Cosmetic Surgery Times October 2012

Transcription

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COSMETICSURGERYTIMES.com | OCTOBER 2012 | Vol. 15 | No. 9
What lies
beneath
What you don’t
know about
the federal
anti-kickback
laws
can
Hurt
You16
page
Also inside:
Breast implants & ALCL
— is there a connection?
page
4
Extended lower blepharoplasty
for bettering below the eyes
page
12
Successful body shaping
in the massive weight
loss patient
page
18
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OCTOBER 2012
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Editorial Advisory Board
Tina Alster, M.D.,
is the founding
director of the
Washington Institute
of Dermatologic
Laser Surgery and
clinical professor
of dermatology
at Georgetown
University. She is
a world-renowned
lecturer and author
on the subject of
cosmetic laser
surgery.
James Carraway, M.D.,
specializes in plastic
and reconstructive
surgery and is
professor, division of
plastic surgery, and
chairman, division
of plastic surgery,
at Eastern Virginia
Medical School.
Steven Fagien, M.D., F.A.C.S.,
is an internationally
renowned cosmetic
eyelid plastic surgeon
with private practice
in Boca Raton,
Fla. He specializes
in cosmetic
blepharoplasty and
injectable agents
for facial aesthetic
enhancement.
David H. McDaniel, M.D.,
practices cosmetic
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He was the 2009
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COSMETIC SURGERY TIMES
4
B O D Y
B R E A S T
F A C E
Although extremely rare, ALCL should be
considered in patients presenting with a
late seroma or palpable mass near an implant
Louise Gagnon
S TAFF CORRESPONDENT
he Food and Drug Administration in
January 2011 released an advisory
statement regarding a possible
association between breast implants
and anaplastic large-cell lymphoma (ALCL).
If a patient who has breast implants presents
with a late seroma or a palpable mass near the
implant, physicians should consider investigating
that patient for ALCL, according to an assistant
professor in the division of plastic and
reconstructive surgery at the University of Toronto
and co-director of the 12th Annual Toronto Breast
Surgery Symposium.
T
“Although ALCL remains exceedingly rare, the
tests to diagnose ALCL are different, and the
specimens are treated differently than the usual
things we look for, like infection or other tumors
that could potentially cause a seroma or a breast
mass,” says Kyle Wanzel, M.D., M.Ed., F.R.C.S.C.
“If you are looking for ALCL, you have to send the
specimen slightly differently,” he explains. “Half
can be placed in formalin, but half must be sent
fresh for lymphoma flow cytology. If ALCL as a
potential diagnosis is not something that is on
your radar screen, you may not send the specimen
appropriately, and hence, you would miss the
diagnosis.
“It appears that the most common
presentation of ALCL in our breast implant
population is a late (greater than one year)
unilateral (one-sided) seroma (fluid collection
around the implant),” he adds. “However,
not all seromas are ALCL. In fact, it is a very
rare cause. More common causes of a seroma
include hematoma, infection, trauma, shear
injury, double capsule, implant rupture or
other type of cancer.”
any correlations for specific indications for surgery or
implant type and how they relate to the risk of future
development of ALCL.”
INITIAL ALARMS The first real concern about
ALCL in breast implant patients arose out of a
study conducted in the Netherlands and published
in the Journal of the American Medical Association
in 2008. Study investigators concluded that the
odds ratio for ALCL linked with breast prostheses
was 18.2. “It meant you were 18 times more likely
to develop ALCL of the breast if you had (breast)
implants,” Dr. Wanzel says.
Subsequent studies have not found similar rates
of risk of developing ALCL in women who have
breast implants. In these investigations, the odds
ratio has been just under or just above 1, meaning
that there is no increased risk to breast implant
patients. In the largest cohort to date, there were
more than 43,000 patients, and the relative risk
was 0.89, Dr. Wanzel says.
DIFFICULT DETERMINATIONS Since the
number of ALCL cases is very small, it is difficult
to make any associations between any of a number
of implant types or patient characteristics and the
possible development of the disease, Dr. Wanzel
says. For example, it remains unknown whether there
is a connection between ALCL and implant shape
or texture, or whether a patient who has undergone
reconstruction after breast cancer surgery is at
higher risk for the disease.
“These are thankfully a very small number of
patients that have had the unfortunate diagnosis of
ALCL,” Dr. Wanzel says. “However, because of the
small numbers and the fact that currently a lot of
data are missing or unknown as yet, we can’t claim
If ALCL is suspected, the FDA recommends that
surgeons obtain either fresh peri-implant seroma
fluid and/or representative portions of the fibrous
capsule for evaluation and send those samples to
a pathologist for evaluation. If anyone were to have
a patient who develops ALCL, Dr. Wanzel says, it is
imperative to contact the FDA.
TREATMENT OPTIONS Currently, there is no
uniform standardized treatment regimen for periimplant ALCL, and some women have undergone
surgical removal of the implants alone while
others have had surgery followed by adjunctive
chemotherapy or radiation therapy, or both.
However, it appears that the type of ALCL that
the breast implant population is getting is much
more curable and seems to have a much better
overall prognosis, Dr. Wanzel says. This is leading
oncologists to contemplate whether adjuvant
therapy (chemotherapy and radiation) is really
necessary. “There are advisory panels looking into
this as we speak,” he says.
“When compared to patients who develop primary
ALCL of the breast and do not have breast
implants, our patients seem to have a much better
prognosis, causing oncologists to investigate
whether or not this is indeed the same disease
entity,” Dr. Wanzel says. To date, there have been
34 published cases and only one published death
due to ALCL of the breast in a 57-year-old woman
who had breast implants 30 years prior to the
diagnosis of ALCL.
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MICROMEDICS
6
B O D Y
B R E A S T
F A C E
TR ANSAXILLARY
TOUCHPOINTS
Suitable for most patients, this breast augmentation procedure
conceals scars effectively
Louise Gagnon
T
he transaxillary approach to breast
augmentation does not produce any more
complications than other approaches
and hides the scar in the underarm, said
Wayne Carman, M.D., F.R.C.S.C., at the 12th annual
Toronto Breast Surgery Symposium.
Dr. Carman, a surgeon in private practice in Toronto,
a member of the surgical staff at Scarborough
Hospital in Toronto, and a past-president of the
Canadian Society of Aesthetic and Plastic Surgery,
explains that most patients are suitable candidates
for transaxillary breast augmentation.
implants. It has been described that if surgeons
are performing transaxillary augmentation without
the use of an endoscope, they are performing the
procedure blind (Pacella SJ, Codner MA. Clin Plast
Surg. 2009;36(1):49-61).
Dr. Carman says he prefers to use saline implants,
and he does not use an endoscope. He typically
places the implants in a submuscular position.
“I do not find endoscopes necessary,” Dr. Carman
says. “I find them cumbersome, and I do not believe
that they provide a clinical advantage.”
“It is applicable to the majority of cases,” Dr.
Carman says. “The scar is hidden in the dome of
the axilla. Physiologically, it is an efficient place to
hide the scar, and psychologically, it is an advantage
for the patient to feel that she doesn’t really have a
scar,” he explains.
Prefilled silicone implants are difficult to fit through
the transaxillary incision, so Dr. Carman prefers to
use saline implants. Patients who would prefer to
have silicone implants placed should generally look
to other types of incisions for a primary augmentation
procedure, he says.
The surgical incision is usually about 2 cm long,
and Dr. Carman avoids extending the scar beyond
the axilla to make it more cosmetically elegant. “You
have to be careful not to extend the scar beyond
the axilla,” he says, noting that the scar is barely
perceptible about one year postprocedure.
Submuscular placement keeps the implants in place
and reduces the risk of forming scar tissue near the
implant, thus lowering the potential for capsular
contracture, according to Dr. Carman.
During his 25 years of practice in Toronto, Dr.
Carman says he has performed more than 1,900
breast augmentation procedures, with the vast
majority (more than 1,600) using a transaxillary
incision. In the balance of augmentation procedures,
he has used periareolar incisions and inframammary
incisions.
