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The effect of brown fat removal on the development of obesity in Zucker and Osborne-Mendel rats.

Removal of significant amounts of brown fat in young Zucker rats maintained at room temperature triggered compensatory changes in the remaining brown fat depots. These changes, which occurred to a greater extent in the lean than in the obese rats, enhanced the thermogenic potential of the remaining depots, thus possibly accounting for the lack of increased adiposity in these lipectomized rats. When the Zucker rats were maintained in the cold, rather than at room temperature, their ability to compensate for removal of the scapular brown fat was compromised, particularly in the obese animals. Under such conditions, the amount of functional brown fat was significantly reduced, and the amount of body fat elevated. In the lipectomized Zucker rats, this increase in adiposity was accompanied by increased body mass. In contrast, in the cold-exposed Osborne-Mendel rats, where lipectomy was not accompanied by compensatory increases in the mass and cellularity of the remaining brown fat depots, increased body fat occurred in the absence of any increase in food intake or in total body mass.

Adipose Tissue, Brown↗

Body sculpturing.

Body contouring surgery is a routine procedure used to improve the aesthetic aspect of the trunk and may be performed in one or more surgical stages. It may involve the abdomen, breasts, flanks, lumbar area, buttocks, trochanter, upper arms, and upper-inner thigh. The author discusses suction lipectomy, augmentation mammoplasty, breast reduction and mastopexy, abdominoplasty, surgery of the trochanter and buttocks, surgery of the thigh, brachioplasty, and combined procedures.

Abdomen↗

Eyebrow, face, and neck lifts for males.

Alternate locations to skin excisions adjacent to the eyebrows for correction of eyebrow ptosis have been presented. Excisions in the upper forehead or in the scalp permit flexibility in width and length of skin or scalp to be excised and may be extended laterally to produce a temporal lift which not only improves the lateral canthal area of sagging skin but also may improve the lower eyelid surgical correction results (Figs. 1 and 3). By use of adequate lipectomy and full-width platysma muscle flaps to support the new neck contour, better and longer lasting results have been accomplished. The currently used techniques for eyebrow, face, and neck lifts for males produce better and longer lasting results than could have been accomplished with previously used techniques. The continued search for improvement in techniques by many surgeons in different areas of the world has enabled these longer lasting and better results to be accomplished.

Adult↗

Illouz's technique of body contouring by lipolysis.

The principal aim of suction lipectomy is to leave intact, as far as possible, the connections between the skin and the underlying tissue, thereby retaining the blood vessels, the lymphatics, and the nerve endings. The author presents his surgical technique and discusses complications, indications, disadvantages of lipolysis, and advantages of his technique.

Abdomen↗

The platysma muscle. Anatomic considerations for aesthetic surgery of the anterior neck.

Our current principles for the treatment of anterior neck deformities originally evolved from cadaver dissections and clinical observations. These principles have been applied over the past seven years in nearly 100 patients. We combine as indicated submandibular lipectomy, excision of the submental fat pad, chin implantation, creation or tightening of the platysma muscular sling, and skin tightening and resection. The muscular sling is created or tightened anteriorly by approximation or imbrication of the platysma muscle in the midline. Skin is removed posteriorly, utilizing a complete or lower facelift incision. Using these techniques, we have not found posterior tightening of the platysma muscle or the creation of platysma flaps to be necessary, although we would certainly use them if other alternatives were ineffective.

Adult↗

The regenerating fascial sheath in lipectomized Osborne-Mendel rats: morphological and biochemical indices of adipocyte differentiation and proliferation.

We investigated the cellular and enzymatic changes that occur as adipose tissue regenerates following bilateral lipectomy of Osborne-Mendel rats. At 6, 8, 10, 12 and 14 days after surgery regenerating fascial sheaths regrowing at the site of the inguinal fat depots were fixed in situ and removed for studies of cellular and tissue morphology at both light and electron microscopic levels. Additional tissue from some animals was prepared for measurement of thymidine kinase and lipoprotein lipase activity. Six days after surgery, fascial sheaths had regrown at the site and contained a few mature unilocular adipocytes as well as numerous other cells, some of which contained non-membrane bound lipid droplets, and which were tentatively identified as pre-adipoblasts and adipoblasts. Over the period from day 6 to day 14 the number of unilocular adipocytes in the tissue doubled and the average cell size increased. These changes in cellular morphology were accompanied by correlative changes in enzyme activity.

Adipose Tissue↗

Aesthetic restoration of the severely disfigured face in burn victims: a comprehensive strategy.

