Fifty: another year older or a milestone?
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Aging↗
Biomedical subjects
Rod J Rohrich
Publications and source records attributed to Rod J Rohrich.
The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches.
An interest in pursuing new theories of the underlying etiology of migraine headaches has been sparked by previously published reports of an association between amelioration of migraine headache symptoms and corrugator resection during endoscopic brow lift. This theory has further been reinforced by recent publications documenting improvement in migraine headaches following injection of botulinum A toxin. There are thought to be four major "trigger points" along the course of several peripheral nerves that may cause migraine headaches. Among these peripheral nerves is the greater occipital nerve. For this reason, the authors have undertaken an anatomic study of this nerve to determine its usual course, potential anatomic variations, and possible points of potential entrapment or compression. The results of this anatomic study have enhanced further development of techniques designed to address these points of entrapment/compression and potentially lead to relief of migraine headaches caused by this mechanism. Twenty cadaver heads from patients with an unknown history of migraine headaches were dissected to trace the normal course of the greater occipital nerve from the semispinalis muscle penetration to the superior nuchal line. Standardized measurements were performed on 14 specimens to determine the location of the emergence of the nerve using the midline and occipital protuberance as landmarks. On the basis of this information, the location of emergence was determined to be at a point centered approximately 3 cm below the occipital protuberance and 1.5 cm lateral to the midline. This location can, in turn, be used to guide the practitioner performing chemodenervation of the semispinalis capitis muscle in an attempt to provide migraine symptom relief.
Humans↗
Current concepts in aesthetic upper blepharoplasty.
LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients. 3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including lasers. 4. Recognize and treat postoperative complications from blepharoplasty. Traditional blepharoplasty has often involved the excision of both lax skin and muscle and excessive removal of fat, leaving patients long term with a hollow orbit and a harsh, operated appearance that accelerates the aging process. Current methods of periorbital rejuvenation are more conservative, are based on concise preoperative evaluation, and involve the limited resection of the coveted soft tissue from the eye to restore a youthful appearance. The authors describe anatomy, preoperative assessment, decision-making and counseling of patients, surgical planning, eyelid marking, and various techniques, including lasers, along with postoperative complications associated with current concepts in aesthetic upper blepharoplasty.
Algorithms↗
Effect of low-level laser therapy on abdominal adipocytes before lipoplasty procedures.
Low-level laser therapy is a new subspecialty for the medical application of lasers that provides therapeutic rather than surgical outcomes for many medical indications. Recently, low-level laser therapy was reported to "liquefy" or release stored fat in adipocytes by the opening of specialized yet not identified cell membrane-associated pores after a brief treatment. Currently, low-level laser therapy is a U.S. Food and Drug Administration-approved technology for improving pain alleviation. To explore these data further, a series of in vitro studies on human preadipocytes and institutional animal care and use committee-approved protocols in a porcine Yucatan model and an institutional review board-approved clinical study were performed. Using a 635-nm low-level laser of 1.0 J/cm supplied to the authors by the vendor, these studies were designed to determine whether alteration in adipocyte structure or function was modulated after low-level laser therapy. Cultured human preadipocytes after 60 minutes of laser therapy did not change appearance compared with nonirradiated control cells. In the porcine model, low-level laser therapy (30 minutes) was compared with traditional lipoplasty (suction-assisted lipoplasty) and ultrasound-assisted lipoplasty. From histologic and scanning electron microscopic evaluations of the lipoaspirates, no differences were observed between low-level laser therapy-derived and suction-assisted lipoplasty-derived specimens. Using exposure times of 0, 15, 30, and 60 minutes in the presence or absence of superwet wetting solution and in the absence of lipoplasty, total energy values of 0.9 mW were delivered to tissue samples at three increasing depths from each experimental site. No histologic tissue changes or specifically in adipocyte structure were observed at any depth with the longest low-level laser therapy (60 minutes with superwet fluid). Three subjects undergoing large-volume lipoplasty were exposed to superwet wetting fluid infiltration 14 minutes before and 12 minutes after, according to vendor instructions. Tissue samples from infiltrated areas were collected before suction-assisted lipoplasty and lipoaspirates from suction-assisted lipoplasty. No consistent observations of adipocyte disruptions were observed in the histologic or scanning electron microscopy photographs. These data do not support the belief that low-level laser therapy treatment before lipoplasty procedures disrupts tissue adipocyte structure.
Abdomen↗
Pharmacokinetics and safety of lidocaine and monoethylglycinexylidide in liposuction: a microdialysis study.