“It is quick and efficient,” Dr. Carman says about the
transaxillary approach. “The total anesthetic time
is a little over 30 minutes. It is certainly not a new
procedure. There are references to it from decades
ago. Some individuals have used subpectoral
placement, and more recently, some have involved
endoscopic assistance.”
ENDOSCOPE, OR NOT? A study in Clinics
in Plastic Surgery maintained that the endoscopic
technique permits the surgeon to predictably
dissect the submuscular pocket and maintain the
position of the inframammary fold while allowing
for the placement of a variety of saline and silicone
Moreover, submuscular placement can reduce the
risk of breasts “bottoming out” because the implants
are supported by the chest muscles. Breasts bottom
out when the lower curvature of the breast expands
too much because of a lack of implant support, he
says.
POTENTIAL COMPLICATIONS Dr. Carman
notes a study that reviewed a single surgeon’s
experience with transaxillary subpectoral
augmentation mammaplasty, which confirmed
that there were equal or lower rates of capsular
contracture, hematoma and infection with the
approach (Huang GJ, Wichmann JL, Mills DC.
Aesthet Surg J. 2011;31(7):781-801).
That study consisted of a population of patients
who Dr. Carman describes as more heterogeneous
because a variety of implants were used and because
some procedures used an endoscope.
In his own experience, which included only primary
cases of augmentation, Dr. Carman has found that a
capsular contracture rate of 3.4 percent occurred in
patients who underwent transaxillary augmentation,
that infections occurred in 0.3 percent of cases, and
that hematomas occurred in 0.9 percent of cases.
In addition, the revision rate for the procedure was
9 percent, attributed mainly to patients reporting
that they found there was an asymmetry in their
appearance, he says. “About 10 percent of patients
come back saying that they want to look different,”
Dr. Carman says.
Because the incision site is not directly on the
breast, achieving symmetry with the transaxillary
incision is more of a challenge than with other types
of incisions, Dr. Carman says.
If a complication occurs that requires a second
surgery, patients might have to utilize a different
incision, usually periareolar or at the breast crease.
Because saline implants are being used, there is a
possibility of deflation, Dr. Carman notes, adding that
he typically places an implant with a volume of about
300 to 400 ccs when doing a transaxillary breast
augmentation.
While it has been observed that younger patients
request larger-volume implants, Dr. Carman says
he has found in his own practice that age has not
influenced the distribution of size.
Much overhang at the inframammary fold or
ptotic breasts may represent a contraindication to
transaxillary breast augmentation, Dr. Carman says.
“If the overhang is significant, I would think about
the periareolar approach instead of the transaxillary
approach.”
One of the issues of debate around the transaxillary
approach to breast augmentation is the possible
impact of the procedure on breast cancer detection
and treatment. One Brazilian study, however, found
that even after transaxillary breast augmentation,
there was preservation of lymphatic drainage and
visible sentinel lymph nodes, allowing for mammary
drainage in selected patients (Roxo AC, Aboudib JH,
De Castro CC, et al. Aesthet Surg J. 2011;31(4):392400).
Disclosures:
Dr. Carman reports no relevant financial interests.
cOSMetIc SUrGerY tIMeS
8
B O D Y
B R E A S T
F A C E
CONUNDRUM
Contracture significantly higher with smooth implants,
particularly in primary breast augmentation, study results show
Louise Gagnon
retrospective review presented at the
12th annual Toronto Breast Surgery
Symposium finds capsular contracture
to be much more common in smooth
implants compared to textured implants.
A
“As with most plastic surgeons, one of the most
common significant complications that I face
is capsular contracture,” says Ronald Levine,
M.D.C.M., F.R.C.S.C., a professor of medicine in
the division of plastic surgery at the University
of Toronto. “I am performing a large volume of
breast implants, and capsular contracture is a
problem.”
According to one study, the reoperation rate at
one year in primary breast augmentation was 14.2
percent, with the most common complication
being capsular contracture. Less common
complications involved rippling, rupture, infection
and hematoma. Other complications included
seroma, asymmetry and malposition (Codner MA,
Mejia JD, Locke MB, et al. Plast Reconstr Surg.
2011;127(3)1300-1310).
In reviewing his own cases, Dr. Levine says he
found that his reoperation rate was similar to the
rate reported in the medical literature. “To me,
this was an unacceptable for a cosmetic, elective
procedure,” he says.
To address capsular contracture, Dr. Levine
reports that he offers open capsulectomy, as
well as changing of the implant pocket and
changing of the implant. If reoperation is
necessary, however, it raises financial issues
between the surgeon and patient. “If you
change the implant, then who will pay for it?”
Dr. Levine asks.
Dr. Levine says he had used smooth implants
for a number of years, and he made a conscious
decision to switch to textured. To date, he has
performed in excess of 200 primary breast
augmentation procedures using textured implants,
he says.
retroSPeCtiVe Study In an effort
to analyze instances of and potential reasons
for capsular contracture, Dr. Levine gathered
data from cases he performed in earlier years
involving smooth implants, with those cases
acting as a control group. He excluded all breast
reconstruction cases, cases with saline implants,
previous implants by another surgeon, anatomic
implants and previous bilateral breast reduction
surgeries.
All cases were primary augmentation cases in
which round silicone implants were used, and
all cases took place from January 2007 through
September 2011.
percent smoked, 12.7 percent had comorbidities,
and 3.3 percent had previous breast surgery.
Of the 168 patients who had smooth implants
(mean age of 31.5, mean BMI of 21.4 kg/m2), 35
percent smoked, 9.5 percent had comorbidities,
and
3.0 percent had previous breast surgery.
Other factors that were investigated include the
device used, including the model, volume and
surface; the incision type, whether periareolar or
inframammary; and the incision pocket, whether
subglandular or subpectoral.
Of the 181 textured implants that were placed,
97 (54 percent) were placed subpectorally, with
the balance being placed subglandularly. An
inframammary incision was made in the bulk
(90 percent, or 162 cases) of procedures where
textured implants were placed, and a periareolar
incision was made in the remainder of the cases.
“The purpose was to look at the impact of texture,
incision selection, pocket selection and the rate
of capsular contracture to determine which of
these variables played the most important role in
capsular contracture,” Dr. Levine says.
Of the 168 smooth implant cases, 54
(32 percent) were placed subpectorally, and the
rest were placed subglandularly. A total of 76
(45 percent) cases with smooth implants were
placed using an inframammary incision, with the
majority involving a periareolar incision.
Dr. Levine and investigators looked at a total of
349 patients, 181 of whom had textured implants
and 168 of whom had smooth implants. In terms
of patient demographics, patients in the study’s
two arms were matched for factors such as age,
comorbidities, diabetes, smoking and body mass
index, as well as previous breast surgery.
The textured implants that were used included
Allergan’s round cohesive gel implants 110, 115
and 120. The smooth implants used included
Mentor’s 350 and Allergan’s 10, 15 and 20.
Some devices have been approved for use in
Canada but not in the United States, Dr. Levine
says.
Of the 181 patients who had textured implants
(mean age of 30.6, mean BMI of 21.5 kg/m2), 34
Dr. Levine and co-investigators performed logistic
regression analysis to find which factors were
OctOber 2012
9
“
I have completely changed my practice because of these results. There
is a 15 times greater risk of capsular contracture with a smooth implant.
”
Ronald Levine, M.D.C.M., F.R.C.S.C.
University of Toronto
most likely to contribute to the development
of capsular contracture. They used p>0.05 to
measure statistical significance.
The Art and Science of Skin Treatments & Rejuvenation
Study reSultS Investigators found there
was a highly statistically significant difference
(p<0.0001) in the capsular contracture rate
between textured implants and smooth implants,
with the capsular contracture rate being 19 percent
with smooth implants and 1 percent with textured
implants.
COURSE CHAIRMAN
ULTIMATE SKIN HEALTH
symposium
“I have completely changed my practice because
of these results,” Dr. Levine says. “There is a 15
times greater risk of capsular contracture with a
smooth implant.”
NOVEMBER 9 - 11, 2012
Dr. Levine says he found no difference in the
capsular contracture rates based on the incision;
that is, if the implant was placed in a periareolar
manner versus through the inframammary fold.
In addition, if the implant was positioned above
or below the muscle, there was no significant
difference in the rate of capsular contracture, he
says.