Although highly specialized burn centers have significantly reduced mortality rates following extensive total body surface area burns, survivors are often left with grotesque facial disfigurement. The strategy of modern facial restoration emphasizes enhancement of aesthetic appearance as significantly as mitigation of functional impairment. Criteria for success are (1) an undistracted "normal" look at conversational distance, (2) facial balance and symmetry, (3) distinct aesthetic units fused by inconspicuous scars, (4) "doughy" skin texture appropriate for corrective makeup, and (5) dynamic facial expression. Since 1985, the author has successfully restored 17 severely disfigured burned faces by replacement of entire aesthetic units with microvascular "prepatterned" composite flaps blended into the facial canvas by cosmetic camouflage techniques. The series includes hemiface (2), neck/jaw (5), chin/lower lip (3), cheek/malar (5), peri-orbital (2), nose (3), upper lip (4), and ear reconstructions (4). Flaps represented are free preauricular (1), radial forearm (6), ulnar forearm (1), free scapular (6), ilio-osteocutaneous (2), temporoparietal (8), vascularized forehead island (3), supraclavicular (1), and SMAS (1). Important to outcome is extensive initial intraoperative "sculpting" to simulate normal planes and contours. Seams are placed at junctions of facial components. Three-dimensional imaging is used to assess architectural asymmetries, and bone grafts are aided by computer-generated acrylic models. Adjunctive procedures include tensor fasciae latae slings, intraoperative tissue expansion, suction-assisted lipectomy, and scar management. After restoration of facial form and texture, flesh color make-up and/or tattooing of beard, lips, scars, eyebrows, etc., aid to hide scars and pigment the skin to harmonize with the rest of the face. In all cases, facial integrity has been aesthetically restored and, in most instances, with makeup, is near normal in social settings at conversational distances. Facial animation is retained and color matches are excellent. One flap was lost early in the series.

Adolescent↗

Augmentation phalloplasty.

Aesthetic procedures can increase the girth and visual length of the penis. Dermal-fat grafts increase penile circumference without the complications that result from fat injections. Release of the suspensory ligaments with skin advancement may increase flaccid penile length. Suprapubic lipectomy and Z-plasty of a penoscrotal web enhance penile appearance. Accurate diagnosis and meticulous technique are mandatory.

Adipose Tissue↗

[Breast reconstruction by abdominis musculocutaneous flap].

Breast reconstruction was carried out with rectus abdominis musculocutaneous flap on 7 women (8 breasts) with defect of breast, and perfect result was obtained on all the patients. The flap which was normally excised in an abdominal lipectomy was used to cover the defect of breast. The rectus abdominis of the flap was used to fill the reconstractive breast and to carry the vascularization from the internal mammary artery. The advantages of the method are as follow: (1) the waist-line is reduced by closing the musculoaponeurtic defect; (2) The scar of the donor area is well hidden by the abdominoplasty; (3) The breast reconstruction need not use an implant. The disadvantage is a risk of postoperative herniation if the suture tears.

Female↗

Reduction mammaplasty by suction alone.

Because unsatisfactory scars often result when traditional methods of reduction mammaplasty are performed, techniques that leave less noticeable scars have been advocated recently. One such technique is suction lipectomy, which has been employed previously, but only for patients who have well-located, small nipple-areola complexes and whose hypertrophy is primarily fat. I have found that concern for the size and location of the nipple-areola complex and cause of hypertrophy are unfounded. Thus reduction mammaplasty by suction alone may be the technique of choice in certain patients. Eleven patients had reduction mammaplasty by suction alone and obtained aesthetically pleasing breasts that had good sensation and minimal scars. As a result, the method is suggested for selected patients: those with minimal to moderately large breasts.

Adolescent↗

The endoscopic breast augmentation: the transumbilical insertion of saline-filled breast implants.

Initial aesthetic breast augmentation with inflatable saline implants has always had the distinct advantage of insertion through a small breast or axillary skin incision. Adapting established techniques utilized in suction-assisted lipectomy, operative endoscopy, and tissue expansion with inflatable saline implants, breast augmentation is possible through an umbilical incision. Under general anesthesia, an incision is made in the umbilicus; a new tubular instrument with an obturator [designated an endotube (Johnson) or mammascope (Christ)] is inserted into the umbilical incision like a suction cannula; it is pushed over the abdominal fascia across the costal margin until it literally pops under the breast fascia; through this tunnel is then inserted an implant coiled like a tobacco leaf; the implant is then inflated to 50 percent more than the final volume and manipulated to help expand the pocket; finally, the excess volume is removed, methyl-prednisolone acetate is placed in the final volume, and the fill tube is removed. The endoscope (laparoscope) is utilized to visualize positioning and to document the absence of bleeding. The umbilical incision is closed after insertion of both implants through the same incision. A series of 91 young women have undergone this procedure with 188 breast implantations without significant bleeding. Implants appear to ride high initially, but they settle into place by 6 weeks. Patients have reported less chest discomfort and some visible temporary upper abdominal swelling. The long-term follow-up is currently being monitored.

