%<1%
• Capsular contractureCapsular contracture 9% 13%9% 13%
• Adjustable volume yes noAdjustable volume yes no
• Price 1/2 twicePrice 1/2 twice
• Prone to rippling 11% <5%Prone to rippling 11% <5%
• Reoperation 4 yr 21% 23%Reoperation 4 yr 21% 23%

45. TUBA:TUBA:
Transumbilical Breast AugmentationTransumbilical Breast Augmentation
• Hollow cannula inserted through umbilicusHollow cannula inserted through umbilicus
• Subcutaneous tunnelSubcutaneous tunnel over muscleover muscle under breastunder breast
• Fiberoptic telescope verifies pocket andFiberoptic telescope verifies pocket and
• Expander is filled with air and thenExpander is filled with air and then
• Exchanged with a deflated saline implantExchanged with a deflated saline implant
• After inflation, the fill tube is removedAfter inflation, the fill tube is removed

46. Example:Example:
Advantages:Advantages:
• Minimal scarsMinimal scars
• FastFast
• with tummy tuckwith tummy tuck
Disadvantages:Disadvantages:
• Over muscleOver muscle
• ImpreciseImprecise
• Not reusableNot reusable
QuickTime™ and a
TIFF (Uncompressed) decompressare needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressare needed to see this picture.
before after
From Dr. Wallach: NYC

47. Mastopexy AugmentationMastopexy Augmentation
• Breast: upper 1/3 chest wall as childBreast: upper 1/3 chest wall as child
• Breasts descends proportionate to weightBreasts descends proportionate to weight
• Larger breasts ‘enter’ the abdomen in theLarger breasts ‘enter’ the abdomen in the
elderlyelderly
• Pregnancy leads toPregnancy leads to deflation with descentdeflation with descent
• Congenital bandsCongenital bands leads to deformityleads to deformity
• Augmentation without lift would lead to doubleAugmentation without lift would lead to double
bubble lookbubble look

48. Techniques of MastopexyTechniques of Mastopexy
• The more lifting required the longer the scarThe more lifting required the longer the scar
• Crescent liftCrescent lift
• Oval Donut liftOval Donut lift
• Tear Drop liftTear Drop lift
• Vertical liftVertical lift
• Mini-Anchor IncisionMini-Anchor Incision
• Formal Anchor IncisionFormal Anchor Incision
QuickTime™ and a
TIFF (Uncompressed) decompres
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompres
are needed to see this picture.
Anchor Lift

49. QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

50. Breast Reduction:Breast Reduction: Evidence Based Medicine ?Evidence Based Medicine ?
Covered by insurance if has s/s >=1:Covered by insurance if has s/s >=1:
• cervical/thoracic pain >1yr&> 3mns of 1 or >:NSA’s, PT, support garmentscervical/thoracic pain >1yr&> 3mns of 1 or >:NSA’s, PT, support garments
• Paresthesia with thoracic outlet syn>3 mons adequate conservative RxParesthesia with thoracic outlet syn>3 mons adequate conservative Rx
• Fungal rash refractory to medication and orFungal rash refractory to medication and or
• Severe strap grooving refractory to supportSevere strap grooving refractory to support
• If > 1kg/breast and above will approve surgeryIf > 1kg/breast and above will approve surgery
• If < 1kg anticipated removal, calculate BSA:mIf < 1kg anticipated removal, calculate BSA:m
• lbs weight x inches height /6262 ( Schnur Scale ):lbs weight x inches height /6262 ( Schnur Scale ):
• example.example. 5ft 3in, 185 lbs:5ft 3in, 185 lbs: 730 g per breast730 g per breast
Schnur, Paul L, et al., "Reduction Mammaplasty: Cosmetic or Reconstructive Procedure?"
Annals of Plastic Surgery. Sept 1991; 27 (3): 232-7

51. Modern AbdominoplastyModern Abdominoplasty
• Must sit up 90 degreesMust sit up 90 degrees, send home with surgical bed, send home with surgical bed
• Must makeMust make lower incisionlower incision 3-4 cm above labia3-4 cm above labia
• Must tighten the rectus muscles: vertical corsetteMust tighten the rectus muscles: vertical corsette
• Must do liposuction of the flanksMust do liposuction of the flanks
• Must not do liposuction to the central flapMust not do liposuction to the central flap
• Usually leads to a weight loss of 15-20 lbsUsually leads to a weight loss of 15-20 lbs
• Pts report sense of early fullness at mealsPts report sense of early fullness at meals
• Some pts overall appetite is reducedSome pts overall appetite is reduced
• Weight loss continues in 48% pts over 1 yr.Weight loss continues in 48% pts over 1 yr.
NO
QuickTime™ and a
decompressor
are needed to see this picture.
YES

53. Post-Bariatric SurgeryPost-Bariatric Surgery
• BMI: ‘Body Mass Index’BMI: ‘Body Mass Index’
• BMI: weight kg/ height M: N = 19-25 approxBMI: weight kg/ height M: N = 19-25 approx
• 65% US ‘overweight’: BMI 25-3065% US ‘overweight’: BMI 25-30
• 25% US population ‘obese’: >3025% US population ‘obese’: >30,,
• World wide problemWorld wide problem
• woman>men, af. amwoman>men, af. am((50% obese50% obese))>hispanic>hispanic((40%obese40%obese))
• Obesity kills: >50%:hypertension, DM, hyperlipidObesity kills: >50%:hypertension, DM, hyperlipid
• Obesity discriminated against in work place, no lawObesity discriminated against in work place, no law
• Surgery for patients with BMI> 40 or >35+ comorbiditySurgery for patients with BMI> 40 or >35+ comorbidity
• 60% increase in number of surgeries/yr US60% increase in number of surgeries/yr US
• 1:150-300 pts die from complications of surgery1:150-300 pts die from complications of surgery

54. Types of Surgery: Gastric Bypass
• Roux-en-Y gastric bypass is the most
popular in the US
• Pouch can be created with staples or
complete division
• Long-term weight loss of 50% of
excess body weight
• Moving Roux limbs distally creates
more rapid weight loss
– Malabsorption problems may be
exacerbated
Effective in weight loss, correction DM, BPEffective in weight loss, correction DM, BP

55. Post-Bariatric SurgeryPost-Bariatric Surgery
• After massive weight loss large pannus’s resultAfter massive weight loss large pannus’s result
• Insurance criteria:Insurance criteria: >100lbs lost>100lbs lost
> 1yr and symptomatic> 1yr and symptomatic
• failed medical therapy,failed medical therapy,
• very individual:very individual: ↑↑ insurance disclaimersinsurance disclaimers
• Insurance covers :Insurance covers : panniculectomypanniculectomy
• Non - Insurance:Non - Insurance: tummy tucktummy tuck
brachyplastybrachyplasty
thigh Liftthigh Lift
buttock Liftbuttock Lift
faceliftfacelift

57. http://www.moulton-barrett.com/
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
“ Celebrate While We Are Young”
Patient Education: no password
required