Dr. Kenneth Benjamin Hughes has published in plastic surgery textbooks, plastic surgery research and plastic surgery journals.  Dr. Kenneth Hughes has given presentations at local, regional, national, and international meetings.

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          Dr. Kenneth Hughes is an expert on many different subjects including breast augmentation and breast augmentation revision, fat grafting, wound healing, scarring and treatment of poor scarring, the evolution of telemedicine, and surgery center safety.

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Preoperative Workup in the Plastic Surgery Patient

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by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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Anatomical Norms

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A general recognition of facial norms and proportions has great relevance for the plastic surgeon during the preoperative assessment. The face can be divided into roughly equal thirds consisting of the trichion to nasal root, the nasal root to nasal base, and the nasal base to inferior mandibular midline (gnathion). All of these relationships are critical in face lifts, brow lifts, upper and lower eyelid surgery, rhinoplasty, and chin implantation.

The forehead comprises the area from the trichion to highest point of the brow. The average height is 7 cm in men and 6 cm in women. An aesthetic eyebrow has its apogee at the lateral limbus with the lateral extent positioned 3 mm superior to the medial. In women, the eyebrow rests up to 3 mm above the supraorbital rim. Conversely, in males, the eyebrow should lie at the level of the rim. The intercanthal distance should be roughly 34 mm in men and 32 mm in women. The youthful eye should exhibit a positive vector, with the lateral canthus 2 mm above the medial. Scleral show should not be present superiorly or inferiorly.

The nose is composed of three sections: root (radix), dorsum, and soft nose. The nose can be divided further into nine total subunits: nasal dorsum, tip, columella, paired ala, paired sidewalls, and paired soft triangles. The soft nose is comprised of the nasal tip, columella, and ala. The width of the ala should roughly equal the intercanthal distance. The angle between columella and upper lip (nasolabial angle) is 100 degrees in men and 105 in women.

The upper incisor show at rest should be about 2 mm. On lateral view of the face, the chin and upper lip should have similar projection.

It is important to realize that these proportions can vary subtly or rather dramatically based upon ethnicity. These norms have largely been developed based upon Caucasian models. Every effort should be made to preserve ethnic identity for any aesthetic facial surgery contemplated.

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Facial Exam

All facial assessments should include a thorough examination of the patient’s skin. The surgeon should note signs of poor skin elasticity, actinic damage, and deep facial wrinkles, as these factors can have dramatic implications upon any excisional or redraping procedure. Cranial nerve V and VII exams in particular should be performed and asymmetries noted. The relative amount of facial fat as well as overall facial shape (e.g. square or conical) should be documented. One should note the height of the trichion, the level of brow descent, and the amount of dermatochalasis. The surgeon should characterize the tear trough, the degree of malar fat pad descent, nasolabial fold prominence, degree of jowling, and relative laxity or banding of the platysma. A discussion of more specific anatomic considerations is better addressed in specific chapters, but one should bear in mind general facial characteristics as no one feature exists in a vacuum. Operating on one aspect of the face inevitably alters perception of the remaining facial elements.

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Preoperative Planning

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The history should include a complete medical and surgical history. The family history should include inquiries about familial bleeding tendencies and problems with anesthesia. A social history should include use of tobacco (nicotine products), alcohol, and illegal drugs. Allergies (including adhesives, skin prep, and latex) and medications (including BCP, OTC, vitamins, and herbal preparations) should be documented.

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The surgeon should be able to accurately determine and predict anatomic characteristics that may result in difficult airways including poor cervical mobility, retrognathia, decreased cervicomental angle, and limited mandibular opening. Mallampati assessment of pharyngeal visualization is also a useful adjunct.

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Patients with coronary artery disease, valvular disease, or congestive heart failure merit special consideration. A cardiologist should evaluate these patients to determine if their disease process is stable before one considers elective surgery for these patients. Patients with valvular disease should receive prophylaxis with amoxicillin or ampicillin. In pcn-allergic patients, clindamycin or a macrolide is appropriate.

The surgeon should obtain an accurate smoking history and determine if the patient has restrictive or obstructive lung disease as well as obstructive sleep apnea. Smoking should be discontinued for at least four weeks prior to elective surgery, and an aggressive smoking cessation program should be instituted. Serum and urine cotinine levels can be utilized to determine patient reliability.

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Patients with chronic liver disease should receive liver function tests and may need a hepatology consult before considering elective surgery as they can carry greater risk for bleeding, malnutrition, and metabolic derangements. Chronic alcohol use can alter metabolism of perioperative drugs.

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Hypertension, a contributor to hematoma formation, should be meticulously controlled. The patient should be well managed on an outpatient regimen, and any blood pressure medication should be taken the day of surgery.

 

Anxiolysis and pain control should be addressed as well. Postoperative cough and vomiting should be controlled to prevent increased intraabdominal and intrathoracic pressures, which can lead to bleeding and hematoma formation. Propofol and a serotonin receptor antagonist such as Zofran should be considered unless contraindicated. Acid blocker prophylaxis should be considered in those with history of gastric esophageal reflux disease, hiatal hernia, and other diseases that may compromise gastrointestinal motility. Finally, patients should be free of ingestion of clear liquids for 2 to 3 hours and of solids for 6 to 8 hours prior to induction.

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Diabetic patients should be well controlled to minimize wound healing implications. Glucocorticoid-dependent patients should be given Vitamin A, in doses of 25,000 IU/d, to help reverse many of the adverse steroid effects.

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Surgical weight loss patients deserve special mention as nutritional deficiencies of vitamins A, C, and K may be present and impair normal wound healing. They may also have protein calorie malnutrition (serum albumin level of less than 3 g/dL may be indicative). Vitamin supplementation and protein supplements should be instituted prior to surgery to minimize wound healing issues.

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To screen for bleeding diatheses, in addition to family history, a personal history of problematic bleeding with minor trauma (dental procedures), frequent nosebleeds, and history of blood transfusions suggest a clotting problem. CBC, PT, and PTT should be ordered, and a hematology consult may be appropriate. Aspirin and NSAIDS should be discontinued at least a week prior to surgery. Patients should stop taking Coumadin and Plavix at least five days prior to surgery and may require a temporizing measure (e.g. LMWH).

