Larry Weinstein, MD, F.A.C.S.
Chester Plastic Surgery
Top Plastic surgery Doctors in New York Metro Area

Surgery Update

Men Fuel Rebound in Plastic Surgery: Sizeable Increases in Facelifts and Other Surgical Procedures for Men

ScienceDaily (Mar. 21, 2011) — Statistics released by the American Society of Plastic Surgeons (ASPS) show that more men are going under the knife. Overall cosmetic plastic surgery procedures in men were up 2 percent in 2010 compared to 2009. However, many male surgical procedures increased significantly. Facelifts for men rose 14 percent in 2010 while male liposuction increased 7 percent.
 2010 ASPS statistics show that men underwent more than 1.1 million cosmetic procedures, both minimally-invasive and surgical. The majority of the the Men's Top 10 fastest-growing cosmetic procedures are surgical, which bucks the previous trend of growth in minimally-invasive treatments.
"The growth in cosmetic surgical procedures for men may be a product of our aging baby boomers who are now ready to have plastic surgery," said ASPS President Phillip Haeck, MD. "Minimally-invasive procedures such as Botox® and soft tissue fillers work to a point. However, as you age and gravity takes over, surgical procedures that lift the skin are necessary in order to show significant improvement."

Men's Top Ten: Fastest-Growing Male Cosmetic Procedures (by percentage increase)

The list comprises the fastest-growing surgical and minimally-invasive procedures from 2009 to 2010. Criteria for inclusion: Procedure performed on at least 1,000 men in 2010. (Surgical procedures are listed in bold).

  1. Facelift -- 14% Increase
  2. Ear Surgery (Otoplasty) -- 11% Increase
  3. Soft Tissue Fillers -- 10% Increase
  4. Botulinum Toxin Type A -- 9% Increase
  5. Liposuction -- 7% Increase
  6. Breast Reduction in Men -- 6% Increase
  7. Eyelid Surgery -- 4% Increase
  8. Dermabrasion -- 4% Increase
  9. Laser Hair Removal -- 4% Increase
  10. Laser Treatment of Leg Veins -- 4% Increase

Plastic surgeons say that another trend they see in male plastic surgery is the type of patient seeking their services. "Typically people think of celebrities and high profile men going under the knife," said Stephen Baker, MD, an ASPS Member Surgeon based in Washington DC. "And while that may be true, the typical male cosmetic surgery patient that I see is an average guy who wants to look as good as he feels. Most of my patients are 'men's men,' the kind of guy you might not think would have plastic surgery." Dr. Baker said that baby boomers who are now reaching retirement age are the new face of the male plastic surgery trend. "They want to look good. So when they have the financial means to do it, they are ready to do it now," said Dr. Baker.

In fact, one of Dr. Baker's patients is an "average Joe" named Joe Marek. Joe recently underwent a facelift and eyelid surgery. The 57-year old said, "I didn't feel that old. I felt young. I was working out. I was pretty active and I wanted to look like I felt inside." Joe also said his 52-year-old girlfriend supported his decision to have plastic surgery.

Men's Top Ten: Most Popular Male Cosmetic Procedures (by volume)
This list comprises the top five surgical and top five minimally-invasive procedures by volume in 2010:
2010 Top Five Male Cosmetic Surgical Procedures

  1. Nose Reshaping (64,000)
  2. Eyelid Surgery (31,000)
  3. Liposuction (24,000)
  4. Breast Reduction in Men (18,000)
  5. Hair Transplantation (13,000)

2010 Top Five Male Cosmetic Minimally-Invasive Procedures

  1. Botulinum Toxin Type A (337,000)
  2. Laser Hair Removal (165,000)
  3. Microdermabrasion (158,000)
  4. Chemical Peel (90,000)
  5. Soft Tissue Fillers (78,000)

Larry Weinstein,MD FACS


AMA, other groups urge tanning ban for minors.

The CBS Evening News (2/28, story 7, 0:15, Couric) reported that the American Academy of Pediatrics is urging a ban on allowing minors to use tanning beds.

The Los Angeles Times (2/28, Forgione) "Booster Shots" blog reported that a policy statement released by the group "cites several studies, including research that shows a link between people overexposed to the sun in childhood and melanoma, one of the deadliest forms of skin cancer." The AAP "joins the World Health Organization, the American Medical Association, and the American Academy of Dermatology in advocating for such a ban."

The Boston Globe (2/28, Kotz) "Daily Dose" blog reported that "last March, an FDA advisory committee recommended that people under 18 be barred from using tanning beds or at least required to have a signed consent form from their parents. The new AAP declaration could help convince the FDA to follow its committee's recommendation, which it's not required to do."

According to CNN (3/1, Park), "the Indoor Tanning Association disagrees that tanning should be legislated." The AP (3/1) and the USA Today (2/28, Winter) "On Deadline" blog also covered the story.

The No-Scar Lip-Lift: Upper Lip Suspension Technique Anthony Echo, Adeyiza Olutoyin Momoh and Eser Yuksel Abstract  Background  Addressing the long upper lip has been a complex problem for some time.

Methods such as the subnasal skin excision and the vermillion advancement technique have been described, but both leave a visible scar. A no-scar lip-lift technique is necessary for a subset of patients who have a long upper lip and will not accept a visible scar.

The upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. A retrospective review of 92 patients who had undergone upper lip-lift with the no-scar suspension technique was performed. Three plastic surgeons assessed the pre- and postoperative results and determined the presence of improvement in four categories: lip shortening, lip projection, incisor show, and vermillion show.