Adult↗

Surgical management of the buried penis.

BACKGROUND: Buried penis is a congenital abnormality in which the phallus is concealed within the surface of prepubic skin. It is probably more common than is generally recognized. The objective was to describe the pathophysiology, and search for the best management of this disease. METHODS: Over a period of 6 years, a total of 31 cases receiving surgery for buried penis at this hospital were analyzed. According to their major pathophysiology, patients were divided into three groups: in the first, the major mechanism was poor skin suspension; in the second, prominent suprapubic fat pad was the major cause. In the third group, the dartos fascia was abnormally thickened and attached to the penile shaft. Different surgical techniques were applied in the different groups. RESULTS: All 15 children in the first group had satisfactory results after penile skin fixation. In the second group, nine children underwent adjunctive lipectomy but only five had satisfactory results. Seven patients in the third group needed degloving of the penis and the three cases who underwent preputial unfurling had severe lymphedema of the inner preputial layer. One of them received revision. The end results were good in the other six patients after long-term follow up. CONCLUSIONS: The buried penis occurs in a spectrum. Although, there are three major pathophysiology mechanisms, most of the patients had a combination. Surgical management should be individualized, and results are usually satisfactory. For the obese patient, weight loss is important. Preputial unfurling and using inner preputial layer to cover the defect should be avoided because of severe postoperative lymphedema.

Child↗

[Gynecomastia].

Gynaecomastia is a benign enlargement of the male breast commonly occurring in healthy adolescent boys and in adults (50 to 80 years old). It is a source of cosmetic and psychologic problems. The secondary forms usually require no therapy other than the removal of any identified inciting cause. Most of the idiopathic forms last only a few months and then gradually disappear. In secondary gynaecomastia and idiopathic forms present for more than 12 months a medical hormonal treatment often fails and the only therapy is surgery consisting in a subtotal subcutaneous mastectomy. In the last years the surgical treatment is often completed with suction lipectomy: this procedure reduces the surgical traumatism. The authors present their experience concerning 47 patients: 27 were surgical treated with subcutaneous subtotal mastectomy and 18 had an abjunctive liposuction treatment with good results.

Adolescent↗

Cervicoplasty: nonexcisional anterior approach.

The purpose of this paper is to demonstrate a technique of cevicoplasty by means of a submental incision exclusively, without removal of skin. This technique is indicated in patients with good-quality skin that has adequate capacity for contraction and redraping. The neck is approached by means of a 3- to 4-cm incision posterior to the submental crease. A thick subcutaneous flap is developed. Initial "open" dissection is continued with dissection using the endoscope. All the fat over the platysma muscle is dissected off. The dissection follows a triangle outlined by the sternocleidomastoid muscles. An insulated suction coagulator is used for hemostasis. Conservative defatting of the subcutaneous layer is done, and no suction lipectomy is used routinely. However, all the fat pad between the platysma borders and the fat pad between the mylohyoid and the digastric muscles are removed. The digastric muscles are either "shaved off" or plicated in the midline with 3-0 nylon sutures. This provides a smooth and flat contour to the submental area. Subplatysmal dissection beyond the submaxillary salivary gland is done with the aid of the endoscope. After a trial of advancement, the medial borders of the platysma are resected, and plication in the midline is performed from the level of the thyroid cartilage to the symphysis of the mandible. In most cases, a backcut on the platysma from the thyroid cartilage level in an oblique direction for about 3 to 4 cm is done to avoid secondary lateral platysma bands. If no good definition on the submental angle is obtained, an interlocked suture suspension with anchoring to the mastoid fascia is performed. The relative value of this maneuver will be discussed. The skin is allowed to redrape. Usually, after medial advancement of the platysma, an additional platysma-skin separation is needed in some segments to allow smooth contour on the surface of the skin. The suture suspension may leave minimal rippling laterally. This usually disappears in a few days. The technique described has been used for several years as an isolated procedure or as a part of a full endoscopic face lift without skin excisions. If used in the right patient, the result is comparable with that of the open excisional approach and has a high rate of satisfaction. The long-term durability remains to be seen.