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Though the risk for postoperative DVT and PE has not proven to be as high as for body contouring procedures, perioperative prophylaxis should be considered for longer operations and patients with multiple risk factors or previous DVT/PE. Young’s “The Need for Venous Thromboembolism (VTE) Prophylaxis in Plastic Surgery”1 provides a more detailed review and analysis.

High fever or prolonged ventilator requirements in patients or a family history thereof should raise suspicion for malignant hyperthermia and precautions should be taken if surgery is elected. With any perioral procedure, herpes prophylaxis should be considered based upon prior outbreaks. Isotretinoin use should be discontinued at least one year before considering any resurfacing procedure or operation.

Given the increasing popularity of the supplement market, the surgeon must have some familiarity with the more commonly ingested items. Echinacea may impair hepatic metabolism and should be discontinued well before surgery. Ephedra was used as an appetite suppressant that resulted in numerous deaths. The FDA prohibited the sale of ephedra in 2004. Garlic, ginkgo, ginseng, and kava inhibit platelet aggregation and should be discontinued at least 7 days prior to surgery. St. John’s wort should be discontinued at least 5 days prior to surgery and avoided postoperatively due to a host of drug-drug interactions. Valerian, a sedative, should be discontinued prior to surgery but should be tapered due to a benzodiazepine-like withdrawal.

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Preoperative Laboratory Testing

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Routine labs do not need to be performed unless elements of the history of physical suggest their appropriateness. Despite this, surgeons continue to order CBC, Chemistry, and PT/PTT routinely. A urine pregnancy test should be considered in all women of childbearing age. EKG may be ordered for the elderly or for those with a history of cardiopulmonary disease.

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Patient Selection and Preoperative Counseling

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Many of the technical pitfalls for a particular operation are presented in their respective chapters, but patient selection and preoperative counseling are perhaps the two most critical elements to having satisfied patients and avoiding poor outcomes. When evaluating the aesthetic patient, the surgeon should be able to recognize a patient’s motivations and expectations. Unrealistic expectations, obsession about appearance, incorrect perception of the surgery, or dismissal of criticism on the part of the patient should produce an uneasy feeling in the surgeon. These findings may merit a second meeting with patient, a psychiatric evaluation, or, perhaps, refusal to perform the procedure.

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Photography in Plastic Surgery

 

by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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Introduction

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Photography is essential to documenting results in all forms of facial plastic surgery: brow lift, upper and lower eyelid surgery, face and neck lift, facial fat grafting, rhinoplasty, chin implants, chin liposuction, and otoplasty. For that matter, photography is important in all cosmetic plastic surgery. All plastic surgeons must acquire the ability to record their results as accurately and precisely as possible. Photography becomes a unique ally in this pursuit, and it is incumbent upon plastic surgeons to develop a relatively sophisticated understanding of photography and its components. Unfortunately, much of the art of photography must be self-taught.

With this is mind, this chapter represents a compendium of insights from several dozen amateur and professional photographers to help elucidate fundamental concepts in photography. The chapter further explores issues in photography singular to plastic surgery and reviews the plastic surgery literature as it relates to photography.

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The Digital Revolution

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The advent of digital photography has rendered conventional film all but obsolete as these digital images can be manipulated, archived, and reconstituted with software to create three dimensional images. Digital imaging and manipulation have revolutionized preoperative planning as well as patient counseling.

The advantages of digital photography are manifold and include no film or processing costs, no need for physical storage of slides or negatives, elimination of scanning of slides, immediate viewing of image, ability to erase images instantly and reuse space, digital compression and transmission for purposes of consultation or discussion.

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Digital Image Capture

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The development of the charge-coupled device (CCD) in 1969 created an image sensor tuned to the visible spectrum of light, which was able to convert captured light to electrical charge. An image is projected onto a capacitor array, causing each capacitor to store an electric charge proportional to light intensity at that location. Ultimately, these charges are converted to binary representation stored digitally. Most cameras are CCD or CMOS (Complementary metal–oxide–semiconductor), both of which are composed of silicon doped with other elements that allow light sensitivity. Red, green, and blue filter strips are placed before the sensor to enable digitization of the color components.

In common parlance, the digital image is captured across an array of pixels. Thus, the number of pixels becomes a determinant of picture resolution. However, the number of megapixels is only one factor. Pixel size relative to overall size of imaging area on the sensor is also important but difficult to determine. Thus, technical reviews and your own observations can prove more reliable.

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Types of Digital Cameras

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Digital cameras can be classified as “point and shoot” cameras and digital SLR (single lens reflex). Digital SLRs are very much like film SLRs apart from image sensor and the LCD screen. Point-and-shoot cameras have evolved tremendously over the last 5 years, many with manual controls that can produce very reliable, reproducible images with excellent resolution. Digital SLRs still have the advantages of greater aperture control, removable lenses, and better image quality secondary to larger pixel size. However, these SLR cameras are more expensive and require more maintenance (lens cleaning).

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Understanding the Functions of the Digital Camera

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Lens

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In general, a lens in conventional film photography with a focal length from 90 to 110 mm is utilized for facial photography. Most digital cameras have preset focal length for portraits, or a portrait mode. This represents the correlative focal length for the smaller sensors in the digital cameras.

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Aperture

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The lens aperture is the size of the opening that admits light to the sensor. A wider aperture allows more light, while a narrower aperture, less light. There is usually an ample range of openings (f-stops) to allow for changing light conditions.

The larger the f-stop the more light admitted and the better suited to dim light situations. Most digital cameras, when using auto mode, perform these calculations to assure optimal aperture.The widest possible aperture characterizes the speed of the lens and refers to the ability of the lens to be used in low light without flash. The standard f/2 would be fast, while f/16 would be slow.