The lip parameters improved, with 85% of the patients showing noticeable lip shortening, 79% showing increased sagittal projection, 74% exhibiting increased incisor show, and 25% exhibiting increased vermillion show. All the patients had improvement in at least one of the four categories. Complications were experienced by two patients with a suture abscess and one patient with an unraveled suture.

The overall lip contours improved after the lip suspension technique, most noticeably in terms of lip height and sagittal projection, and the scar was hidden intranasally.
Keywords  Lip lift – Lip suspension – Lip aesthetics – Long upper lip – Ptotic upper lip

Note upper lip elevation techniques have been described with or without skin excision. The lips need to look youthful with fullness and good angles. Suspension techniques maybe applicable in some cases. Larry Weinstein,MD FACS


Areola and Nipple-Areola-Sparing Mastectomy for Breast Cancer Treatment and Risk Reduction: Report of an Initial Experience in a Community Hospital Setting

Annals of Surgical Oncology, 03/02/2011

Harness JK et al. – Areola–sparing and nipple–areola–sparing mastectomies can be safely performed in the community hospital setting with low complication rates and good short–term results.

Eating vegetables gives skin a more healthy glow than the sun
ScienceDaily, 01/12/2011  

New research showed that eating a healthy diet rich in fruit and vegetables gives you a more healthy golden glow than the sun. Carotenoids are antioxidants that help soak up damaging compounds produced by the stresses and strains of everyday living, especially when the body is combating disease. Responsible for the red colouring in fruit and vegetables such as carrots and tomatoes, carotenoids are important for our immune and reproductive systems. While this study describes work in Caucasian faces, the paper also describes a study that suggests the effect may exist cross culturally, since similar preferences for skin yellowness were found in an African population. Note: it is important to eat fresh vegetables and fruits to maximize your health and skin. Larry Weinstein MD FACS


Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years
Annals of Surgical Oncology, 01/12/2011    

Jensen JA et al. – Five–year recurrence rate is low when NSM (nipple–sparing mastectomy) margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high–risk patients. NSM can be performed safely with all types of breast reconstruction. Note: Relative to individual Cancer surgeons opinion. Larry Weinstein MD FACS


Customized Planning of Augmentation Mammaplasty with Silicone Implants Using Three-Dimensional Optical Body Scans and Biomechanical Modeling of Soft Tissue Outcome  Aesthetic Plastic Surgery, 01/11/2011 

Gladilin E et al. – Based on individual three–dimensional data and physical modeling, the described approach enables more accurate and reliable predictions of surgery outcomes than conventionally used photos of prior patients, drawings, or ad hoc data manipulation. Moreover, it provides precise quantitative data for bridging the gap between virtual simulation and real surgery. Note: This is a dubious at best. Larry Weinstein MD FACS

Hand Volume 5, Number 4, 354-360, DOI: 10.1007/s11552-010-9263-y

Review Articles of Topics: Is there Light at the End of the Tunnel? Controversies in the Diagnosis and Management of Carpal Tunnel Syndrome Mathew S. Prime, Jonathan Palmer, Wasim S. Khan and Nicholas J. Goddard       


Carpal tunnel syndrome is a common disorder responsible for considerable patient suffering and cost to health services. Despite extensive research, controversies still exist with regards to best practice in diagnosis, treatment, and service provision. Current best practise would support the use of history, examination and electro-diagnostic studies. The role for ultrasound scanning in diagnosis of carpal tunnel syndrome is yet to be proven. It appears magnetic resonance image scanning has a role where a rare cause for carpal tunnel syndrome may be suspected and also in the detailed reconstruction of the anatomy to aid endoscopic procedures. Treatment options can be surgical or non-surgical and patient choice will dictate the decision. For non-surgical interventions many options have been trialled but until now only steroid use, acupuncture, and splinting have shown discernable benefits. Open surgical decompression of the carpal tunnel appears to be more simple and cost-effective than minimally invasive interventions. For those patients who reject surgery, splinting, acupuncture, and steroid injection can play a role. Recent work looking at different service delivery options has shown some positive results in terms of decreasing patient waiting time for definitive treatment. However, no formal cost-effectiveness analysis has been published and concerns exist about the impact of a stream-lined service on surgical training. In this review, we look at the different diagnostic and treatment options for managing carpal tunnel syndrome. We then consider the different service delivery options and finally the cost-effectiveness evidence.

Keywords  Carpal tunnel syndrome - Electro-diagnostic studies - Non-operative treatment endoscopic surgery - Cost-effectiveness


15 Year Experience with Primary Breast Augmentation

Plastic and Reconstructive Surgery, 11/19/2010
This review shows that the use of Total Re–operation(TR) rates as an indication of complications of breast implants can lead to both an overestimation of implant–related complications and the inaccurate conclusion that silicone implants result in higher complication rates than saline implants. The Implant Specific Re–operation (ISR) rate may therefore provide a more accurate incidence of implant complications than TR, which includes re–operations for factors unrelated to the implant. Implant and non–implant related causes of reoperation following breast augmentation should be more clearly reported.


Assessment tool predicts blood clot risk after plastic surgery
EurekAlert, 11/19/2010  

Patients undergoing plastic or reconstructive surgery should receive a risk assessment before their procedure to predict whether they'll develop potentially fatal blood clots in the legs or lungs. Because past studies have shown that some plastic and reconstructive surgery patients are at high risk for developing clots and only about 50 percent of surgeons administer clot–preventing medications after surgery.