High doses of lidocaine are administered to patients undergoing liposuction. Monoethylglycinexylidide, the active metabolite of lidocaine, is 80 to 90 percent as potent as lidocaine, and its relative toxicity is approximately that of lidocaine. Monoethylglycinexylidide has not previously been measured in studies on lidocaine in liposuction. The aims of this study were to characterize systemic exposure to lidocaine and monoethylglycinexylidide and to measure lidocaine and monoethylglycinexylidide levels within the tissues. Five female volunteers between the ages of 29 and 40 years underwent liposuction. Lidocaine (1577 to 2143 mg, corresponding to 19.9 to 27.6 mg/kg) was infiltrated during the procedure. Levels of lidocaine and monoethylglycinexylidide in blood and lipoaspirate were assessed perioperatively. Tissue lidocaine and monoethylglycinexylidide levels were measured postoperatively using a microdialysis technique in vivo. The peak (maximal) concentration of lidocaine plus monoethylglycinexylidide was 2.2 to 2.7 microg/ml. Time to peak lidocaine plus monoethylglycinexylidide was 8 to 28 hours after infiltration began. Absorbed lidocaine was estimated to be 911 to 1596 mg; therefore, 45 to 93 percent (mean, 64 percent) of the infiltrated dose was ultimately absorbed. Lipoaspirate analysis showed that 9.1 to 10.8 percent (mean, 9.7 percent) of the infiltrated dose was removed during the procedure. Tissue lidocaine levels below 5 microg/ml were demonstrated from 4 to 8 hours postoperatively. The peak lidocaine plus monoethylglycinexylidide concentration was within safe limits in this group of subjects. Time to peak lidocaine plus monoethylglycinexylidide signifies a delayed peak and therefore a longer period of potential lidocaine toxicity than was originally thought. Microdialysis results demonstrated that tissue lidocaine levels may be subtherapeutic within 4 to 8 hours of the procedure. Investigation into factors controlling the resorption of lidocaine during liposuction is warranted in an effort to improve the duration of effect. Furthermore, considering the active metabolite monoethylglycinexylidide, longitudinal studies are necessary to determine whether improving the side effect profile of lidocaine by reducing the dose administered during liposuction may be possible without decreasing the perioperative analgesic effect.
Adipose Tissue↗
Oral nutritional supplementation accelerates skin wound healing: a randomized, placebo-controlled, double-arm, crossover study.
Nutritional therapy is critical for wound healing in people with severe malnutrition or specific metabolic deficiencies. Medical claims from manufacturers of many oral supplements are marketed to surgical patients for decreasing edema, bruising, and discomfort. The effect of supplementing nutrients on soft-tissue wound healing in otherwise normal, healthy adults is an area of clinical importance, but little information is available. Proteolytic enzymes have been reported to moderate the inflammatory cycle and may up-regulate the healing process. The goal of this study was to perform a clinical trial in normal, healthy adults that examined the effects of an oral nutritional supplement (InflammEnz, Enzymes, Inc., Parkville, Mo.) on soft-tissue healing times. Twenty-six normal, healthy volunteers were recruited into a randomized, crossover, placebo-controlled, clinical trial consisting of two phases, each lasting 21 days. In phase I, subjects were subjected to a 3-mm forearm skin biopsy and randomly received a placebo or oral supplement (four capsules per day for 7 days). After a 2-week washout period, a second biopsy was performed to start phase II, with each subject receiving the respective placebo or supplement capsules. Digital photographs were taken during wound healing in both phases and analyzed for wound areas (in square millimeters) and perimeters (in millimeters). Twenty-two subjects completed the clinical trial. On the basis of wound surface areas, 17 subjects had improved wound healing and five subjects did not respond or responded only slightly to the supplement treatment. The mean +/- SD healing time of the subjects responding to supplement-treated wounds was 15 +/- 2.2 days, compared with 18 +/- 2.5 days for the placebo group. The 17 percent acceleration of wound-healing time was significant (p < 0.005). In subjects responding to oral supplements, less redness in the wounds was observed that may have been associated with less inflammation. The authors' results demonstrate that InflammEnz oral supplementation accelerated soft-tissue wound healing in 77 percent of normal, healthy subjects studied. The authors' study validates observations made that this supplement modulates the wound-healing process and suggests that many patients with minor soft-tissue wounds may benefit from treatment.
Adult↗
Hemodynamic physiology and thermoregulation in liposuction.