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Shutter Speed

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The shutter speed represents the amount of time the shutter is open. There is a reciprocal relationship between shutter speed and f/stop. Thus, there exist multiple combinations of shutter speed and f/stop that can generate the same amount of light reaching the lens.

Without a flash, slower shutter speeds may lead to suboptimal image due to hand motion of the photographer if the camera is not mounted. With a flash, shutter speed can be slower than 1/250.

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ISO

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ISO (International Organization for Standards) is a measure of the sensor’s sensitivity to light. One of the great advantages of digital cameras is that you can change the ISO settings, a characteristic that was film specific. However, as you increase ISO settings to compensate for lower light conditions, noise increases. Noise is the result of increased pixel sensitivity to light causing sensor misinterpretation. The lowest possible ISO setting should be utilized to maximize quality. Thus, changes in aperture, shutter speed, flash and ISO settings all affect the exposure and ultimate image generation.

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Image Compression and Storage

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Image data from digital cameras can be saved in several different formats, RAW, TIFF, and JPEG being the most common. RAW files represent the full uncompressed image file. RAW is not a standardized file format. RAW file formats differ from one camera manufacturer to another and require special software peculiar to that manufacturer. TIFF (Tagged Image File Format) uses lossless compression, which preserves image quality. This form of file compression creates a less compressed, larger file than that produced with JPEG. JPEG (Joint Photographic Experts Group) is the most common method of compression and can be done at different levels; more compression gives smaller files while simultaneously degrading the image. JPEG compression uses a compression algorithm which sacrifices image quality for smaller file sizes. In most digital cameras available, one can select Fine or SuperFine image compression which corresponds to higher quality (less compressed) JPEG setting. More specifically, in most digital cameras, there is a choice of resolutions, which can be as low as 640 × 480 pixels and as high as the resolution of the camera allows (e.g. 3024 × 2016 for a 6 MP camera).

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Facial Photography Studio and Technique

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To ensure reproducibility, a dedicated photography room should be utilized. With lighting for the background, the front, and both sides, one can create a good picture without shadows. This even lighting scheme is intuitive, simple to create (although not inexpensive), produces soft rather than harsh facial features, and does not require a flash. An alternative and comparable lighting scheme would consist of two front lights positioned at 45 degree obliquities and a background light (Figure 1). These two oblique lights can also be used for patient alignment on oblique view acquisition. If a separate flash is used, it should be positioned in front of the patient so that the shadow develops behind the patient.

The patient should be devoid of all personal affects, and the background should be uniform. The background can be a single color sheet or wall, preferably black or blue. The patient’s hair, if obtrusive, should be fixed behind the ears to allow visualization of all facial landmarks.

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The camera can be positioned on a tripod, which is recommended, at the height of the patient’s face. A frontal, two oblique, two lateral, and a worm’s-eye view are the conventional views to be obtained, although other orientations and animated views may be useful for certain procedures. Floor markings for patient foot position enhance reproducibility. Uniform head alignment can be facilitated by placing marks along the wall to focus and orient the patient gaze. The midsagittal plane, by using the grid viewfinder, can be used to align head position. Frankfort’s line, representing the infraorbital rim in continuity with the tragus, can be used as a reference for the horizontal level. In addition, the canthi or tragi position can serve the same purpose. To minimize rotation in the frontal view, reference the visibility of the ears.

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Fat Grafting

by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon
 

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Indications

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Structural fat grafting is used to enhance contour in virtually any area amenable to grafting and the indications are continually expanding. The first and most common indication for structural fat grafting is breast reconstruction defects. With the increased popularity of fillers for facial augmentation, fat grafting for facial augmentation has been due to plentiful nature of filler material available and decreased cost, particularly for larger volume needs or as an adjunctive measure in facelifts.

Less common indications include buttock augmentation, breast augmentation, and hand rejuvenation. It has been also received recent attention for volume restoration in acquired or congenital conditions such as HIV lipodystrophy, Parry-Romberg syndrome, and craniofacial microsomia.

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Anesthesia

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As with many liposuction procedures, the choice for anesthesia is largely dictated by amount of tissue to be harvested, number of harvest sites, as well as the number of areas to be augmented and the volume to be instilled. Some minor revisions can be performed under local anesthesia alone. Tumescent anesthesia may allow donor site surface area to be increased. However, there is a theoretical concern of disruption of fatty tissue and concomitant decreased survival with these methods.

In addition, the manner of liposuction and technique utilized should be considered. Removal through smaller volume Luer-Lok syringes is theoretically less traumatic to the fat and less painful to the patient as compared to fat harvest through traditional suction cannulae with much greater suction pressures.

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Details of Procedure

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Typical donor sites for fat grafting include the abdomen and thighs. They are convenient access points in the supine position as breast reconstruction defects and facial augmentation are the most common indications. This also permits a two team approach in which one can harvest, while another can inject. However, almost any site with readily accessible fat will serve as an adequate donor site.

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Incisions for access should be placed in relaxed skin tension lines, skin creases, previous scars, striae, or hirsute areas. Although, creating the most optimal contour in donor areas, particularly in large volume aspiration, should be the guiding principle. Avoidance of contour deformities should trump the concern over the addition of small incisions.

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A common approach to fat harvesting utilizes blunt-tipped Coleman cannulae applied to Luer-Lok syringes. Some surgeons prefer 10 ml syringes (Coleman), but others opt for larger syringes due to faster harvest times. Once the fat is harvested, the specimen is centrifuged and separated to create the fat sample to be injected for augmentation. 10 ml syringes centrifuged at 3000 RPM for 3 minutes is a typical protocol observed by Coleman. After separation by centrifugation, the top layer contains oil, the middle layer contains viable fat, and the bottom layer contains other more dense liquid materials, primarily the local infiltrate. Decanting after gravity sedimentation is another variant for creation of an appropriate specimen for injection.

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Once the harvested fast is prepared, injection can be performed with 1 ml syringes for face and hand injections due to need for precision. 3 ml syringes may be more appropriate for breast reconstruction defects or buttock augmentation.