Our strategy in complication management of augmentation mammaplasty with polyacrylamide hydrogel injection in 235 patients☆
Sheng-Kang Luoac , Gunang-Ping Chena, Zhong-Shen Suna, Ning-Xin Chengb c
Received 14 May 2010; accepted 6 October 2010. published online 12 November 2010.
Corrected Proof

Polyacrylamide hydrogel (PAAG) was once widely used in breast augmentation in China. Although it had been banned for augmentation mammaplasty in 2006, a large number of patients whose breasts were augmented with the gel injection have continued to seek medical advice because of its complications. The clinical management of these complications has never been standardised.
The data of a total of 235 patients with complications following PAAG-injected breast augmentation have been summarised and the types and causations analysed. Magnetic resonance imaging (MRI) was undertaken in 228 patients with palpable masses, breast pain or tenderness, asymmetry or deformity and functional or psychological problems to eliminate neoplasm, infection and to delineate the diseases. The surgical gel evacuation via periareolar incisions was performed for all patients and immediate silicone breast prostheses were implanted in 108 patients and were delayed in 28 cases by 6 months.

Most patients (214/235) of the group were satisfied with the treatment, and symptoms disappeared after removal of the gel. The gel distribution and involved tissue were well defined and neoplasm was ruled out by MRI. Postoperative MRI in 68 patients revealed that no obvious PAAG remaining. In either immediate or delayed reconstructive patients with silicone breast implants, good breast contour presented. A diagnosis and management strategy for these complications is proposed.
In conclusion, the breast masses, pain and deformity are major complications after PAAG-injected breast augmentation. Psychological problems should be paid attention to. MRI is a sensitive and accurate method for diagnosis and treatment evaluation. Surgical removal of injected gel is the preferred method for complication management. The implantation of silicone prostheses for breast contour restoration after PAAG evacuation is effective for patients under strict selection. Our strategy for treating PAAG-related complications proved useful.

Keywords: Strategy, Polyacrylamide hydrogel, Augmentation mammaplasty, Complication, Breast contour restoration


Breast Augmentation and Mastopexy Using a Pectoral Muscle Loop
Aesthetic Plastic Surgery, 11/08/2010  Clinical Article

Auersvald A et al. – Augmentation mastopexy has historically challenged the creativity of plastic surgeons. Recurrent breast ptosis is the main cause for revision after such a primary operation. Avoiding the need for reoperation and achieving long–term projection and upper pole fullness have been the main focus for the work of many authors. In this study, a new approach for a stable and lasting breast shape based on the use of the pectoral muscle was conceived. Augmentation mastopexy using a loop of the pectoral muscle to hold the implant is a new and effective way to obtaiin long–lasting projection and upper pole fullness. Note: Breast augmentation and breast lift are procedures I am doing for over 20 years which have not required a Pectoralis Muscle loop. Larry Weinstein, MD FACS

Looking older than your age may not be a sign of poor health
EurekAlert, 11/08/2010  Free full text

Even though most adults want to avoid looking older than their actual age. The study found that a person needed to look at least 10 years older than their actual age before assumptions about their health could be made. Few people are aware that when physicians describe their patients to other physicians, they often include an assessment of whether the patient looks older than his or her actual age. For patients, it means looking a few years older than their age does not always indicate poor health status. The study found that when a physician rated an individual as looking up to five years older than their actual age, it had little value in predicting whether or not the person was in poor health. However, when a physician thought that a person looked 10 or more years older than their actual age, 99 per cent of these individuals had very poor physical or mental health. Note: It is true looking older than your stated age is equated with poor health. I have seen many people over the years with severe weight loss who looked much older then there stated age. Larry Weinstein,MD FACS


Plastic & Reconstructive Surgery:
November 2010 - Volume 126 - Issue 5 - pp 1419-1427
doi: 10.1097/PRS.

No Differences in Aesthetic Outcome or Patient Satisfaction between Anatomically Shaped and Round Expandable Implants in Bilateral Breast Reconstructions: A Randomized Study

Gahm, Jessica M.D., Ph.D.; Edsander-Nord, Åsa M.D., Ph.D.; Jurell, Göran M.D., Ph.D.; Wickman, Marie M.D., Ph.D.


Background: The demand for bilateral mastectomy and immediate breast reconstruction has increased in recent years, primarily due to the development of genetic testing. The aim of this study was to evaluate if there was a difference between anatomically shaped and round permanent expandable implants in one-stage bilateral breast reconstruction after bilateral prophylactic mastectomy.

Methods: The anatomically shaped permanent expander implant McGhan Style 150 (Inamed, Santa Barbara, Calif.) was compared with the round permanent expander implant Siltex Becker 25 (Mentor, Santa Barbara, Calif.). Thirty-six women who opted for bilateral prophylactic mastectomy and immediate reconstruction with implants from 2004 to 2006 were included and randomly assigned to each group [18 women (36 breasts) per group]. Time to follow-up was a minimum of 2 years after the bilateral prophylactic mastectomy. Implant-related complications, breast symmetry, aesthetic outcome, and patient satisfaction were evaluated. Aesthetic outcome was evaluated by an expert panel that also tried to recognize if the breasts were reconstructed with anatomically shaped or round implants. Patient satisfaction was evaluated by a questionnaire.

Results: Average time to follow-up was 30 months (range, 24 to 49 months). There was no statistical difference between the two implant groups in terms of complications, breast symmetry, or outcome scores from the expert panel and patient assessment. The expert panel guessed the right implant shape in 42 percent of the anatomically shaped implants and 66 percent of the round implants.