Adult↗

Technical considerations in powered instrumentation.

This article reviews some of the technical engineering aspects of the soft-tissue shavers and bone-cutting drills. An improved understanding of these principles may allow the practicing surgeon to optimize the desired aggressiveness and precision of the instrument in his or her hands. Powered instrumentation has found extended uses beyond sinus disease, such as submental lipectomy (soft-tissue shaver) and modifying the bony nasal dorsum (bone cutting bur). Changes in drill design to address these and other surgical situations are discussed.

Endoscopy↗

[Madelung's disease. Clinical case and review of the literature].

Symmetrical benign lipomatosis (Madelung's disease) is extremely rare. Approximately 200 cases have been reported in the literature. SLB is a syndrome characterized by the occurrence of symmetric lipomas of the neck. No clear etiology has been recognized while a frequent association with systemic metabolic abnormalities has been described. The only effective therapy is the palliative surgical removal of the fatty tissue by lipectomy or liposuction. Experience with surgically treated patients shows the tendency of this disease to recur.

Female↗

A new technique for correction of the hidden penis in children and adults.

PURPOSE: A phenomenon known as hidden penis has numerous origins, including congenital buried penis and obesity with descent of the escutcheon. No previous report to our knowledge mentions abnormal hypermobility of ventral skin and dartos fascia, which is a major cause of surgical treatment failures. Because the skin and dartos fascia are inadequately attached to Buck's fascia, the corporeal bodies telescope proximally inside the scrotum and pubis. Therefore, the subdermis of the penoscrotal junction must also be tacked to the tunica albuginea ventrally to stabilize the proximal penile skin and prevent the penis from retracting into the scrotum. The surgical technique for correction of the hidden penis in adult and pediatric patients with adequate penile shaft skin is described. MATERIALS AND METHODS: Surgery for hidden penis from multiple causes was performed in 6 adults and 7 children. Tacking sutures were taken from the subdermis of the ventral penoscrotal junction to the tunica albuginea in all cases. A combination procedure with either suprapubic dermatolipectomy, tacking of the penopubic subdermis to the rectus fascia, penoscrotal Z plasty, circumcision revision or lateral penile shaft Z plasty also was performed in some patients. RESULTS: Improvement was noted in all cases. One child requires suprapubic lipectomy for optimal improvement and 3 minor wound problems occurred. CONCLUSIONS: Surgery for hidden penis achieves marked aesthetic and often functional improvement. Surgical failure can be diminished by placing ventral tacking sutures from the tunica albuginea to the subdermis of the penoscrotal junction.

Adult↗

Skin and wound infection by rapidly growing mycobacteria: an unexpected complication of liposuction and liposculpture. The Venezuelan Collaborative Infectious and Tropical Diseases Study Group.

OBJECTIVE: To describe 10 patients with skin and soft tissue infection caused by rapidly growing mycobacteria after cosmetic liposuction and liposculpture. DESIGN: Case series. SETTINGS: Eight private geographically separate surgical facilities from a single metropolitan area. PATIENTS: Eight patients with definite and 2 with presumptive cases of skin and soft tissue infection caused by rapidly growing mycobacteria after cosmetic surgery procedures during a 24-month period. Microorganisms were isolated from the purulent drainage obtained from wounds or fistulas in 8 cases and were identified as Mycobacterium fortuitum (3 cases) and Mycobacterium abscessus (5 cases) by routine microbiologic techniques. Acid-fast bacilli were observed on Ziehl-Neelsen-stained smears in the 2 remaining cases, but these ultimately failed to grow. In 2 of the surgical units, no apparent environmental predisposing factors were identified after thorough microbiologic environmental investigation. Clinically, all patients exhibited signs of inflammation, microabscesses, and purulent wound drainage within 24 months of abdominal and/or thigh liposuction or homologous fat tissue injection. INTERVENTION: A combined therapeutic approach including surgical drainage, debridment, and prolonged (>3 months) treatment with combined antimicrobial agents including clarithromycin was used in all cases. RESULTS: Nine of 10 patients responded to the combined therapeutic approach, and no evidence of infection was present during at least 12 months of follow-up. CONCLUSION: To our knowledge, this is the first series of patients with rapidly growing mycobacterial infections to be described after liposuction and liposculpture. Rapidly growing mycobacteria should be included in the differential diagnosis of skin and soft tissue infection after cosmetic surgery.

Abdomen↗