The goal of the Ultimate Skin Health Symposium is
to provide participants with the most up-to-date and
comprehensive information on all matters pertaining
to the skin and skin rejuvenation. Participants will learn
in-depth treatment protocols for a wide range of skin
conditions, including photo damage, hyperpigmentation
and melasma, rosacea, acne, scars, and rhytides,
providing a solid foundation for clinical practice.
ZEIN OBAGI, MD
Highly acclaimed international
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Study limitationS Dr. Levine says the
study has limitations such as its retrospective
nature and the fact that the data originate from a
single surgeon’s experience.
Highlights
In addition, there was a shorter follow-up period
with the textured implants than with the smooth
implants, and no patients were lost to follow-up, he
explains.
tSuccessful skincare dispensing and treatment bundling
The study did not statistically analyze whether
there was significant difference in rippling between
the textured and smooth implants, but Dr. Levine
notes that anecdotally, he has not observed rippling
to be a problem with textured implants.
tWorld renowned faculty
tLive patient workshops: injectables and topical agents
tChemical peels
Non-CME Half-day Course November 11, 2012
“The Personal Approach to Skin Health Restoration”
Adopting the Universal ZO® Skin Health approach for all
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For the full program and more information,
please visit www.ultimateskinsymposium.com
Registration
A recent study found incision was a variable
that influenced the rate of capsular contracture,
with transaxillary incisions producing the
highest incidence of contracture, followed by
periareolar and inframammary (Jacobson JM,
Gatti ME, Schaffner AD, et al. Aesthet Surg J.
2012;32(4):456-462).�
Disclosures:
Dr. Levine reports no relevant financial interests.
Teri Valls Phone: 305.663.1628 Email: [email protected]
Online: www.ultimateskinsymposium.com
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10
B O D Y
B R E A S T
F A C E
R ES U R FAC I N G
REVISITED
Whether full field or fractional, customization is key when planning a
successful laser rejuvenation treatment plan
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
he evolution of laser resurfacing has culminated in the ability
to truly customize treatments, and the number and frequency
of peels, the depth of dermal penetration, and the downtime
each patient can dedicate to recovery should all be dialed into
the treatment plan, say Jason N. Pozner, M.D., co-owner of Sanctuary
Medical Aesthetics Center in Boca Raton, Fla., and Lawrence Bass,
M.D., the head of Bass Plastic Surgery in New York. They joined
Montclair, N.J., surgeon Barry DiBernardo, M.D., to discuss the
capabilities of full field versus fractional lasers at the 2012 American
Society for Aesthetic Plastic Surgery meeting in Vancouver.
T
“It didn’t necessarily do a drastically better job, but once details were
refined it was certainly more predictable and safer and offered a lower
complication rate than some of the chemical peels — particularly the
deep peels,” he says.
“Full field laser resurfacing can give you excellent improvement for deep
wrinkles,” Dr. Bass adds. “Some people need that type of treatment.
If the patient is older and has really deep wrinkles or has significant
sun damage, an aggressive full field laser peel is still the right answer.
However, it is critical that patients understand that this is a treatment
that entails significant recovery time.”
“One of the variables is the amount of associated downtime, and that
depends on the laser and how aggressive the treatment is, and that
is based on the patient’s pathology,” Dr. Pozner says. “Full field laser
resurfacing has evolved to the point where we can attain a greater level
of precision after deciding what the patient needs, what kind of recovery
time they can tolerate and then dialing in a treatment that fits that bill.”
FULL FIELD VERSUS FRACTIONAL With full fi eld laser
resurfacing, 100 percent of the surface of the treated area is removed,
whereas with fractional laser resurfacing, approximately 15 to 45
percent of the treated surface area is removed. The availability of
these two options enables practitioners to use more aggressive full
field treatments for patients who need greater intervention, and lighter
fractional treatments for patients who require less rejuvenation, Drs.
Bass and Pozner say.
Other alternatives include repeated fractional resurfacing for acne
scars, or a combination of full field and fractional treatments for
patients who can benefit from the nuances of these distinct modalities,
the doctors say.
‘GOLD STANDARD’ According to Dr. Bass, full field laser
resurfacing can be considered the gold standard because it has been
available since the mid-1990s, when it essentially replaced chemical
peels and dermabrasion.
This patient had fractional Er:YAG laser resurfacing. She is shown before (top)
and six months after treatment.
(Photos credit: Lawrence Bass, M.D.)
OCTOBER 2012
11
“
Full field laser resurfacing has evolved to the point
where we can attain a greater level of precision.
”
Jason N. Pozner, M.D.
Boca Raton, Fla.
When full field lasers were first
introduced they were either “on” or
“off.” Today, they can be dialed up
or down from very light to very heavy,
depending on the patient’s needs,
Dr. Bass says.
FRACTIONAL HIGHLIGHTS
The alternative to full field treatment
is fractional treatment. “With
fractional lasers, we can perform
lighter recovery treatments for
patients who are not advanced
in terms of aging changes. In
addition to shorter recovery, there
is also substantially less risk of a
complication,” Dr. Bass says.
The interesting thing, he says, is that
“we can do things with fractional
peels that we can’t do with full
field. About the shallowest that we
ever go with a fractional peel is
probably the deepest we would ever
go with a full field peel,” Dr. Bass
says. “The shallowest we would
go with a fractional peel would be
250 microns to 350 microns deep,
whereas we routinely go 850 microns
and sometimes even deeper than a
millimeter with a fractional peel. If
we went that deep with a full field
peel we would heal with a scar. With
a full field peel, 250 microns to 300
microns would be considered very
aggressive resurfacing, and we never
ever go deeper than that.”
This is why fractional treatment
is the appropriate choice for acne
scars, he says. “You have to be
able to go deep to the origin of the
scar. You may have to do it several
times, but you can go very deep with
an extremely good safety margin
with fractional lasers. The risk of
scarring is probably 100 to 1,000
times less with fractional than
with full field. We are significantly
less likely to make a scar with a
fractional treatment if it’s properly
performed.”
CONFRONT COMPLICATIONS
The key to complications in laser
resurfacing is simple, Dr. Pozner
says: Catch them early.
“Frequent follow-up is important
to avoid complications,” he says.
“You can most likely avoid almost
everything, but you have to learn
how to treat these complications just
in case. They are not that frequent,
but the same ones happen over
and over again and they are usually
allergic reactions to the topical
ointments or something else that is
applied afterward. If you develop a
specific protocol and follow the same
postop routine and keep patients on
track with explicit instructions for
postop care and see them frequently
afterwards, you typically will do well
and significantly limit complications
or at least catch them early.”
Adds Dr. Bass, “When you make
an open wound you have to take
care of it. So seeing the patients
early on in recovery to catch any
mistakes in how they are managing
their skincare, as well as appropriate
recognition of any healing delay or
infection, will save you weeks or
potentially even months of trouble.
Skin infections, fortunately, are not
very common with laser peeling, but
they don’t look like typical infections
in a regular cut, so they can be hard
to recognize.
“Once you know what signs to look
for, such as a surface that is not
progressing to heal, reopens, shows
increasing pain or punctuate marks,
among other things, then it is easy
to eradicate instead of letting an
infection get well-established,” Dr.
Bass says. “If you keep the skin
surface clean and remove superficial
necrotic skin, the body will mount
much less inflammatory response
and you can keep the postop redness
period down to four to six weeks.”
American Board of
Cosmetic Surgery, Inc.
The only Board devoted
exclusively to Cosmetic Surgery
2013 ANNUAL EXAMINATION
October 19 - 20, 2013
ABOG Facility, Dallas, TX 75204
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(1) New two-tier recognition of fellowship training; and
& Extremity Cosmetic Surgery or Facial Cosmetic Surgery
Application Deadline: May 1, 2013
2013
RECERTIFICATION
EXAMINATIONS
January 2013
Las Vegas, Nevada
(Held in cojunction with AACS 29th
Annual Scientific Meeting)
Application Deadline: December 1, 2012
October 20, 2013
ABOG Facility, Dallas, TX
(Held in conjunction with ABCS 2013 Annual Examination)
Application Deadline: September 1, 2013
NEW CONTACT INFORMATION:
American Board of Cosmetic Surgery, Inc.