Conclusion: In immediate one-stage breast reconstruction after bilateral prophylactic skin-sparing mastectomy, anatomically shaped and round permanent expander implants had comparable complication rates, aesthetic outcomes, and patient satisfaction after 2 years of follow-up.


Breast Reduction by Liposuction in Females, Aesthetic Plastic Surgery, 11/02/2010  Clinical Article Jakubietz RG et al. –

Liposuction breast reduction is appealing due to selective removal of fat, ease of the procedure, and minimal scarring. The main disadvantage is that a correction of shape and ptosis is not possible with liposuction, and only young patients can expect an aesthetically pleasing result. Elderly patients may benefit from faster recovery times, a less invasive procedure, and low costs. The application of a new technique to a cancer–prone organ represents a potentially serious medicolegal issue because follow–up imaging may be impaired and a possible spread of cancer cells cannot be ruled out. Despite its technical appeal, breast reduction by liposuction alone mandates a cautious approach. Note: I have done a case with liposuction alone, and have done many cases with the aid of liposuction to remove the upper secondary fatty tissue, the lateral armpit fatty tissue and sometimes just to contour the breast for a better result. Larry Weinstein,MD FACS


Outcome Analysis in 93 Facial Rejuvenation Patients Treated with a Deep Plane Facelift, Plastic and Reconstructive Surgery, 10/29/2010

Despite a significant recovery period, patient satisfaction is high, with 96.7 percent of patients reporting a more youthful appearance after surgery. Scar dissatisfaction is rare (2.2 percent). With proper patient preparation and education, facial rejuvenation effectively meets patient expectations. These findings support the recommendation of surgical facial rejuvenation to patients who wish to look younger. Note: If a SMAS alone is added to a facelift, it has been found in previous studies to last longer. A new PDS stitch I use under the neck appears to add results with little increase in down time. Larry Weinstein, MD FACS

Autologous Gluteal Lipograft

Aesthetic Plastic Surgery, 10/07/2010 Nicareta B et al. – The key to
successful gluteal fat grafting is familiarity with the technique, knowledge of the gluteal topography, and understanding of the patient’s goals. With experience, the surgeon can predict the amount of volume needing to be grafted to produce the desired result. Although the aim of every surgeon is to produce the desired augmentation of the gluteal region by autologous fat grafting in one stage, the patient should be advised that a secondary procedure may be needed to accomplish the desired result.


Double-Mesh Technique for Correction of Abdominal Hernia Following Mammary Reconstruction Carried Out with Bipedicled TRAM Flap and the Primary Closing of the Donor Area by Using a Single Polypropylene Mesh
Aesthetic Plastic Surgery, 10/07/2010  Clinical Article

Souto LRM et al. – Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle is still an option well accepted in many parts of the world. However, bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall following mammary reconstruction carried out with bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps by using two polypropylene prostheses overlapped in different anatomical planes. The correction of delayed deformities of the abdominal wall after mammary reconstruction with bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps using double mesh was carried out in an effective and secure way, providing an interesting surgical option for mastologists and plastic and general surgeons.


Consecutive Procedures and a Patient Satisfaction Assessment
Aesthetic Plastic Surgery, 10/07/2010  Clinical Article

Castello MF et al. – A conventional superficial musculoaponeurotic system face–lift is well established because it allows the skin envelope to be rotated in a bit more lateral direction than the cephalad redirection of the superficial musculoaponeurotic system flap. The authors believe that the rhytidectomy technique described in this report has several beneficial attributes. High vertical elevation of the superficial musculoaponeurotic system flap delivers a long–lasting benefit and addresses the problem of neck laxity and platysma redundancy, leading to a correction of the neck contouring and jowls. Nasolabial folds appear to be smoothed, and malar flattening is restored by imbrications of the superficial musculoaponeurotic system flap over the cut edge in the malar prominence. This investigation demonstrates that the rhytidectomy technique is safe and produces highly predictable results.


Refinements in Abdominoplasty: A Critical Outcomes Analysis over a 20-Year Period

Trussler, Andrew P. M.D.; Kurkjian, T. Jonathan M.D.; Hatef, Daniel A. M.D.; Farkas, Jordan P. M.D.; Rohrich, Rod J. M.D.Results: Two hundred fifty patients undergoing abdominoplasty from 1987 to 2007 were included in the study. The use of a “superwet” liposuction technique in combination with abdominoplasty significantly decreased intraoperative blood loss (p < 0.04) and length of hospital stay (p< 0.05). Liposuction volume and region had no significant effect on abdominoplasty outcome, although refinements in operative technique, including abdominal and flank ultrasound-assisted liposuction, high superior tension, and limited abdominal undermining, did improve the postoperative aesthetic score. Venous thromboembolic events significantly decreased with aggressive venous thromboembolism prophylaxis (p < 0.001).
Conclusions: The technical evolution of a single surgeon's 20-year experience demonstrates that liposuction can be safely and effectively combined with abdominoplasty. Preoperative trunk analysis, intraoperative surgical refinements including superwet technique and ultrasound-assisted liposuction, and perioperative venous thromboembolism prophylaxis significantly improve the outcome of abdominoplasty. Note: liposuction if used within safe parameters is a reasonable adjunct to improved results in Abdominoplasty or tummy tucks.Larry Weinstein, MD

Larry Weinstein,MD FACS


Enhanced Eyelashes: Prescription and Over-the-Counter Options
Aesthetic Plastic Surgery, 09/02/2010