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However, the volume to be injected into an area should be the guide. An HIV lipodystrophy patient who may require 40 ml of fat augmentation to one side of his face may be more efficiently augmented with 3ml syringes initially followed by 1 ml syringes for final refinements. More important, large volumetric amounts injected in a single pass should be discouraged as this leads to greater fat necrosis, greater potential for infection, and poorer graft survival. The gauge of the cannulae to be introduced for fat grafting in the face should be in the 18 gauge range, though eyelids may require smaller bore cannulae.

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The principles of placement as articulated by Coleman center around the concept that harvested fat must be positioned so that the greatest surface area of contact between it and host tissue is created. This is done to encourage as much diffusion, oxygen exchange, and nutrient exchange as can be obtained.

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Blunt tip cannulae are usually used and fat is injected upon withdrawal. Coleman recommends 0.1 ml maximum volume per pass to minimize potential for irregularities and maximize surface contact with host tissue. Fat is much harder to shape with digital manipulation than many of the filler agents. As such, precise placement is recommended.

These procedures can produce a considerable recovery period of 2 to 4 weeks, which may be longer than most patients expect. The persistent swelling associated with these injections is greater than that associated with Botox or conventional filler treatments to which many patients are accustomed. As such, patients should be educated about convalescence time.

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Pitfalls

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Most common complications include surface irregularities due to errors in technique, migration, and patient healing characteristics.

Fat necrosis, infection and abscess formation are more prevalent in single, large volume fat injections.

Microcalcifications after fat grafting for breast augmentation may lead to greater numbers of biopsies and unnecessary surgical procedures due to difficulties in mammographic interpretation.

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Pearls

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Fat embolus may be avoided by epinephrine injection into the area to be augmented as well as the use of the use of blunt cannulae.

Sharper cannulae may be more appropriate for freeing adhesions and augmenting scarred or fibrous beds, but these cannulae still carry greater inherent risk to surrounding structures.

Most important in structural fat grafting is Coleman’s principle that fat must be positioned so as to ensure the greatest surface area of contact between it and host tissue. Small volumes injected upon cannula withdrawal through multiple passes minimize the potential for irregularities and complications and maximize graft survival.

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Facelift

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by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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1)What are the factors that result in the aging face?

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Referred to as elastosis, this process results in loss of collagen and elastin fibers due to:

a) Extrinsic factors = actinic damage and gravity

b) Intrinsic factors = genetic factors

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2)Name three factors which contribute to less than ideal results in facelift?

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a) Poor elasticity

b) Heavy actinic damage

c) Deep, coarse facial rhytids

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3)Please explain UV light damage?

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a) UV light induces photoaging through generation of reactive oxygen species (ROS) that damage enzymes after being absorbed by chromophores. Alpha tocopherol, a superoxide scavenging antioxidant, may counter these effects. The mechanism of dermal damage occurs via induction of three metalloproteinases capable of degrading the dermal collagen matrix.

b) UVB causes direct damage; wavelength: 280 to 315; responsible for most of DNA damage of skin.

c) UVA acts through other active molecules; wavelength: 315-400 nm; causes damage if 100 to 1000X dose of UVB (unfortunately there is considerably more UVA light making it through the ozone).

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4) What are the endogenous changes that occur with aging?

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a) Glycosaminoglycans and proteoglycans decrease with age – Rationale for use of Restylane and Hylaform

b) Collagen decreases by 6 % per decade resulting in dermal thinning. There is a decrease of Type I collagen. Type I:III ratio actually increases.

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5) Discuss various disorders and whether facelift would be contraindicated?

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a) Cutis Laxa: degeneration of elastic fibers in dermis, skin does not spring back into position, autosomal dominant, autosomal recessive, and X-linked forms all exist, recessive form worst of disease presenting with systemic signs, surgery may be indicated

b) Pseudoxanthoma elasticum: occurs in 2 dominant and 2 recessive forms: recessive form (Type II) – entire skin is loose fitting, diagnose by biopsy to differentiate from cutis laxa, surgery may be indicated if do not have severe systemic symptoms

c) Ehlers-Danlos Syndrome (Cutis Hyperelastica): hypermobile joints, very thin, friable, and hyperextensible skin, subcutaneous hemorrhage, may stretch skin up to 15 cm or more and it will shrink back, posttraumatic bleeding, poor wound healing (due to inadequate production of enzyme lysyl oxidase), surgery contraindicated

d) Progeria (Hutchinson-Gilford Syndrome): rare, unknown etiology, autosomal recessive, craniofacial disproportion (due to premature closure of epiphyses), baldness, pinched nose, protruding ears, micrognathia, loss of subcutaneous fat, arteriosclerosis, and cardiac disease, do not reach reproductive age, surgery contraindicated

e) Werner’s Syndrome (Adult Progeria): autosomal recessive, baldness, aged facies, hypo and hyperpigmentation, short stature, high pitched voice, cataracts, mild DM, muscle atrophy, osteoporosis, premature arteriosclerosis, various neoplasms, severe microangiopathy, surgery contraindicated

f) Meretoja Syndrome: systemic form of amyloidosis, excessively lax skin in persons 20 years or older, facial polyneuropathy, amyloid deposits in perineurium and endoneurium of peripheral nerves, facial neuropathy helps differentiate this disease, surgery contraindicated

g) Idiopathic skin laxity disorders (MDE): patchy areas of mid-dermal elastolysis (MDE), localized fine wrinkling, without systemic abnormalities, pathogenesis is poorly understood, surgery contraindicated

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6) Discuss the difference between facial soft tissue perfusion over the lateral versus the anterior or central face?

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a) Anterior face – perfused by numerous small musculocutaneous perforators;

b) Lateral face – perfused by relatively few but large fasciocutaneous perforators;

c) By virtue of elevating facial flaps a significant portion of the fasciocutaneous perforators are disrupted so that the soft tissue must rely on the central musculocutaneous perforators. Medial dissection thus must be performed conservatively in order to avoid blood flow compromise.

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7) What is the cause of the hollowed out look in the cheek region following a facelift during which the malar fat was transposed to its pre-ptotic locale?