419 Ridge Road, Suite C, Munster, IN 46321
Phone: 219-836-8585
Fax: 219-836-5525
Email: [email protected]
www.americanboardcosmeticsurgery.org
B O D Y
B R E A S T
F A C E
Extended lower blepharoplasty can best address
the lid-cheek junction
Ilya Petrou, M.D.
lower eyelid and midface cosmetic extended blepharoplasty is an
innovative surgical technique that can best address the lid-cheek
junction, one of the central goals in rejuvenation of the lower eyelid,
says Jeffrey Schiller, M.D., clinical assistant professor of ophthalmology
at the University of Medicine and Dentistry of New Jersey, Newark.
A
The lower eyelid region has become a very popular target for both nonsurgical
and surgical rejuvenation procedures, ranging from minimally invasive filler
and fat grafting techniques to blepharoplasty. The orbitomalar sulcus is the
hollow between the lower eyelid and upper cheek, and the medial part of this
depression has been termed the tear trough. The tear trough is caused by the
tethering of the skin by its attachment to the orbicularis oculi origin on the
VIDEO MINUTE
Check out Dr. Schiller’s lower blepharoplasty
procedure here: cosmeticsurgerytimes.com/
extendedSchiller
maxilla, Dr. Schiller says, and it is this area where rejuvenation techniques are
aimed at correcting the tear trough.
wHY eXtended? According to Dr. Schiller, the three components of
the orbitomalar sulcus region that will generally need to be addressed include
orbital fat prolapse above the sulcus; the orbicularis retaining ligament (ORL)
and orbicularis oculi tethering of the skin to the maxilla and zygoma just
inferior to the orbital rim; and the descent of the cheek or loss of volume
inferior to the sulcus.
“The true anatomy around the eye and what is seen in textbooks vary to a
certain degree. The images in most textbooks depict the orbicularis muscle
as a doughnut that originates on the medial canthal tendon, but in reality, the
muscle also originates on the maxilla directly beneath the tear trough hollow,”
says Dr. Schiller, who also has offices in New York.
A standard blepharoplasty procedure will typically entail removing excess skin
and fat from above the tear trough area. However, according to Dr. Schiller,
standard blepharoplasty does not adequately correct the orbitomalar sulcus
deformity.
Getty Images/Photographer’s Choice RF/Peter Nicholson
12
OctOber 2012
13
“
In some blepharoplasty techniques currently used, the ORL is cut and then fixated/
repaired by suturing it along the edge of the orbit. In my opinion, such techniques are
not only unnecessary but can cause significant scarring and contour abnormalities.
”
Jeffrey Schiller, M.D.
New York
“Standard blepharoplasty will address
the bag or bulge above the orbitomalar
sulcus, but it will not correct the
circular hollow beneath that bulge.
Here, an extended lower blepharoplasty
that addresses the whole lid-cheek
junction is a much more effective
technique to correct this cosmetic
thorn,” Dr. Schiller says.
How it’s done Dr. Schiller
developed an extended lower
blepharoplasty technique that involves
aggressively releasing the tethering
of the ORL at the lateral and middle
third of the orbitomalar sulcus, and
medially, the lower orbicularis oculi
muscle origin. He says that releasing
the tethering of these tissues to the
lower eyelid and cheek allows lifting of
the cheek and smoothening of the lidcheek junction and tear trough.
Following IV sedation, the fat
pockets are infiltrated with local
anesthesia (lidocaine 2 percent with
epinephrine 1:100,000) through the
transconjunctival approach, while
the suborbicularis plane is injected
transcutaneously across the entire lid to
2 cm below the inferior orbital rim, at
the lateral canthal region, and over the
lateral orbital rim periosteum.
The lower lid is then everted and
using a CO2 laser, an incision is made
transversely in the inferior fornix (in
most cases) through the conjunctiva
and through the lower eyelid retractors.
The orbital fat is then exposed and
resected conservatively in the medial,
central and lateral fat pockets as
needed. The arcuate expansion of
the inferior oblique separating the
central from the lateral fat pockets is
preserved, and the conjunctival incision
is closed with one or two interrupted
6-0 plain gut sutures.
Using the carbon dioxide laser, Dr.
Schiller makes a subciliary incision
through the skin and orbicularis oculi
muscle 2 mm inferior to the lash line
from the junction of the central and
medial thirds of the lower lid to the
lateral orbital rim, usually 1 cm to 2
cm lateral to the lateral commissure.
Using the laser, Dr. Schiller says he
will perform a suborbicularis dissection
inferiorly, ending at the inferior orbital
rim. The skin-muscle flap is then
retracted and digital palpation and
direct visualization beneath the flap
localizes the ORL.
Dr. Schiller then proceeds to divide
the multiple lamellae of the ORL in
the suborbicularis/preseptal plane to 2
cm inferior to the orbital rim, including
the attachment at the lateral orbital
thickening. In order to achieve a full
mobilization of the eyelid and cheek
and to efface the tear trough when
present, Dr. Schiller says he divides
the fibers of the orbicularis oculi origin
into the face of the maxilla close to the
bone medially, until palpation verifies
that all tethering of the eyelid to the
orbital rim is released.
The flap is then gently pulled
superiorly and the amount of
redundancy is determined. Using the
laser, Dr. Schiller will conservatively
resect the skin-muscle flap in two
triangles created by a vertical incision
at the lateral aspect of the flap
lateral to the lateral commissure. He
then supports the skin-muscle flap
by suturing the orbicularis fascia to
the lateral orbital rim periosteum
with a superior and slightly lateral
vector using a 4-0 polyglactin
horizontal mattress suture. The skin
is then closed with a running 6-0
polypropylene suture.
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“The extended lower blepharoplasty
technique using the CO2 laser is
relatively easy to perform and can be
mastered with appropriate training.
It allows me to smooth the contour
of the lid-cheek junction
14
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14
B O D Y
B R E A S T
F A C E
A 57-year-old woman shown before (top) and
15 months after upper and extended lower
blepharoplasty with cheek lift.
(Photos credit: Jeffrey Schiller, M.D.)
Blepharoplasty
continued
descended and/or deflated malar fat pad, returning
the region to its once youthful appearance,” Dr.
Schiller says.
stUdY detAiLs Dr. Schiller conducted a
retrospective study of 80 consecutive patients
(65 female, 15 male, average age 63 years) who
underwent an extended lower blepharoplasty
that included transconjunctival removal of
herniated orbital fat (most cases), transcutaneous
suborbicularis dissection, and skin-orbicularis
resection, with CO2 laser lysis of the ORL and the
orbicularis origin. The study assessed the efficacy,
risks and complications associated with the
procedure, and patients were followed up from four
to 26 months.
Results showed that the extended lower
blepharoplasty technique can achieve a
significant improvement of the lid-cheek junction
and rejuvenation of the upper midface. The
complications seen with the procedure are similar
to those encountered in standard blepharoplasty,
and according to Dr. Schiller, the rate at which the
complications occur are not significantly higher than
that for standard transcutaneous blepharoplasty
techniques.
Other surgeons will perform similar lower
blepharoplasty techniques, but with the inclusion
of more complicated and elaborate fixations of the
ligament or cheek, Dr. Schiller says. Direct lysis
A 75-year-old woman before (top) and 14 months
after upper and lower extended blepharoplasty with
cheek lift. She shows mild retraction of the lateral
right lower eyelid, Dr. Schiller says.
of the ORL and orbicularis insertion with the CO2
laser not only helps correct the orbitomalar sulcus
deformity, but also allows the surgeon to easily
redrape the tissue without the need for canthoplasty,
canthopexy, or other more elaborate fixation
techniques in many cases, he explains. Moderate
and even severe malar festoons can be corrected
with this technique.
“In some blepharoplasty techniques currently used,
the ORL is cut and then fixated/repaired by suturing
it along the edge of the orbit. In my opinion, such
techniques are not only unnecessary but can cause
significant scarring and contour abnormalities,” he
says.
insUFFiCient oPtions According to Dr.