Jones D – Originally indicated for the reduction of intraocular pressure, the synthetic prostaglandin analog bimatoprost was recently approved for the treatment of hypotrichosis of the eyelashes. In a double–blinded, randomized, vehicle–controlled trial, bimatoprost safely and effectively grew natural eyelashes, making them longer, thicker, and darker. Bimatoprost was generally safe and well tolerated and appears to provide an additional option for individuals looking to improve the appearance of their eyelashes. Note: I have been using latisse for many of my patients with significant improvement noted in many of them. Larry Weinstein, MD

Plastic & Reconstructive Surgery:
September 2010 - Volume 126 - Issue 3 - pp 1063-1074


Capsular Contracture with Breast Implants in the Cosmetic Patient: Saline vs. Silicone. A Systematic Review of the Literature  Plastic and Reconstructive Surgery, 08/10/2010 Implants placed beneath the pectolalis muscle that are massaged on a regular basis have a low incidence of capsular contracture. The new silicone gel implants may start off softer the saline implants. Larry Weinstein, MD FACS


Health-Related Quality of Life, Patient Benefit and Clinical Outcome after Otoplasty Using Suture Techniques in 62 Children and Adults  Plastic and Reconstructive Surgery, 08/10/2010 Otoplasty for prominent ears is one of the most rewarding operations in my practice. Careful suture techniques are key to good results. Larry Weinstein, MD FACS


No differences in aesthetic outcome or patient satisfaction between anatomical or round shaped expandable implants in bilateral breast reconstructions: a randomized study

Plastic and Reconstructive Surgery, 07/19/2010

Gahm J et al. – In immediate one–stage breast reconstruction after bilateral prophylactic skin sparing mastectomy, anatomically and round–shaped permanent expander implants had comparable complication rates, aesthetic outcomes and patient satisfaction after two years follow up.


No significant difference in benefit for longer surgical procedure... Comparison of Morbidity, Functional Outcome, and Satisfaction Following Bilateral TRAM Versus Bilateral DIEP Flap Breast Reconstruction
Plastic and Reconstructive Surgery, 06/17/10

Background: The potential for donor site morbidity associated with bilateral pedicled TRAM flap breast reconstruction has led to the popularization of DIEP flap reconstruction. This study compares post-operative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction.

Methods: One-hundred and five women with bilateral pedicled TRAM flaps were compared to 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Post-operative follow-up data was obtained through Short Form-36, FACT-B, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys.

Results: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data was otherwise similar. Abdominal hernias occurred in 3 TRAM patients (2.9 %) and in no DIEP patients, whereas abdominal bulges occurred in 3 TRAM patients (2.9 %) and 4 DIEP patients (6.9 %); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Post-operative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the SF-36 subjective energy category (p = 0.01) and mean FACT-B score (p = 0.01).

Conclusion: This study suggests no significant differences in donor site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction. (C)2010American Society of Plastic Surgeons Note; The extended surgical time, inherent risk factors in a longer procedure and lack of significant benefit may preclude the use of this flap in most patients. Larry Weinstein, MD FACS

A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction
Obesity Surgery, 06/10/10


The transversus abdominis plane (TAP) block acts on the nerves localised in the anterior abdominal wall muscles. We evaluated the efficacy on post-bariatric (PB) patients undergoing body-contouring abdominoplasty. We retrospectively evaluated PB patients undergoing abdominoplasty with flank liposuction and compared results to a matched group of TAP aesthetic patients. Outcomes evaluated were the analgesic requirements during the early postoperative days. Fifty-one patients (PB n = 27, aesthetic n = 24) were assessed. No complications were observed. All PB patients required analgesia until the second postoperative day contrarily to most aesthetic ones. Patients with greater flap resected and higher pre-abdominoplasty BMI had greater morphine consumptions. In PB patients, the larger amount of tissues resected corresponded to a greater stimulation of pain fibres that cannot be paralleled by a concomitant increase of the local anesthetic administered. This partially invalidates TAP’s efficacy on PB patients.

Keywords  Transversus abdominis plane - Pain - Locoregional analgesia - Abdominoplasty - Body contouring - Obesity surgery - Bariatric surgery
Note: My patients with abdominoplasty usually go home the same day of surgery. They do well with oral pain medications. Larry Weinstein,MD FACS


Key Points in Mastopexy

Aesthetic Plastic Surgery, 06/04/10 Javier De Benito1 and Kyrenia Sánchez


Breasts represent femininity and any change of shape may affect their appearance. Breast ptosis may be caused by several factors, including significant weight loss, pregnancy, long breastfeeding periods, and involution of the postmenopausal breast tissue. Breast ptosis may be associated with breast hypoplasia; thus, in case of a mastopexy with or without the use of implants being indicated, several considerations have to be taken into account: the wishes of the patient, age of the patient, degree of ptosis, parenchymal volume, covering tissue, quality of the tissue, pocket implant, shape and content of the implant, and resulting scars.

Keywords  Breast augmentation - Mastopexy Note: Breast ptosis or saggy baggies can be corrected with a breast lift - Mastopexy or sometimes with replacement of volume with an implant. An implant can be used with degrees of lifting that include a crescant lift, periareola lift, lollypop or inverted T. There is a high degree of patient satisfaction with this procedure.

Larry Weinstein,MD FACS


Immediate Breast Reconstruction with Implants After Skin-Sparing Mastectomy: A Report of 96 Cases
Aesthetic Plastic Surgery, 05/19/10 , Fa-Cheng Li1  , Hong-Chuan Jiang and Jie Li



Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has become increasingly popular as an effective treatment for patients with early-stage breast cancer requiring mastectomy. This study aimed to evaluate the clinical outcomes of IBR using permanent gel breast implants and Becker expandable breast implants after SSM.