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The malar fat pad itself may atrophy due to disruption of its blood supply resulting in the hollowed out look of the cheek. The malar fat pad is perfused preferentially by the angular artery musculocutaneous perforators. If this fat is mobilized in the skin layer and aggressively translocated ( > 2 cm), the blood supply can be disrupted. The malar fat pad should be kept in continuity with the SMAS layer. This maneuver preserves its musculocutaneous perforators if requiring greater than a 2 cm lift.

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8) What is the endpoint to each of the described dissection layers in the cheeks?

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a) Skin elevation: release of the nasolabial fold

b) SMAS elevation: upturning of the modiolus

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9) Discuss some of the differences between the male and female face and implications on facelift?

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a) The rate of hematoma (6 to 8%) in the male is twice that of a female.

b) The vascularity of the skin flap, primarily due to the beard, makes hemostasis more difficult.

c) The beard in the male argues in favor of a pretragal incision, as the beard can obscure the light reflex of the anterior scar. Furthermore, a retrotragal incision may produce unwanted hair growth overlying the tragus.

d) The beard and sideburns of the male can be grown longer to mask superior hairline migration.

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10) Describe the superficial musculoaponeurotic system or SMAS?

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The SMAS was first described by Mitz and Peyronie by 1976. The SMAS becomes attenuated centrally and more fascial over the parotid fascia and over the zygoma region. Understanding the continuity of the SMAS with other facial planes will allow for safe mobilization and will protect all facial nerve branches.

From superior to inferior, the SMAS is continuous with :

a) Galea, frontalis

b) Superficial temporal fascia (STF) or temporoparietal fascia (TPF)

c) SMAS

d) Platysma

e) Superficial cervical fascia (SCF)

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11) Describe the continuity at the tissue plane of the deep temporal fascia?

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From superior to inferior:

a) Cranial periosteum

b) Deep temporal fascia (DTF)

c) Parotidomasseteric fascia

d) Deep cervical fascia (DCF)

The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly. The superficial layer then becomes the parotidomasseteric fascia.

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12) Which of the mimetic muscles are innervated along their anterior surface?

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The buccinator, mentalis, and levator anguli oris. All of the other mimetic muscles are innervated deeply.

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13) Describe the retaining ligaments and their significance?

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a) Osseocutaneous ligaments include the zygomatic and mandibular ligaments. Zygomatic ligaments are responsible for malar fat descent and nasolabial fold deepening.

b) Soft-tissue cutaneous ligaments include the masseteric cutaneous ligaments, which stretch from the anterior border of masseter to the skin and are responsible for jowling.

c) Orbicularis oculi cutaneous ligaments are stretched with herniation of orbital fat pad and loss of malar fat pad support following its descent. Stretch of these ligaments is associated with the development of festoons.

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14) Describe several of the most common approaches to facelifting?

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Most plastic surgeons perform some combination of SMAS and skin relocation. The direction of SMAS pull tends to be vertical as opposed to skin flap redraping, oriented along a more horizontal vector.

a) Skin only: SubQ undermining without addressing SMAS. Safe plane of dissection, but reliance upon only skin tensioning may compromise longevity.

b) SMAS plication: improves facial contour and shape through suture manipulation and is preferred in the thin patient where facial volume is at a premium.

c) Formal SMAS elevation: may allow for better fixation than plication alone which may improve longevity of result.

d) Lateral SMASectomy: popularized by Baker involves excision of a 1 to 2 cm strip of SMAS along the anterior border of the parotid, extending from the mandibular border obliquely to the malar pad. The strip orientation can be altered to influence the vector of SMAS lift. Technique may not be suitable for thin patient.

e) MACS (minimal access cranial suspension): developed by Tonnard – the SMAS is purse-string sutured to the deep temporal fascia with two sutures to correct the neck and the lower third of the face and sometimes an additional suture to address the malar fat pad. The skin flap is elevated through a preauricular and pretemporal hairline incision.

f) Deep plane procedure: advocated by Hamra and Barton – both the skin and SMAS are mobilized in continuity preserving blood supply to the overlying skin. However, differential vectors of the skin and SMAS cannot be created with this technique and facial nerve injury is 4 times as common as with subQ undermining techniques.

g) Subperiosteal face lifting through a temporal or lower lid approach can be useful in the young patient with little skin laxity. Patients with more pronounced skin laxity require more traditional techniques that excise and redrape skin. The technique does not address the lower third of the face or the neck, only the midface.

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15) Describe the various nerves and their significance to facelift?

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a) Buccal branch: if injured not typically symptomatic since it demonstrates collateral innervation in 70% of patients

b) Frontal or temporal branch: collateral innervation observed in only 15 % patients; found on Pitanguy line from 0.5 cm below tragus to 1.5 cm above lateral eyebrow. The temporal branch of the facial nerve is found within the temporoparietal fascia above the zygoma. Dissection must either be subcutaneous and superficial to the frontal branch or deep to the temporoparietal fascia.. The temporal branch or branches cross the middle third of the zygoma. Below the zygoma, one should stay superficial to the parotidomasseteric fascia to prevent injury.

c) Marginal mandibular branch: travels along mandibular angle; 81 % travel above border of mandible vs. 19 % below body of mandible; damage to this nerve causes loss of depressor anguli oris and depressor labii inferioris function. The platysma can compensate for its role to some extent in cases of MM injury.

d) Great auricular nerve (GAN): located at 6.5 cm inferior to external auditory meatus as it crosses the anterior belly of the sternocleidomastoid muscle; the nerve runs in close proximity to the external jugular vein and is invested in the superficial fascia of the sternocleidomastoid (SCM)

e) Lesser occipital: innervates superior cranial surface of ear, may be injured at it runs along the posterior border of the SCM

f) Greater occipital nerve: supplying the mastoid area not typically injured as its path is more posterior to the field of dissection

g) Auriculotemporal nerve: supplies the tragus and the root of the helix and can be seen running superficial to the temporoparietal fascia during the subcutaneous elevation of the temporal flap during a facelift

h) Spinal Accessory Nerve: not typically injured as it supplies the SCM from the deep surface

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16) Discuss several common ways of dealing with the neck in a facelift?