Little is known about the physiology of large-volume liposuction. Patients are exposed to prolonged procedures, general anesthesia, fluid shifts, and infusion of high doses of epinephrine and lidocaine. Consequently, the authors examined the thermoregulatory and cardiovascular responses to liposuction by assessing multiple physiologic factors. The aims of their study were to serially determine hemodynamic parameters perioperatively, to quantify perioperative and postoperative plasma epinephrine levels, and to chronologically document fluctuations in core body temperature. Five female volunteers with American Society of Anesthesiologists' physical status I and II underwent moderate- to large-volume liposuction. Heart rate, blood pressure, mean pulmonary arterial pressure, cardiac index, and central venous pressure were monitored. Serum epinephrine levels and core body temperature were assessed perioperatively. The hemodynamic responses to liposuction were characterized by an increase in cardiac index (57 percent), heart rate (47 percent), and mean pulmonary arterial pressure (44 percent) (p < 0.05). Central venous pressure was not significantly altered. Maximum epinephrine levels were observed 5 to 6 hours after induction. Significant correlations between cardiac index and epinephrine concentrations were shown intraoperatively (r = 0.75). All patients developed intraoperative low body temperatures (mean 35.5 degrees C). An overall enhanced cardiac function was observed in patients subsequent to large-volume liposuction. The etiology of the altered cardiac parameters was multifactorial but may have been attributable in part to the administration of epinephrine, which counters the effects of general anesthesia and operative hypothermia. Additional explanations for raised cardiac output may be hemodilution or emergence from general anesthesia. Elevated mean pulmonary arterial pressure may be a result of subclinical fat embolism demonstrated in previous porcine studies, although fat was not observed in urine. The unchanged central venous pressure levels indicate that young healthy patients with compliant right ventricles can accommodate the fluid loads of large-volume liposuction. Overall hemodynamic parameters remained within safe limits. Within these surgical parameters, patients should be clinically screened for cardiovascular and blood pressure disorders before liposuction is undertaken, and preventative measures should be taken to limit intraoperative hypothermia.
Adult↗
Benjamin Franklin and plastic surgery.
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Famous Persons↗
Shelling and plastic surgery.
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Attitude of Health Personnel↗
Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty.
Dorsal hump reduction can create both functional and aesthetic problems if performed incorrectly. Component dorsal hump reduction allows a graduated approach to the correction of the nasal dorsum by emphasizing the integrity of the upper lateral cartilages when performing dorsal reduction. Use of this approach can minimize the need for spreader grafts in primary rhinoplasty patients. Possible untoward sequelae of dorsal hump reduction include long-term dorsal irregularities caused by uneven resection or overresection or underresection of the osseocartilaginous hump irregularity; the inverted-V deformity; and excessive narrowing of the midvault. The component dorsal hump reduction technique is a five-step method: (1) separation of the upper lateral cartilages from the septum, (2) incremental reduction of the septum proper, (3) dorsal bony reduction, (4) verification by palpation, and (5) final modifications (spreader grafts, suturing techniques, osteotomies). A graduated approach is described that offers control and precision at each interval. Fundamental to the final outcome is the protection and formation of strong dorsal aesthetic lines that define the appearance of the dorsum on frontal view. Furthermore, preservation of the transverse portions of the upper lateral cartilages is essential to maintain patency of the internal nasal valve, maintain the shape of the dorsal aesthetic lines, and avoid the inverted-V deformity. Finally, if needed, spreader grafts are enormously adaptable and can be customized for any deformity (unilateral or bilateral, visible or invisible) to handle functional or aesthetic problems.
Adult↗
Nasal reconstruction--beyond aesthetic subunits: a 15-year review of 1334 cases.
A retrospective analysis was performed on 1334 patients who underwent nasal reconstruction between 1986 and 2001. The senior author performed all reconstructions in this series after Mohs' histographic excisions. Only secondary reconstructions were performed without a preceding Mohs' excision. Methods of reconstruction, number of operations per patient, locations of defects, and complications were recorded. Using preoperative and postoperative photographs, aesthetic results were reviewed. Basal cell carcinoma was the most common lesion, followed by squamous cancer and melanoma. The average age of the patients was 51 years. Cancers most commonly arose on the dorsum, ala, and tip. Of 1334 cases, a 1.9 percent recurrence rate was documented. The average time between surgery and clinical recognition of recurrence was 39 months. All recurrent lesions were reexcised by the Mohs' technique. Eighty-one percent of reconstructions were completed in three or fewer stages. Seventy-five percent of reconstructions were completed in two stages. Primary dermabrasion or primary laserbrasion using carbon dioxide or erbium lasers was used in nearly every case. Early secondary dermabrasion or laserbrasion was used in a few cases where indicated. A 1.2 percent revision rate was noted (16 patients). Thirteen partial flap necroses required revision. Three patients experienced dehiscence at the donor site of paramedian forehead flaps. A preferred philosophy toward nasal reconstruction is described. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue. Six core principles are advocated that guide efficient and successful nasal reconstruction: (1) maximal conservation of native tissue is advised; (2) reconstruction of the defect, not the subunit, is advised; (3) complementary ablative procedures, such as primary dermabrasion, enhance the final result and decrease the number of revisionary procedures; (4) primary defatting also decreases the number of revisionary procedures; (5) when possible, the use of axial pattern flaps is preferred; and (6) good contour is the aesthetic endpoint.