A review of 96 patients undergoing IBR with Beck expandable or permanent gel breast implants after SSM from July 2002 to December 2006 was performed. Of the 96 patients, 30 had IBR after SSM with conservation of the nipple–areola complex (NAC). The mean patient age was 42 years (range, 29–57 years). Aesthetic outcomes were assessed according to the breast volume, shape, and symmetry with the opposite breasts after a mean follow-up period of 44 months.


The aesthetic outcomes were graded as excellent for 29 patients, good for 47 patients, fair for 12 patients, and poor for 8 patients. The overall complication rate was 11.5% (11/96). The complications included prosthesis loss after skin flap necrosis subsequent to hematoma formation (n = 1), skin necrosis (n = 2), partial necrosis of preserved NAC (n = 1), capsular contracture (Baker 4, n = 2), wound infection not involving the prosthesis (n = 2), inversion of the injection port (n = 2), and seroma (n = 2).


This study demonstrates that prosthetic breast reconstruction is a safe, reliable method with minimal complications and good to excellent aesthetic results for the majority of patients with early-stage breast cancer. For selected patients, NAC-sparing mastectomy can be performed without increasing the risk of local recurrences. Success depends on patient selection, proper incision for SSM, total coverage of the prostheses with muscles, and careful intra- and postoperative management.
Keywords  Breast implants - Breast neoplasms - Mammaplasty - Mastectomy

Study links tanning to increased risk of melanoma.

USA Today (5/27, Szabo) reports that "people who have ever used tanning machines were...more likely to develop melanoma than others, according to a study" published in Cancer Epidemiology, Biomarkers & Prevention.

The Time (5/27, Park) "Wellness" blog reported that investigators "began with more than 2,000 individuals, half of whom had documented cases of melanoma, and half whom did not, and asked them about their tanning habits, which included questions about their outdoor sun exposure as well as use of indoor tanning equipment." The researchers found that "lifetime exposure to outdoor sunlight, whether through jobs or leisure activities, was not associated with an increased risk of developing skin cancer, but use of tanning beds was." In other words, "those who tanned indoors had a 74% greater risk of developing melanoma than those who never used the machines." 

Note: Sun exposure and tanning machines have proven to increase skin cancer. Please use 30 or above sunscreen this summer, avoid the sun between 10 AM and 2 PM, where protective clothing and avoid tanning machines. Larry Weinstein, MD FACS

Otoplasty Using a Modified Anterior Scoring Technique
Archives of Facial Plastic Surgery, 05/26/10

Objective To evaluate long-term results of otoplasty using standardized measurements.

Methods We performed a retrospective study of patients who underwent otoplasty using a modified anterior scoring technique combined with postauricular fixation sutures. Two hundred twenty-two consecutive patients (421 primary otoplasties) were included. Each auricle was examined before surgery, after surgery, and at a long-term follow-up visit, and the distance between the lateral helical rim and the mastoid surface was measured at 3 points. In addition, patient satisfaction was evaluated using a questionnaire.

Results Seventy-two percent of 222 patients were examined at a long-term follow-up visit. Follow-up of 301 auricles was on average 6.25 years (range, 44-106 months). The mean preoperative measurements among all auricles were 23.3 mm at the uppermost point of the helix, 28.6 mm at the middle, and 25.9 mm at the lobule; these values were 14.2, 14.0, and 16.1 mm, respectively, at the end of the operation and 16.0, 17.5, and 17.4 mm, respectively, 6 years later. Long-term data revealed a median 2-mm lateralization of the auricle. The aesthetic result of otoplasty was rated as “very good” by 71.8% of patients and as “good” by 19.4% of patients; 6.9% of patients thought the result was “satisfactory” and 1.9% “unsatisfactory.” Complete recurrence of the protrusion was seen in 7 ears (2.3%) and partial recurrence within the upper third of the pinna in 26 ears (8.6%).

Conclusions Otoplasty using a modified anterior scoring technique combined with postauricular fixation sutures provides long-term improved results in 91.2% of cases. Complications and sequelae are few, and rates are comparable to those of other long-term studies. A 2-mm lateralization of the auricle may be expected. Standardized measurements of the auricle are important because they supplement the overall aesthetic evaluation of the corrected ear and provide an objective baseline for long-term follow-up.


Alar Soft-Tissue Techniques in Rhinoplasty
Archives of Facial Plastic Surgery, 05/18/10

Objectives To describe various techniques, including alar base reduction, alar flaring reduction, and alar hooding reduction and present a decision-making treatment algorithm and quantifiable guidelines for soft-tissue excision, along with scar outcomes from a single-surgeon practice. The soft tissue of the nasal tip, ala, and nostrils is important in overall nasal tip dynamics. Excisional alar contouring is an essential part of many successful cosmetic rhinoplasty outcomes.

Methods The various soft-tissue excision techniques are described in detail and an algorithm is provided. Quantitative analysis of excision parameters was performed using statistical analysis. Finally, qualitative scar analysis was performed and scar outcomes were statistically derived.

Results Seventy-four patients were female and 26 were male. Of the procedures reviewed, 47% involved alar soft-tissue excision. Alar base reduction was performed in 46 patients (46%). Alar flare reduction was performed in 16 patients (16%). Alar hooding reduction was performed in 2 patients (2%). Mean scar outcome scores ranged from 0.55 to 0.69.

Conclusions Alar soft-tissue techniques are often necessary to achieve a balanced outcome and superior results when performing rhinoplasty surgery. Therefore, they should be an integral part of every rhinoplasty evaluation and surgical plan as indicated.