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a) When rejuvenating the lower face and neck, the surgeon must determine if wide subcutaneous undermining to or near the midline through the lateral incisions will allow adequate submental contour or if a submental incision must be employed.

b) Indications for a submental incision may include patients with extensive neck fat, moderate to severe skin laxity, a lax decussation of the platysma, or to improve visualization in dealing with platysmal bands, subplatysmal fat, full anterior digastric muscles, and prominent submandibular glands. A platysmaplasty, such as Feldman corset platysmaplasty or some medial plication variation, is commonly used to address a lax platysma.

c) Suction lipectomy is most effective in those patients with no, mild, or moderate skin laxity but can serve as a useful adjunct to other manuevers.

d) Fat removal at any level should be conservative to avoid contour abnormalities and the “dug-out” neck deformity.

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17) Discuss the complications of rhytidectomy?

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a) Hematoma: most common complication at 3% in females; more common in men averaging 6 to 8 %; associated with systolic blood pressure of 150 or greater. Stop meds with anticoagulant effect, such as aspirin, Plavix, Coumadin, NSAIDS, ginkgo, garlic, and vitamin E at least 1 week prior to surgery.

Avoid vomiting, coughing, anxiety, or pain as these are contributing factors. Drains do not prevent hematomas The treatment of a hematoma is evacuation.

b) Postoperative hypertension, which can lead to hematoma. To avoid this, may prophylax with chlorpromazine 25 mg 1 hr before completing surgery and again 3 hours after surgery; repeat dose at 4 hr intervals for 24 hours if SBP > 150; may also use po clonidine or clonidine patch

c) Nerve injury: buccal branch most often injured but is asymptomatic; GAN: second most common nerve injury (the most common symptomatic nerve injury); Marginal mandibular nerve is injured more often than frontal branch nerve due to advent of platysmal slings that has resulted in an increased incidence of transient marginal mandibular deficits

d) Skin dehiscence or skin slough : associated with aggressive medial dissection of the skin flap, tension at the closure, and cigarette smoking; nicotine known to trigger release of epinephrine and increase platelet adhesion; nicotine retards wound healing; treatment is local wound care, healing by secondary intention; scar revision as needed, and frequent visits for reassurance

e) Alopecia: the tension of the closure is usually the culprit (facelift should be a redraping more than a tensioning procedure); electrocautery at the level of the hair follicle, rough tissue handling, and poor scalp flap design may all contribute. Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair root to a small extent. The healing scar may produce a variable amount of hair.

f) Wide scars or cross hatched scars – frequently due to excessive tension at closure. One should use fine sutures (5-0 or 6-0) that are removed in 5 days.

g) Displacement of the sideburn and temple hair can be avoided by a hairline incision

h) Noticeable postauricular scar – these incisions should always be placed in the auriculomastoid sulcus to obscure visibility.

i) “Double chin” – A submental incision placed directly in the submental crease can accentuate a "double chin". Placing the incision 1 to 2 cm inferior to the crease allows undermining in the area and the scar is hidden in the mandibular shadow.

j) Pixie and loving cup ear deformities – there should be no tension when insetting the earlobe to avoid these two deformities.

k) Infection: RARE, less than 0.5% after facelift

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The Role of Dermal Matrices in Breast Augmentation

 

        by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

 

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         Breast augmentation and particularly revision breast augmentation occasionally require extremely specialized knowledge in the role of dermal matrices.  Dr. Kenneth Benjamin Hughes was a leading author in a recent peer-reviewed article along with colleagues including other professors at Harvard Medical School.  At Hughes Plastic Surgery in Los Angeles and Beverly Hills, Dr. Kenneth Hughes, MD has an elite background and possesses a unique set of skills that can get you the results you want, no matter how difficult the surgery may seem. 

The following is a summary of the article in Annals of Plastic Surgery published this year, The Role of Dermal Matrices in Breast Augmentation and Reconstruction.

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Part I: Types of Dermal Matrices in Breast Augmentation

Part II: Dermal Matrices in Breast Augmentation

Part III: Dermal Matrices in Breast Reconstruction and Augmentation

Part IV: Dermal Matrices in Secondary Breast Augmentation

Part V: Complications of Dermal Matrices in Breast Augmentation

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Part I: Types of Dermal Matrices in Breast Augmentation

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by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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          The use of acellular dermal matrices, available since 1994, has become more widely accepted in abdominal wall and breast reconstruction procedures and its indications continue to expand.1 Complicated breast augmentations, particularly secondary, may require dermal matrix coverage.  Revision augmentation that may require more soft tissue coverage from tissue thinning may be good candidates as well.  Various types of dermal matrices exist that differ in intraoperative preparation, method of storage and cost.2  

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1) Types of Acellular Dermal Matrices

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a) Alloderm®

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             AlloDerm® (LifeCell Corp., Branchburg, NJ) incorporates skin from a human cadaver that undergoes removal of the epidermis and other cells; this reduction in antigenicity provides for a negligible incidence of graft failure and tissue rejection. 3 The resultant product is a biological acellular matrix that favors cell repopulation and rapid revascularization.3 During the process of regeneration, Alloderm® is incorporated into the pre-existing tissue in four stages 1) Damaged tissue is targeted by circulating stem cells 2) Once damaged tissue is located, stem cells are deposited and proceed to adhere to the matrix 3) Differentiation into tissue-specific cell types occurs  4) A new matrix is formed from the differentiated cells which allows for tissue regeneration.4    AlloDerm® has been commonly employed for wound coverage,  fascial defect repair, and post-mastectomy breast reconstruction  uses , but its indications are rapidly expanding into a multitude of areas in which soft tissue camouflage is required for contour defects.