Schiller, many patients exhibit varying degrees of
orbital fat prolapse, skin and orbicularis redundancy,
lower eyelid margin and canthal tendon laxity, malar
fat pad descent and volume loss, globe prominence,
orbitomalar sulcus formation as well as midface
projection or protrusion. Though different techniques
including filler and fat grafting procedures are used
to improve the aesthetic of the lid-cheek junction,
Dr. Schiller says these are often insufficient in
achieving a longer-lasting aesthetic correction.
“Being able to lift the cheek back and correct any
sagging by releasing the tethering is a very simple
and effective technique. Filler procedures, on the
other hand, will need to be repeated every six to nine
months and the patient will be exposed to the risks
and complications associated with filler procedures
the surgeon’s view beneath the right lower eyelid skinmuscle flap. the short arrow shows the suborbicularis
oculi fat pad. the long arrow points to fibers of the
orbicularis oculi originating on the maxilla beneath the
tear trough.
every time the procedure is performed,” Dr. Schiller
says.
To date, Dr. Schiller has performed the extended
lower blepharoplasty technique in more than 140
patients with some follow-up extending out to five
years. Longevity of results is similar or better than
those expected with standard blepharoplasties, as
the modified technique creates a more effective
lifting of the tissues, he says.
The aging changes of the eyelid do not stop at the
eye, Dr. Schiller says, but at the hollow below the
bulge. Some patients do not have bags under their
eyes, but instead they have excessive hollowing at
the orbital rim. This technique would be ideal for
such cases and can achieve dramatic results, he
explains.
“Surgical facial rejuvenation techniques today are
structured around releasing the tethering of the
osseocutaneous retaining ligaments to help lift the
sagging tissues, and are commonly used in brow and
face lifts. The same concept is true for correction/
improvement of the lower eyelid as the tissues
can easily be mobilized and repositioned with this
procedure,” Dr. Schiller says. “In my experience, the
lower extended blepharoplasty technique proves to
be a very effective adjunct to lower blepharoplasty
when rejuvenating the lower eyelid and midface.”
Disclosures:
Dr. Schiller reports no relevant financial interests.
2012
November 29th - December 1st, 2012*
Discussions in Dermatology
Hurry!
• Dermatologists Pre-Conference Pricing: $450 (September 19-30, 2012)
Standard Pricing: $500 (October 1 - December 1, 2012)
• Core Cosmetic Surgeons/Dermatologists in 1st Year Practice: $100
• Non-Exhibiting Industry Members & Family Practitioners/ObGyn/PA/NP/Other PreConference Pricing: $950 (through October 31, 2012)
Standard Pricing: $1,000 (November 1 – December 1, 2012)
www.CosmeticSurgeryForum.com
Course Director: Joel Schlessinger, M.D.
For more information, please contact:
Natasha Mohr
Phone: 402-697-6564
Our 4th Year at the Palazzo Las Vegas!
Invited Faculty
Heidi Waldorf, MD
Ellen Gendler, MD
Mark Rubin, MD
Steven Dayan, MD
Deborah Sarnoff, MD
Jeanine Downie, MD
Julie Woodward, MD
Joe Eastern, MD
Cheryl Burgess, MD
Jeanette Graf, MD
Marc Darst, MD
Pamela Basuk, MD
Barry Lycka, MD
Michael Gold, MD
Rhett Drugge, MD
Adam Rotunda, MD
Carl Thornfeldt, MD
Michael Persky, MD
Allan Wirtzer, MD
Doris Day, MD
Haines Ely, MD
Candace Spann, MD
Erin Gilbert, MD
Michael Kane, MD
Lectures
•
•
•
•
•
•
•
•
Cosmeceuticals: Which ones are hype and which really work
Integrating social networks into your patient communications
Which is the best EMR for a dermatology practice?
Neurotoxins: And Now There Are Three.
How to Best Spend $100,000 on a Device
How to Purchase a Laser
Defending Your Online Reputation
Andmore!
CME Information - This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation
Council for Continuing Medical Education through the joint sponsorship of the Dulaney Foundation, Practical Dermatology and Cosmetic
Surgery Forum, LLC. The Dulaney Foundation is accredited by the ACCME to provide continuing medical education for physicians. The
Dulaney Foundation designates this live activity for a maximum of 21.75 AMA PRA Category 1 Credits™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
Cory Maas, MD
Vivian Bucay, MD
Hema Sundaram, MD
Mimi Cummings, MD
Cheri Ditre, MD
Tracy L. Drumm
Joe Niamtu, MD
Emily Altman, MD
16
What lies
beneath
Even as an aesthetic surgeon,
what you don’t know about
the federal anti-kickback
laws can hurt you
C
Rochelle Nataloni
osmetic surgeons may
think they are insulated from
anti-kickback laws because
Medicare and Medicaid do not
play heavily into their practice
models. But as long as they
accept third-party insurance
payment for some nonelective
or semi-elective procedures,
they need to be aware of and
comply with these mandates,
said California and Nevada
healthcare attorney Walter G.
Sullivan, M.D., J.D., at the 2012
American Society for Aesthetic
Plastic Surgery meeting.
Dr. Sullivan is a former plastic surgeon who now
practices law, primarily helping surgeons comply
with fraud and abuse regulations and helping them
when they make a misstep.
“I try to keep physicians out of trouble, and then I
try to help them if they get in trouble. Frankly, a lot
of their agreements and the way they do business
would be absolutely reasonable and smart from
a business point of view in any other industry,
but the federal government has passed laws that
make it illegal to do many of these very reasonable
things in a medical practice,” Dr. Sullivan says.
“For example, if two physicians associate in the
same office and they refer back and forth to each
other, their agreements and how they pay rent to
each other, among other things, are subject to
considerable scrutiny by the government.
“Basically, any time a physician does something
that makes himself or herself more attractive to
patients as a doctor there’s a possibility that antikickback laws are being violated,” Dr. Sullivan says.
“If you’re doing something extra, such as providing
transportation to a surgical center, for instance, that
can be considered a kickback and the legality of
that could be questioned.”
Getty Images/VettaFactoria/Singula (woman)/Comstock (scales)
The anti-kickback law and the physician self-referral
law, also known as the “Stark law” because it was
championed by Rep. Pete Stark, (D-Calif.), govern
the physician’s ability to refer to another entity in a
manner that might result in personal financial gain.
These regulations, while pertaining specifically to
Medicare, Medicaid and TRICARE, have impacted all
patient referrals, according to an American Society
of Plastic Surgeons Group Practice Task Force.
awarded a portion of the funds recovered, typically
between 15 and 30 percent. With draconian fines,
the reward could be in the millions of dollars.
“When a person sees an anti-kickback violation,
they can file a ‘qui tam’ suit, and that’s just since
Obamacare was passed two years ago,” Dr. Sullivan
says. “We haven’t seen the results of that yet.
It’s going to take a few years, but there’s going to
be a lot of these kinds of suits, and doctors are
going to feel like they’re public enemy No. 1, and
they’re going to have to be really careful to make
sure they’re not doing anything that an employee
can later come back at them for. It’s hard for the
government to find out about these things; someone
basically has to report it, and they can.
“Normally, the government is after big hospital
systems or drug companies,” Dr. Sullivan continues.
“But they like to go after doctors every now and
then as a warning to other doctors. So when, for
instance, a disgruntled employee files the suit, the
government has the option of taking it over or not,
and sometimes they do and sometimes they don’t.
If they don’t, then the person can continue to
pursue the action on their own.”
Dr. Sullivan points out that most states now apply
all the fraud and abuse laws that were originally
proposed specifically for federal programs such as
Medicare and Medicaid to private insurance as well.
“Physicians have to assume that these laws apply
to the patients that they are treating,” he says.
“There are numerous ways to prevent problems, but
physicians usually don’t even know that the things
they are doing violate the laws.”
“The federal anti-kickback law concerns any
federal healthcare program, such as Medicare and
Medicaid, but most states now apply those laws
to private insurance as well, and it’s rare that any
aesthetic surgeon doesn’t accept any third-party
payer insurance,” Dr. Sullivan says.
One of the problems is that “doctors still make
verbal agreements with other doctors, and that’s
just dumb,” he says. “You have to get it in writing
because there are problems — disagreements —
that can come up later. It has to be in writing so
you both know what the deal is.”