Adult↗
The limited scar mastopexy: current concepts and approaches to correct breast ptosis.
The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy.
Breast↗
A walk through Franklin's Philadelphia: then and now.
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Cities↗
A moment of silence.
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Aspirations, Psychological↗
Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002.
The purpose of this survey was to assess the current trends in breast reduction techniques and to compare satisfaction rates and complications associated with traditional incision and limited incision techniques. In September of 2002, a breast reduction survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 554 of the members returned the survey. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions. The results showed that 56 percent of the respondents use only the inferior pedicle and Wise pattern techniques, whereas 6.9 percent of the respondents use only the limited incision techniques. Physician satisfaction was rated as 4 on a scale of 1 (unsatisfied) to 5 (very satisfied) for both the limited incision and traditional incision groups. Patient satisfaction was rated as 4 for the limited incision group and as 5 for the traditional incision group. This difference in patient satisfaction per surgeon was statistically significant (p < 0.05). The traditional group reported a lower complication rate than did the limited incision group (p < 0.05). The most frequent complications for the traditional incision group were compared with those of the limited incision group. Practice profiles, liposuction, and opinions regarding future changes in breast surgery were also analyzed. The majority of surgeons reported that they did not anticipate changing their practices to accommodate advances in limited incision techniques; however, 89 percent reported that the new limited incision techniques and liposuction are trends that are here to stay.
Cicatrix↗
The key to long-term success in liposuction: a guide for plastic surgeons and patients.
Patients need to have realistic expectations for a long-term successful body contour result. There are four key elements for long-term successful improvement in body contour, and the patient is responsible for the first three: exercise, a proper diet, and other positive lifestyle changes; and successful body contouring. An extensive survey requesting information about the procedures, areas of liposuction, lifestyle habits, and satisfaction was mailed to 600 patients who had liposuction surgery performed between 1999 and 2003. One hundred and eight surveys were undeliverable and 209 completed surveys were returned (34.8 percent of 600 mailed surveys and 42.5 percent of 492 delivered surveys). Data were analyzed by a binary logistic regression with backward elimination. Weight gain (versus no weight gain) was used as the dependent variable. The results showed that regardless of whether the patient did or did not gain weight, both groups reported being very satisfied (30 percent and 48 percent, respectively) or satisfied (43 percent and 34 percent, respectively) with their procedure. Among the weight gain patients, 72 percent would still have the procedure again, compared with 82 percent of responders who did not gain weight. When asked if they would recommend the procedure to family or friends, 90 percent of responders who did not gain weight would recommend the procedure whereas only 74 percent of responders who did gain weight would recommend the procedure (p < 0.001). Among those patients who gained weight, only 29 percent thought their appearance was excellent or good (compared with 79 percent of those who did not gain weight). Among the 57 percent of patients who did not gain weight, 35 percent report exercising more postoperatively (compared with only 10 percent in the weight gain group, p = 0.002) and 50 percent report eating a healthier diet (22 percent in the weight gain group report eating a healthier diet, p = 0.002). In the weight gain group, 67 percent report no change in their diet regimen and only 17 percent thought their productivity increased (compared with 25 percent among the no weight gain group, p = 0.002). Successful body contouring surgery requires a patient to embrace positive lifestyle habits. The results of this survey have been used to create a quantitative decision-making framework or a "road map" for patients and plastic surgeons to use for navigating toward successful long-term results.
Clothing↗
Rhinoplasty with advancing age.
Rhinoplasty in the aging patient poses a unique set of challenges to the plastic surgeon. Aging patients usually have different expectations and motivations than their younger counterparts; therefore, open communication and frank discussions are paramount to define realistic goals. Anatomically, changes in skin quality, cartilage characteristics, underlying bony framework, and the nasal airways mandate special considerations to optimize the functional and aesthetic results. This review will present a practical approach to the management of the nose in the aging patient.
Aged↗
Obesity in America: an increasing challenge for plastic surgeons.
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Adult↗