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b) Strattice®

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          Strattice® (LifeCell Corp., Branchburg, NJ) is porcine dermis denuded of cells that contributes to the propagation of an antigenic response.  This proprietary process causes a marked reduction in 1, 3 alpha galactose epitope, a major component of the xenogeneic rejection response.  Strattice is a  reconstructive tissue matrix that supports tissue regeneration used primarily in implant based/tissue expander reconstruction of the breast.6 

  

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c) DermaMatrix®

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          DermaMatrix® (Synthes CMF, West Chester, PA) is human skin in which both the epidermis and dermis are removed from the subcutaneous layer of tissue in a process utilizing sodium chloride solution while preserving the original dermal collagen matrix. This reduces the incidence of rejection and inflammation.  Once DermaMatrix® is transferred to the patient; the collagen matrix is infiltrated by the host cells promoting neovasularization and fibroblast deposition. It is important to note that DermaMatrix® is used only for homologous tissue; however it has a wide variety of applications including nasal reconstruction, lower eyelid reconstruction, cleft palate repair, abdominal wall repair and breast reconstruction post mastectomy. DermaMatrix® has the distinct advantage of rapid rehydration, bacterial inactivation and it does not necessitate the need for refrigerated storage. 7  

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           A study by Becker et al2 compared the use of AlloDerm® and DermaMatrix® in 30 patients (50 breasts) who had immediate expander-based breast reconstruction. Patients were followed up for a mean of 6.7 months. It was found that both dermal matrices were well incorporated and histological examination showed proof of neovascularization. There was a 4% complication rate attributed to wound infection and seroma formation, however no significant dissimilarities were observed in the complication profiles of both groups. The results of this study suggest no important differences among the use of AlloDerm® as opposed to DermaMatrix®. Basu et al8 demonstrated that based on histopathologic analysis, acellular cadaveric dermis has remarkably lower levels of inflammatory parameters; capsule fibrosis, vessel proliferation,  granulation tissue formation, fibroblast cellularity , chronic inflammatory changes, and foreign body giant cell inflammatory reaction than native breast capsules suggesting that acellular cadaveric dermis exhibits certain properties that may reduce formation of a capsule and therefore provides an excellent alternative to total submuscular implant placement in breast reconstructive procedures.

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Part II: Dermal Matrices in Breast Augmentation

 

by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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         The use of acellular dermal matrices in breast reconstruction is becoming more popular in part due to the better cosmetic and psychological outcomes associated with their use.8,9 Their benefits in primary prosthetic breast reconstruction which include a lower incidence of capsular contracture, improved implant coverage and support and better management of implant position have been highlighted in numerous studies.2,9-21 Allogenic acellular matrices can be used in both immediate and delayed single-stage expander-based reconstruction aiding in reconstruction of the inframammary fold, providing much needed inferolateral prosthesis coverage and eliminating donor-site morbidities leading to a reduction in muscle dysfunction and pain as well as an early recovery period.2,22 Furthermore it permits immediate implant placement post mastectomy through expansion of the submuscular pocket volume.9,10,14,22 One factor however that may serve as a deterrent for the use of acelluar dermal matrices in breast reconstruction procedures is its high cost which may range anywhere from $3,536 to $4,856 per breast.23 For the most part, aesthetic outcomes supersede cost as demonstrated in a study conducted by Salzberg9 were AlloDerm® was used in 49 patients (76 breasts) who underwent immediate reconstruction to provide total coverage over the prosthesis alleviating the need for breast expansion prior to placement of an implant and to minimize muscle dissection. The outcome was said to be favorable with good symmetry.

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Acellular Dermal Matrices for Secondary Breast Augmentation

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          Some of the most complicated and challenging predicaments to correct are deformities of the breast following breast augmentation and augmentation mastopexy. They are of the most complex procedures that a plastic surgeon may face with a significantly higher rate of complications compared to primary procedures, perhaps due to the fact that there may be encapsulation or stretch of breast tissue caused by excessive scarring or thinning attributed to the use of large implants.23,35 In a 2 year study where 78 patients who underwent breast augmentation and augmentation mastopexies  with acellular dermal matrices were enrolled and followed up for 12 months, no capsular contractures were reported although, two complications did occur; implant malposition and hematoma formation. This data suggests that with the use of acellular dermal matrices the capsular contracture rate following secondary augmentation and augmentation mastopexy procedures is markedly reduced. 35 In a more recent retrospective study by Hartzell et al23 a single surgeons’ experience using acellular dermal matrix  following breast augmentation from 2005 to 2009 was analyzed during which 23 patients (38 breasts) were included. Of the 38 breasts, implant malposition was reported in 22 and surface irregularities in 28, with both appearing in 12 patients. Following their revision procedure, 20 patients showed improvement in the aesthetic appearance of their breasts, 3 patients required an additional procedure and 1 patient was found to have incurred an infection for which the human acellular dermal matrix was removed. In the end, the authors proclaim the use of human acellular dermal matrix a safe alternative for correction of breast deformities following augmentation. 

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Part III: Dermal Matrices in Breast Reconstruction and Augmentation

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by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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Acellular Dermal Matrices for Breast Reconstruction after Mastectomy with Tissue Expander/Implant

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        The use of a tissue expander or an implant in post mastectomy breast reconstruction can be a daunting task. Most reconstructive surgeons prefer the use of autologous tissue. Despite the fact that implant based reconstruction may appear to be technically easier, quicker and less costly, it is not without limitation when used in reconstructive procedures. Acellular dermal matrices have been used in single as well as staged reconstruction with good aesthetic results and low complication rates. 12,14 Typically, the tissue expander/implant is positioned just below the pectoralis major muscle to cover its superior and medial poles. For coverage of the lateral and inferior poles either additional muscles are elevated (pectoralis minor or serratus anterior) contributing to another layer between the skin and implant hence lowering the incidence of contour irregularities and implant exposure, or subcutaneous tissue only is used.2,14,22,29,30