BEWARE THE REGULATIONS With 200,000
pages of Centers for Medicare and Medicaid Services
regulations, Dr. Sullivan acknowledges that it’s
essentially impossible for physicians to be aware
of all of the nuances, but he points out that it is
crucial to understand that any practice that does not
operate on a 100 percent aesthetic (or procedures
not covered by insurance) system is subject to these
laws. The passage of the Affordable Care Act makes
this more timely than ever.
While the average attorney is good at agreements
and contracts and corporation law, they typically
don’t know the recent developments in healthcare
law, Dr. Sullivan says, and healthcare law has
recently become its own specialty.
“Under ‘Obamacare,’ any anti-kickback violation is
now automatically a false claim, and a false claim is
very serious and subject to the ‘qui tam’ statute,”
Dr. Sullivan says.
“Qui tam” is a mechanism in the law that allows
citizens with evidence of fraud against government
contracts and programs to sue, on behalf of the
government, in order to recover the stolen funds.
In compensation for the risk and effort of filing a
“qui tam” case, the citizen whistle-blower may be
“General attorneys may not be aware of the
ramifications of the agreements that they’re
structuring with respect to medical practices.
All agreements and anything special you’re doing
should be looked over by a healthcare attorney just
to make sure that you’re not going to violate the
law,” Dr. Sullivan says.
For more information:
ASPS Group Practice Task Force paper “Practice Integration Opportunities
for Plastic Surgeons, Report of the Group Practice Task Force” — http://
www.plasticsurgery.org/Documents/medical-professionals/health-policy/
Accountable%20Care%20Organizations/Group%20Practice%20WhitePaper%20Final.pdf
For more information about anti-kickback laws, see:
http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/
index.html?redirect=/physicianselfreferral/
OCTOBER 2012
17
B O D Y
B R E A S T
F A C E
Corset
trunkplasty
Novel procedure contours massive weight loss
patients’ bodies safely, effectively
Ilya Petrou, M.D.
he corset trunkplasty (Corset Body Lift) is a body contouring
procedure that can effectively address the redundant skin rolls in
massive weight loss patients and significantly improve abdominal
and waistline contours, all while limiting complications seen with
other surgical approaches, says Alexander Moya, M.D.
T
“Similar to a traditional abdominoplasty and belt lipectomy, the corset
trunkplasty treats the lower abdomen, but it will also target the oftenneglected upper abdomen, thereby enhancing the entire waistline,” says
Dr. Moya, director of Geisinger’s Center for Aesthetics and Cosmetic
Surgery and Weight Loss Body Contouring Program, Danville, Pa.
The lower body lift was originally designed for non-weight-loss patients,
Dr. Moya says. It was then modified to the circumferential belt lipectomy
to address weight-loss patients more effectively.
Getty Images/UpperCut Images/Hill Creek Pictures
18
OCTOBER 2012
19
“
The corset trunkplasty treats the lower abdomen, but it will also target the
often-neglected upper abdomen, thereby enhancing the entire waistline.
”
Alexander P. Moya, M.D.
Danville, Pa.
Good contouring results can be difficult to
achieve in those who do not fit the ideal
patient model of the commonly performed
belt lipectomy, he explains. In many women,
the procedure will result in the lack of an
aesthetically pleasing waistline.
An alternative option, Dr. Moya developed
the corset trunkplasty technique, which can
be used on a wider range of patients. This
includes the ideal to the more complex patient
with multiple skin rolls, and it works regardless
of an individual’s overall body size or amount of
excess skin.
Most female patients who undergo the
procedure end up with the corset trunkplasty
sought-after hourglass figure, Dr. Moya says.
HOW IT’S DONE The corset trunkplasty is
performed entirely in the supine position and
utilizes a standardized approach to determine
the vertical abdominal resection (removal of
the horizontal skin redundancy). Dr. Moya says
this is key to the procedure.
All preoperative markings are performed in the
supine position once the patient is prepped
and draped and include the vertical midline
Corset trunkplasty preop supine.
(All photos credit: Alexander Moya, M.D.)
(extending from xiphoid down to the pubis),
lower chest (extending from side-to-side,
following the inframammary folds in women)
and pubic reference lines.
According to Dr. Moya, the vertical resection is
determined in a very routine manner utilizing
a simple tailor-tacking technique. This allows
for maximum skin removal while guaranteeing
closure of the defect without undermining.
The horizontal skin redundancy extending
from the lower chest to flanks is pulled tightly
together towards the midline, inverted, and
temporarily stapled. In this way, Dr. Moya can
more accurately assess how much skin can be
removed from the chest down to the pubis, he
explains.
The stapled skin is then marked and released.
The marked areas are connected to one another
on each side and to the top and bottom of the
preoperative midline marking to form a vertical
ellipse shape.
This redundant skin pattern is directly
resected off the underlying muscular fascia,
temporarily resulting in a large defect that
will often encompass the entire abdominal
Corset trunkplasty vertical resection
markings resembling a large vertical
ellipse.
wall. Any ensuing abdominal wall plication
can then be easily performed due to the
extent of exposure, Dr. Moya says. This step
not only enhances overall contour, but also
facilitates primary closure without undermining
by reducing the size of the vertical defect, he
explains. This aggressive resection of horizontal
skin redundancy followed by simple primary
closure provides the greatest improvement in
abdominal and waistline shape while limiting
wound complications.
NEXT STEPS Subsequent steps of the
corset trunkplasty address the two “dog-ears”
at the superior and inferior poles of the midline
incision (created by the large vertical resection
and its associated closure) and any remaining
redundancy affecting the upper and lower
waistline as needed. Dr. Moya performs two
transverse incisions — one at the lower chest
(which extends from the midline onto the upper
back, depending on the amount of redundant
lateral chest/upper back skin to be removed)
and the other at the level of the pubis (which
can extend from the midline onto the lower
back, depending on the amount of redundant
hip/lower back skin to be removed).
“The three incisions are instrumental
Corset trunkplasty vertical resection
defect, which encompasses the
entire abdominal wall and extends
beyond the costal margins.
22
Corset trunkplasty postop supine
demonstrating final on-table corset
shape.
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22
B O D Y
B R E A S T
F A C E
“
Because the corset trunkplasty does not require undermining
along the midline closure, complications are limited and are less
than other techniques that require extensive undermining.
”
Alexander P. Moya, M.D.
Danville, Pa.
Corset trunkplasty skin pattern (with six-inch ruler).
Typical pattern of skin removal from the lower chest
to lower abdomen, which averages 4.7 kg, Dr. Moya
says.
Trunkplasty
continued
in maximizing skin removal from the
anterolateral trunk and improving overall body
shape. While the midline incision has the
greatest impact on reducing the size of the
waist, the lower chest and pubic (lower trunk)
incisions enhance the upper waistline contour
and the lower waistline contour, respectively,”
Dr. Moya says.
The transverse incisions can also be adjusted,
catering to the specific needs of the patient.
This gives the technique great versatility,
Dr. Moya says. For example, one can limit
the procedure by utilizing short incisions for
removing the upper and lower midline “dogears” only, thus reducing overall operative time
and cost, or one can extend the incisions onto
the upper back and/or lower back for increased
skin removal and an improved overall waistline
contour.
“Confluent incisions are one of the biggest
worries of plastic surgeons, as these can lead
to complications. However, because the corset
trunkplasty does not require undermining along
the midline closure, complications are limited
A 52-year-old female patient with BMI of 20 who
underwent laparoscopic gastric bypass with
140-pound weight loss. Images are before (left)
and 10 months after corset trunkplasty resulting
in 5 1/2-pound skin resection. Dr. Moya says the
procedure significantly improved the patient’s
abdominal and waistline shape, enhancing her
hourglass figure. The procedure was performed
without the use of a postoperative drain.
A 28-year-old female patient with BMI of 37 who
underwent laparoscopic gastric bypass with
160-pound weight loss and significant complex skin
redundancy. Images are before (left) and one week
after corset trunkplasty resulting in a 20 3/4-inch
skin resection. The trunkplasty completely eliminated
the multiple skin rolls and comprehensively reshaped
the patient’s abdominal and waistline contour, Dr.