Note: Alar flare reduction and alar base reduction are common procedures in my rhinoplasties with most patients pleased with their results. Larry Weinstein, MD FACS

Predictors of Satisfaction With Facial Plastic Surgery
Archives of Facial Plastic Surgery, 05/18/10

Objective To identify demographic and psychological factors that predict satisfaction or dissatisfaction with outcomes among patients undergoing facial plastic surgery.

Methods All patients presenting to the Center for Facial Cosmetic Surgery at the University of Michigan between January 1, 2007, and January 1, 2008, were asked to participate. Patients answered an initial baseline survey consisting of demographic information and an assessment of their baseline level of optimism/pessimism in addition to a surgery-specific outcome questionnaire both preoperatively and 4 to 6 months postoperatively.

Results Fifty-one patients (mean [SD] age, 53 [13.0]; 69% female; 98% white) participated. Patients over the mean age of 53 years were more satisfied with their results than those under the mean age (P = .01). Patients currently being treated for depression were more satisfied with surgical outcomes than those not being treated (P = .05). No correlation was identified between baseline optimism/pessimism or other baseline factors and patients' perceived surgical outcomes. Surgeons were decidedly less positive in their assessment of the outcome than patients.

Conclusion Despite a priori hypotheses that patients treated for depression might be more pessimistic and rate their satisfaction lower than other patients, patients treated for depression show a trend toward greater satisfaction from facial plastic surgical procedures than those not treated for depression.


Dual Plane Prosthetic Reconstruction Using the Modified Wise Pattern Mastectomy and Fasciocutaneous Flap in Women with Macromastia
Plastic and Reconstructive Surgery, 05/13/10

Introduction: Skin sparing mastectomy (SSM) and immediate breast reconstruction in women with macromastia is often difficult. The Wise pattern skin reducing mastectomy often provides the best options for shape and symmetry, however, is not without morbidity. We reviewed our experience with a modified Wise pattern mastectomy and tissue expander reconstruction to improve safety.

Methods: All patients with breast cancer who underwent a SSM and modified Wise pattern skin reducing reconstruction with tissue expander were included. A dual plane technique was used by covering the expander with the pectoralis muscle and a vascularized lower pole fasciocutaneous flap. Patient demographics were queried and outcomes were assessed.

Results: Twenty seven patients (34 breasts) underwent tissue expander reconstruction using the dual plane vascularized coverage technique. The average BMI was 34 (range: 24-42). The average contralateral reduction weight was 502 grams on all 20 unilateral reconstructions. Post-operative complications occurred in 37 %, with seroma being the most common 17% (n=6/34). The unplanned re-operation rate was 15%. The average follow-up was 16 months (range: 2 months to 4.5 years).

Conclusion: We have demonstrated that modifications to the Wise pattern mastectomy with tissue expander using a dual plane of vascularized tissue coverage can optimize results in patients with breast cancer and macromastia. Complications still occur, however, they can usually be treated conservatively.
(C)2010American Society of Plastic Surgeons

Augmentation–Mastopexy Using an Autologous Parenchymal Sling
Aesthetic Plastic Surgery, 05/12/10


Mastopexy–augmentation is an important treatment to address breast deflation. Combining these two procedures is technique-sensitive, with a reported high revision rate and propensity for complications. We describe an approach to achieve aesthetic breast correction in an effective, reproducible, and safe manner while minimizing untoward sequela.

A vertical mastopexy, using a superior dermoglandular pedicle, is coupled with a subpectoral breast implant with the support of a longitudinal autologous sling of breast fascia, termed autologous sling augmentation–mastopexy.

Twenty consecutive patients, aged 25-49 years, were treated by this technique, with a follow-up period of at least 1 year. Aesthetic improvement of breast shape, projection, and nipple position were achieved in all patients. No major complications, including infection, necrosis, or implant exposure, occurred. Minor wound-healing deficits at the inferior aspect of the vertical resection occurred in three patients. One patient required implant exchange early postoperatively because of saline leakage. No revisions were necessary to adjust breast symmetry or nipple position.

We describe a mastopexy–augmentation technique, based on patient selection, mastopexy resection pattern, and implant size and position, to improve breast aesthetics safely and reproducibly while minimizing complications and the need for near-term revision.

Keywords  Mastopexy–augmentation - Breast - Autologous parenchymal sling

Mammaplasty with Inferior Pedicle Flap After Massive Weight Loss

Aesthetic Plastic Surgery, 05/10/10
Miguel Modolin1  , Wilson Cintra Jr.1, Maira Marques Silva1, Liacyr Ribeiro2, Rolf Gemperli1 and Marcus Castro Ferreira1    Abstract     Background      

After massive weight loss, one of the stigmas that afflict women is the remaining deformity of the breasts which become flaccid and ptotic, with an absent or flat upper pole. The authors propose the use of a well-established mammaplasty technique to fill the upper pole, reshape the breast cone, and correct ptosis with nipple–areola complex (NAC) repositioning.    


A total of 16 patients were analyzed; all underwent gastroplasty between 18 and 24 months prior to mammaplasty. The mean age was 41.6 years (range = 26–62) and the mean BMI previous to the mammaplasty was 29.2 kg/m2 (range = 24.9–38.9). The technique included a dermo-lipo glandular flap pedicled on the inframammary fold (IMF) together with a superior flap containing the NAC.    


