What's new in plastic surgery 2013

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  • The use of a chilled plate at a fixed temperature will bias the thermal profile in tissue within a couple of hundred milliseconds. The addition of laser energy will result in a thermal profile with a peak temperature at a depth which is determined by the chilled plate temperature and the fluence and wavelength of the laser energy, for energy pulses in the range of 200 ms or less. The plate clamps the skin surface at a fixed temperature as eliminating skin surface temperature as a variable. Also shot to shot fluctuations in cyrogen volume, duration and distance are eliminated.
  • The use of a chilled plate at a fixed temperature will bias the thermal profile in tissue within a couple of hundred milliseconds. The addition of laser energy will result in a thermal profile with a peak temperature at a depth which is determined by the chilled plate temperature and the fluence and wavelength of the laser energy, for energy pulses in the range of 200 ms or less. The plate clamps the skin surface at a fixed temperature as eliminating skin surface temperature as a variable. Also shot to shot fluctuations in cyrogen volume, duration and distance are eliminated.
  • Let’s take a closer look at the laser action The laser’s photo thermal and photo disruptive effect breaks the adipocytes
  • What's new in plastic surgery 2013

    1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 11. Sculptra Before and AftersSculptra Before and Afters before first after first after second after third
    12. 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. 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. 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. 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. 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. 17. Rex Moulton-Barrett, MDRex Moulton-Barrett, MD ScitonSciton ProfileProfile Broad Band Light: BBLBroad Band Light: BBL
    18. 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. 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. 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. 21. Epidermis Dermis • Denatures collagen causing immediate contraction • Activates collagen generating fibroblasts leading to long-term remodeling Sciton SkinTyte
    22. 22. SkinTyte treatment of the neck Before Immediately After
    23. 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. 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. 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. 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. 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. 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. 29. SmartlipoSmartlipo
    30. 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. 31. Smartlipo Effect on the adipocytes
    32. 32. ProLipo EquipmentProLipo Equipment • liposuction cannulaeliposuction cannulae • fiber and handlefiber and handle
    33. 33. The Results Case Studies Before After 6 monthsBefore After 3 months
    34. 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. 35. Example: cheek and lower lidExample: cheek and lower lid
    36. 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. 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. 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. 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. 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. 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. 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. 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%
    44. 44. 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
    45. 45. 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
    46. 46. 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
    47. 47. 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
    48. 48. 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.
    49. 49. 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
    50. 50. 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
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. 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

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