Moya says. The procedure was performed without the
use of a postoperative drain.
and are less than other techniques that require
extensive undermining,” Dr. Moya says.
superficial wound dehiscence and small areas
of skin necrosis, both requiring local care only,
he says.
The current procedure does not require the use
of a postoperative drain, partially due to the
lack of undermining, Dr. Moya says. Though
the corset trunkplasty initially utilized drains,
he has since improved the technique with the
use of ultrasonic (Harmonic ultrasonic scalpel
and shear, Ethicon Endo-Surgery) technology
to minimize surrounding tissue damage and
seal lymphatic channels as well as bidirectional
barbed sutures (Quill Knotless Tissue-Closure
Device, Angiotech) for tighter and motion-free
closures, he explains.
“The evolution of the technique with these
small but significant changes allowed me
to move to a drainless procedure. I have
experienced no seromas in my last 80
patients,” Dr. Moya says.
POTENTIAL COMPLICATIONS Over
the past six years and nearly 140 patients
in whom Dr. Moya has performed the corset
trunkplasty, he has experienced a 30 percent
complication rate. The majority of these
complications were very minor, including
As the surgical technique averages around
four to five feet of incisions, Dr. Moya says he
believes that these minor complications may be
considered negligible when compared to such
large resections.
“The aesthetic approach to the massive
weight loss patient has been changing. We
have always been taught to limit scars or hide
them if we can to get the best of both worlds
with regards to contouring results. I have
discovered that they will look beyond scars for
a significant improvement in body shape, and
the best way to achieve that is to perform a
procedure that utilizes a vertical resection to
address the complexity of skin redundancy.
That’s where the corset trunkplasty fits in,” Dr.
Moya says.
Disclosures:
Dr. Moya is a consultant for Ethicon Endo-Surgery and Angiotech
Pharmaceuticals.
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24
B O D Y
lipo
B R E A S T
F A C E
Lessons in
SAFElipo proves to be a safe, effective
nonthermal option for maximizing
smooth and even fat removal
Ilya Petrou, M.D.
AFELipo provides a nonthermal
liposuction, fat-grafting and bodyshaping method that minimizes
bleeding, tissue trauma and contour
deformities while maximizing smooth and
even fat removal, and it can be utilized with
excisional procedures safely and effectively,
says Simeon Wall Jr., M.D., a plastic surgeon
at The Wall Center for Plastic Surgery,
Shreveport, La.
S
Conventional wisdom dictates
that the more aggressive, or
more superficial, a surgeon
performs liposuction, the
higher the chances of creating
a contour deformity. This is
Dr. Wall
why most surgeons use more
conservative liposuction
techniques, Dr. Wall explains.
Newer thermal-based technologies such as
laser-assisted liposuction (LAL), ultrasoundassisted liposuction (UAL) and radiofrequency
modalities have promised various procedural
improvements, but in general they have
resulted in increased complications and longterm problems, Dr. Wall says, adding that
SAFElipo provides a better solution in the
effort to achieve greater effectiveness with
fewer irregularities.
“With SAFElipo, we do not really have this
give-and-take problem anymore,” Dr. Wall
says. “We can be extremely thorough and
achieve very dramatic results and yet we
do not increase the risk of creating contour
deformities or other problems associated
with traditional or thermal-based liposuction
technologies.
“In fact, you can be about as dramatic as
you want and the risks of irregularities and
unevenness do not go up,” Dr. Wall adds. “It’s
also nice not to have to worry about burning
the skin and other tissues. The equalized fat
we leave behind with SAFELipo is viable, in a
receptive, healthy tissue bed, as opposed to a
tissue bed that has been burned, coagulated
and inflamed by an internal thermal device.”
TALKING TECHNIQUE SAFElipo is
based on a three-step process: Separation, fat
Aspiration, and Fat Equalization, Dr. Wall says.
The fat globules are first separated from one
another and from their attachments such
as blood vessels, nerves and the stromal
architecture. The fat separation is performed
using specialized probes, with or without a
power-assisted vibrational device, leaving
separated and viable fat behind. This is in
stark contrast to laser and radiofrequency
modalities, which destroy the targeted fat and
coagulate the surrounding structures, Dr. Wall
says.
Next, aspiration of the separated fat is
performed. This is less aggressive than
standard techniques, as the already separated
and largely intact fat cells can be easily
harvested, Dr. Wall explains. This is followed
up with the final step of fat equalization,
where the remaining bed of fatty tissues is
smoothened out and aesthetically contoured.
“Regardless of the liposuction technique used,
we plastic surgeons always think that the area
we just finished suctioning is smooth, but
in actuality, it usually isn’t,” Dr. Wall says.
“There are almost always irregularities present
with thicker and thinner areas of fat left
behind. With fat equalization, we can precisely
further separate the remaining irregular
OCTOBER 2012
25
fat deposits and reposition them and smooth them out. These
serve as what I call ‘local’ fat grafts that help to achieve much
smoother contouring results that are lasting.”
STATEMENT OF OWNERSHIP, MANAGEMENT, AND CIRCULATION
(Requester Publications Only)
(Required by 39 USC 3685)
1. Publication Title: Cosmetic Surgery Times
PROTECTION IS PARAMOUNT SAFElipo can be
2. Publication Number: 1094-6810
performed using both power-assisted liposuction (PAL) and nonpower techniques and with some other up-and-coming modalities,
but not with internal thermally based modalities (ultrasound,
laser, radiofrequency), as they are generally incompatible with the
concepts of fat preservation and equalization, Dr. Wall says.
3. Filing Date: 9/28/12
“On one hand, we have the liposuction technologies racing to see
which one can kill the fat and surrounding structures the most
effectively. On the other hand, we have all the modern pioneers
of fat grafting coming to a consensus that regardless of the
technique, we need to protect and preserve the grafted fat and
recipient bed to maximize results,” Dr. Wall says.
4. Issue Frequency: Published monthly except for combined issues in November/December and June/July
5. Number of Issues Published Annually: 10
6. Annual Subscription Price (if any): $95.00
7. Complete Mailing Address of Known Office of Publication: 131 West First Street, Duluth, St. Louis County,
Minnesota 55802-2065
Contact Person: Joe Martin
Telephone: 218-740-6375
8. Complete Mailing Address of Headquarters or General Business Office of Publisher:
2501 Colorado Avenue, Suite 280, Santa Monica, CA 90404.
9. Full Names and Complete Mailing Addresses of
Publisher: Amy Ammon, 485 Route 1 South Building F, 1st Floor, Iselin, NJ 08830
Editor-in-Chief: Amy Stankiewicz, 24950 Country Club Blvd., North Olmsted, OH 44070
Managing Editor: Susan R. Schell, 24950 Country Club Blvd., North Olmsted, OH 44070
10. This publication is owned by: Advanstar Communications Inc., 2501 Colorado Avenue, Suite 280, Santa Monica,
CA 90404. The sole shareholder of Advanstar Communications Inc. is: Advanstar, Inc., whose mailing address is
2501 Colorado Avenue, Suite 280, Santa Monica, CA 90404.
11. Advanstar Communications Inc. is a borrower under Credit Agreements dated May 31, 2007, with various
lenders as named therein from time to time. As of June 12, 2012, the agent for the lenders is: Credit Suisse,
Administrative Agent, 11 Madison Avenue, New York, NY 10010.
12. Does Not Apply
13. Publication Title: Cosmetic Surgery Times
14. Issue Date for Circulation Data Below: Aug-12
15. Extent and Nature of Circulation
Average
No. Copies
Each Issue
During
Preceding 12 Months
10,745
No. Copies of
Single Issue
Published
Nearest
to Filing Date
10,867
1. Outside County Paid/Requested Mail
Subscriptions Stated on PS Form 3541
6,006
5,824
2. In-County Paid/Requested Mail
Subscriptions Stated on PS Form 3541
0
0
3. Sales Through Dealers and
Carriers, Street Vendors,
Counter Sales, and Other
Paid or Requested Distribution Outside USPS
30
37
4. Requested Copies Distributed by Other Mail Classes
Through the USPS
0
0
6,036
5,861
A. Total Number of Copies
B. Legitimate Paid and/or Requested Distribution
A 52-year-old male patient before (top two images) and six months after
SAFELipo of the circumferential trunk, chest and axillary sculpting.