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          In an attempt to reduce the time needed for the entire reconstructive process by eliminating the need for tissue expansion, Breuing and Warren 10 utilized a technique in which subpectoral-sub-AlloDerm® pockets were created to completely enclose the breast implant. An AlloDerm® sling was used to anchor the lower pole of the pectoralis major muscle. For the most part, postoperative results demonstrated lower-pole projection, good symmetry, and a volume match compared with preoperative size. In a study of 30 immediate implant-breast reconstructions with human acellular dermal matrix over an 8 month mean follow up period, in which Zienowicz and Karacaoglu14 sewed AlloDerm® to the lower pole of the released pectoralis major superiorly, the serratus anterior flap laterally and the chest wall inferomedially, a 0% complication rate (no symmastia, bottoming-out deformity or rippling) was reported. This approach enables easy manipulation of the implant pocket to allow for optimal cosmetic breast contouring and maintenance of thicker muscle coverage in the medial and upper poles as well as providing the support necessary to sustain a strong lower pole. Another distinctive method is the use of an inferolateral Alloderm® hammock which attaches to the serratus anterior laterally and rectus abodminis fascia inferiorly to create an implant pocket in which it is easy to control implant position. This was used in 67 breasts; 30 silicone implant reconstructions, 23 revisional implant reconstructions for capsular contracture after capsulectomy, 10 immediate expander-implant reconstruction and 4 delayed expander-implant reconstructions. No complications were reported over a 6 month to 3 year follow up period and patients were satisfied with the final outcome. 1

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Part IV: Dermal Matrices in Secondary Breast Augmentation

 

by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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Acellular Dermal Matrices for Secondary Deformities in Breast Augmentation

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           Owing to the benefits of acellular dermal matrices in breast reconstruction surgeries, it has also been applied to various implant related changes, namely implant associated breast deformities.31 The use of acellular dermal matrices can be used to improve coverage and durability of implants as well as obtaining better shape of the reconstructed breast.17 In a study conducted between 2003 and 2009, Spear et al31 reviewed 52 patients who had acellular dermal matrix with 77 breast prostheses. The authors established indications for use of dermal matrix as being; deficiency of skin flap, treatment of malposition, rippling, capsular contracture and implant bottoming-out. 74 of 77 were deemed successful with only 3 failures; rippling in one patient, infection in the other and bottoming out in the third. In a series of 34 patients, with breast implant related problems, Duncan32  found a 2.9% capsular contracture rate with an 85% patient satisfaction rate and an improvement in palpable rippling. To address breast implant rippling, contracture, symmastia and bottoming out using human acellular dermal matrix, Baxter33 found stable outcomes in 80% of revisions. Over a 52 month follow up period, Salzberg9 reported a 0% rate of contracture. The same result was observed in studies conducted by Zienowciz and Karacaoglu14 as well as Breuing and Colwell13.

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Part V: Complications of Dermal Matrices in Breast Augmentation

 

by Dr. Kenneth Benjamin Hughes, Los Angeles Plastic Surgeon

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Complications of Acellular Dermal Matrices in breast surgery

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            Despite the fact that acellular dermal matrices are treated under aseptic conditions to minimize immunogenicity while simultaneously maintaining matrix structure to permit host cells to repopulate the graft.22,24 the theoretical risk of infection has been investigated thoroughly. Ultimately, human acellular dermal matrix should be able to resist infection owing to its ability to revascularize, recullularize and integrate itself within the host tissue following implantation.25 However due to the time required for such processes to happen, a window period emerges whereby infection can occur.

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          Another concern with the use of acellular dermal matix is its ability to tolerate exposure to irradiation.25,26 In a study by Nahabedian 25 to determine the aptitude of AlloDerm to resist infection and irradiation, 476 breasts (361 women) that underwent reconstruction; 100 breasts (76 women) using Alloderm® and the rest without were compared. It was found that the rate of infection did not differ significantly between the AlloDerm group (5%) and the control group (5.85%). In addition, irradiation had no effect on the rate of infection or adherence. Reported complications included seroma (5%), dehiscence (4%) and skin necrosis (3%) which can occur with standard reconstruction when exposed to radiotherapy. Overall, it was demonstrated that the risk of infection did not vary with or without AlloDerm® and that it is perfectly tolerant of both infection and irradiation.

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           Komorowska-Timek et al20 suggest that the use of AlloDerm® reduces the rate of radiation related inflammation and pseudoepithelium formation in a study were 2 implants were placed in the backs of 41 rats, 20 of which underwent irradiation of their implants and 21 who served as controls. It was observed that radiation induced inflammation increased at 12 weeks in the control group but was diminished in the AlloDerm® group. This data supports the use of AlloDerm® limiting the progression of contraction, fibrosis and capsular formation.

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           Bindingnavele et al12 analyzed the charts of 41 patients (65 breast) who underwent staged breast reconstruction with acellular cadaveric dermis for complication rates and found that they were extremely low; seroma (3 patients), wound infection (2 patients), hematoma (1 patient) and expander removal (1 patient).

Nguyen et al27 found that there were no variations in the readmission rates for IV antibiotics in a series of 321 implant based reconstructions of whom 75 used Alloderm® and 246 did not. However, the rate of explanation as a result of infected fluid collections was significantly lower in the control group in comparison to the AlloDerm® group.

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          In contrast, Chun et al19 reported an increase in the rate of infections and seroma in a series of 415 implant-based reconstructions where the use of acellular dermal matrices contributed to a rise in the incidence of seroma by 4.24 times and of infection by 5.37 times. They emphasize careful and meticulous post operative management. In another study by Lanier et al28 the increase in rate of infection with use of acellular dermal matrices was attributed to size of the breast being larger than 600g.  Liu et al22 used acellular dermal matrix and observed an elevation in the risk of infection that was not of statistical significance. This higher complication rate could perhaps be due to other individual risk factors; higher body mass index, smoking, larger implant size, which are known to cause an increase in the overall complication rate.   

 

          In a metanalysis of 53 articles, Adetayo et al1 identified the most common complication associated with the use of Acelluar Dermal Matrices in Breast and Abdominal wall surgery as being wound infection; 16% followed by seroma formation and breast implant failure; 8% and 6% respectively. It was also mentioned that administration of chemotherapy increased the rate of seroma and exposure to radiation raised the incidence of cellulitis.

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