(Photos credit: Simeon Wall Jr., M.D.)
C. Total Paid and/or Requested Circulation
(Sum of 15b (1), (2), (3), and (4)
D. Non-requested Distribution
1. Outside County Non-requested Copies as Stated
on PS Form 3541
According to Dr. Wall, whether fat is being removed (liposuction)
or added (grafting), surgeons should aim to protect and preserve
all the remaining fat and surrounding structures for optimal
results. With SAFElipo, unwanted fatty tissue is removed without
causing bleeding, through significantly less traumatic liposuction,
and the remaining preserved fat cells are used locally in the
minimally traumatized fertile bed left behind to smoothen out
contour, he says. The treated areas can also be treated with fat
shifting and/or fat grafting concurrently.
4,165
4,452
2. In-County Non-requested Copies
Stated on PS Form 3541
0
0
3. Non-requested Copies Distributed Through the
USPS by Other Classes of Mail
0
0
4. Non-requested Copies Distributed
Outside the Mail
425
443
E. Total Non-requested Distribution
(Sum of 15d (1), (2), (3) and (4))
4,590
4,895
F. Total Distribution
(Sum of 15c and e)
10,626
10,756
119
111
G. Copies not Distributed
“Yes, we need to remove excess fat, but preserving what we leave
behind has far more benefits,” Dr. Wall says. “The exciting part
is that we’re just beginning to understand why many of these
SAFELipo results turn out so well, why many times even the
skin improves, and what role the interplay of the remaining fat,
adipose-derived stromal cells and the body’s regenerative signals
play in the remodeling that happens after surgery.”
Disclosures:
Dr. Wall reports no relevant financial interests.
H. Total
(Sum of 15f and g)
10,745
10,867
I. Percent Paid and/or Requested Circulation
56.80%
54.49%
16. Publication of Statement of Ownership for a Requester
Publication is required and will be printed in the October issue of this publication.
17. Name and Title of Editor, Publishers, Business
Manager, or Owner: Christine Shappell, Audience Development Director
Signature: ____________________________________________________
Date: 9/28/12
________________________________________________________
I certify that the statements made by me above are correct and complete.
|
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30
B O D Y
B R E A S T
F A C E
side
Among other potential adverse events associated
with abdominoplasty, abdominal skin sensitivity can
decrease, according to one Brazilian plastic surgeon
Louise Gagnon
here are advantages and disadvantages to
abdominoplasty and lipoabdominoplasty,
but one procedure is not superior to the
other, according to the past Brazilian
National Secretary of the International Society of
Aesthetic Plastic Surgery.
T
“Which is the better procedure depends on the
patient,” says Fabio X. Nahas, M.D., Ph.D., M.B.A.,
associate professor of the plastic surgery division,
Federal University of Sao Paulo.
According to Dr. Nahas, numerous complications
can occur with abdominoplasty, such as the
development of seromas, the recurrence of rectus
diastasis and the loss of skin sensitivity.
The danger associated with decreased skin
sensitivity is that patients may be exposed to an
elevated risk of burn injury; patients who had
undergone abdominoplasty presented decreased
sensitivity to pressure and hot temperature as
demonstrated in a study of 40 patients (Farah AB,
Nahas FX, Ferreira LM, et al. Plast Reconstr Surg.
2004;114(2)577-582).
In a similar study, patients who had undergone
lipoabdominoplasty had preservation of their
abdominal skin sensitivity, Dr. Nahas says.
SEROMA INSIGHTS In 2007, Dr. Nahas
conducted a study of 21 female patients who had
undergone abdominoplasty and had at least one of
these characteristics: body mass index exceeding
25 kg/m2, weight loss greater than 10 kg, previous
incision in the supraumbilical region, or present
thinning of the subcutaneous in the area above the
umbilicus. To detect fluid collection postoperatively
in the abdominal wall, ultrasound was performed
on each patient from 15 to 18 days after the
operation.
If surgeons perform an open abdominoplasty
and do not use stitches to reattach the flap down
to the fascia, seromas can develop, Dr. Nahas
explains. If surgeons choose to perform an open
abdominoplasty, they should use quilting sutures,
which avoid the friction of the flap and the possible
development of a seroma.
RECTUS DIASTASIS CORRECTION
Often, when abdominoplasty is performed, the
surgeon corrects the rectus diastasis. One option
involves the plication of the anterior rectus sheath
performed with an absorbable suture, Dr. Nahas
says.
In a study published in Aesthetic Plastic Surgery,
Dr. Nahas performed an abdominoplasty in 12
women who had a musculoaponeurotic deformity.
The rectus diastasis was measured before the
procedure with computed tomography scanning at
3 cm above and 2 cm below the umbilicus. After
plication of the anterior rectus sheath, postoperative
CT scans showed correction of the rectus diastasis
(Nahas FX, Ferreira LM, Ely PB, Ghelfond C.
Aesthetic Plast Surg. 2011;35(1)43-48).
“When you do an abdominoplasty and you open
up the abdomen, you can treat myoaponeurotic
deformities correctly,” Dr. Nahas says. “The patient
may have a need for correcting the myoaponeurotic
layer. When you have that (open) exposure, you can
treat deformities.” In addition, patients may have
congenitally malpositioned muscles or have had
many pregnancies, he says.
Although it increases operating time, L plication of
the external oblique muscle has an overall effect
on the shape and contour of the abdomen in a
positive fashion, Dr. Nahas says. It also reinforces
the musculoaponeurotic layer.
BMI AND MORE Factors such as smoking, the
Average fluid collection was 8.2 cc. In two
cases, fluid collection was greater than 20 cc
collected above the fascial layer, and these
patients were aspirated. After aspiration, they
experienced no recurrence of seroma (Nahas FX,
Ferreira LM, Ghelfond C. Plast Reconstr Surg.
2007;119(3):1060-1064).
presence of diabetes and hypertension increase
the likelihood of patients developing complications
with either abdominoplasty or lipoabdominoplasty,
Dr. Nahas says. Another observation of his is that
more and more patients coming to his practice
have larger body mass indices: less than half of his
last 75 patients have had normal range BMIs, with
more than half having BMIs that would classify
them as overweight or obese.
Some are seeking surgical assistance to reduce
their weight and body mass indices, which is not
a correct indication for neither abdominoplasty
nor lipoabdominoplasty, he notes. One technique,
however, can be more suitable than another
depending on the patient’s profile risk.
Yet surgeons are beginning to impose a ceiling on
BMIs, opting not to perform invasive procedures
such as abdominoplasty on patients who
have BMIs of 35 kg/mg2 or more, Dr. Nahas
says, adding that he does not impose strict
criteria on candidates for abdominoplasty or
lipoabdominoplasty.
“Some patients do not want to go through
bariatric surgery,” he says. “If you do not offer
them a procedure, they cannot reap the benefit of
something that could be positive for them.”
Abdominoplasty, however, is not a guarantee of
warding off weight gain, Dr. Nahas says. In one
follow-up investigation of patients who underwent
abdominoplasty, he found that patients gained on
average 6.5 kg postoperatively.
Still, the physical changes that result from
abdominoplasty can lead to improved quality of
life, improved self-esteem and improved selfimage, according to a six-month follow-up study
(Azevedo de Brito MJ, Nahas FX, Barbosa MVJ, et
al. Ann Plast Surg. 2010;65(1):5-10).
Moreover, in a study of 19 women who had a
mean age of 35 and a mean body mass index of
23 kg/m2, all respondents reported that they had
enhanced sexual functioning and enhanced sexual
satisfaction as a result of the physical changes
related to the procedure: mons pubis elevation
and exposure of the clitoris prompt a change in
the sexuality of female patients (Azevedo de Brito
MJ, Nahas FX, Bussolaro RA, et al. J Sex Med.
2012;9(3):918-926).
Disclosures:
Dr. Nahas reports no relevant financial interests.
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Cosmetic Surgery Times October 2012

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