All patients who underwent surgery were satisfied with the outcomes since a more aesthetic breast shape was achieved, with projection of the upper pole and correction of ptosis. Adverse events included dehiscence at the junction point of the flaps in the inframammary fold, which resolved with secondary-intention wound healing in three patients; partial necrosis of the areola in one patient; epidermolysis in one of the NACs in one patient; and infection in one of the breasts in one patient, which resolved with proper antibiotic therapy.


When compared to the current mammaplasty techniques performed in formerly obese patients, this is a good surgical option because it uses tissues adjacent to the breast itself and does not require silicone prosthesis for breast augmentation. The patients reported increased self-esteem and improvement in their quality of life. Keywords  Obesity - Weight loss - Mammaplasty - Inferior pedicle flap        

Note: This is a technique I have used in a reverse abdominoplasty in which the excess skin and subcutaneous tissue of the upper abdomen are used to make the breasts more perky. Larry Weinstein, MD FACS


Aesthetic Breast Augmentation and Thoracic Deformities
Aesthetic Plastic Surgery, 05/03/10
 P. Wolter3  , S. Lorenz2 and C. Neuhann-Lorenz1  

(1)  Praxis für Plastische und Aesthetische Chirurgie, Theatinerstrasse 1, 80333 München, Germany

(2)  Department of Plastic, Reconstructive, Hand and Burn Surgery, Klinikum Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany

(3)  Department of Plastic Surgery, Hand Surgery, Burn Center, University Hospital of the RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany

To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.

Keywords  Aesthetic breast augmentation - Thoracic deformities - Silicone breast implants - Breast asymmetry  -  Poland's syndrome - Retrospective study  Note: Many patients have thoracic problems with their chest wall which are enhanced with breast implants. Many more patients with real problems with their chest walls or breast maldevelopment have breast augmentation then movie stars or dancers. Larry Weinstein, MD FACS


Correlation Between Scoliosis and Breast Asymmetries in Women Undergoing Augmentation Mammaplasty
Aesthetic Plastic Surgery, 04/28/10

Background: Breast asymmetries and scoliosis influence the results of augmentation mammaplasty. Although a variety of methods have been proposed to resolve breast asymmetries, to date, no simple preoperative algorithm has been proposed for predicting the breast volume and decreasing breast asymmetries in the place of subjective or expensive evaluation. The relationship between the scoliosis and breast volume asymmetry was further analyzed statistically in this study.

Methods: The study enrolled 60 scoliotic patients from 780 patients undergoing augmentation mammaplasty between January 2000 and March 2008. The average follow-up period was 2 years. The inclusion criteria required hypoplastic breasts, a difference in bilateral breast volumes greater than 20 ml, and scoliosis with a Cobb angle greater than 10°. The authors’ surgical algorithm demonstrated an anthropomorphic equation for predicting breast volume and selecting the correct implant size.

Results: Pearson regression analysis showed that the breast volume asymmetry difference was significantly correlated with the severity of scoliosis (Cobb angle) (correlation coefficient, 0.901). No correlation between the difference in pre- and postoperative nipple and inframammary levels and the severity of scoliosis was noted. Augmentation mammaplasty significantly decreased the breast asymmetry differences (volume and nipple level) (p < 0.001). The average preoperative estimated breast volume was 45.3 ml for the smaller breast and 88.4 ml for the larger breast.

Conclusion: This study found that the severity of scoliosis showed significant correlation with the breast volume asymmetry differences. Augmentation mammaplasty for breast asymmetries decreased not only the volume difference but also the difference in nipple levels.  

Keywords:  Augmentation mammaplasty - Breast asymmetries - Implant - Scoliosis 

Note: Breast asymmetry can be secondary to spinal and chest bone deformities. Scoliosis is a special case which can give more significant abnormalities of the breast on a developmental and aging process. I have had good success with improvement in patients with scoliotic related breast asymmetry. Larry Weinstein, MD FACS


Upper Body Reshaping for the Woman with Massive Weight Loss: An Algorithmic Approach
Aesthetic Plastic Surgery, 04/22/10


Body contouring after massive weight loss represents a rather new surgical field. Many areas of the body are affected such as the back, the upper arms, and the breasts in the upper body. Combining more than one such area in a single operative step can yield many advantages. The author proposes a single-step approach to the upper body of the woman with massive weight loss and offers an algorithm to simplify the operative plan.

Based on the characteristics of the individual, each adjacent region is analyzed for the potential of surgical improvement. Several lifting techniques can be used to restore the shape of each region. The breast represents a rather unique entity in which three basic types can be recognized. Accordingly, a surgical plan is formulated and discussed with the patient.

The presented algorithm was used successfully for 17 consecutive women after massive weight loss. Although the time for these combined operations was increased, patient safety was not reduced nor were the number of complications increased compared with multiple smaller operations. The overall treatment plan for this patient group was greatly enhanced and simplified with this approach and resulted in great patient satisfaction.

Body contouring after massive weight loss presents a steadily increasing surgical field. Typically, multiple operative steps are required to achieve the patient’s ultimate goal. The author offers a surgical algorithm that aids in the operative planning for the upper body of such patients that simplifies this operation and yields great patient satisfaction.

Keywords  Algorithm - Body-lift - Breast - Massive weight loss - Surgery - Upper body
Note: I have been using an extended abdominoplasty with thigh lift for some years with very nice results in most patients. see tummy tucks.


LASER removal of fat cells.
Mary K. Caruso-Davis1, Thomas S. Guillot2, Vinod K. Podichetty3, Nazar Mashtalir4, Nikhil V. Dhurandhar4, Olga Dubuisson4, Ying Yu4 and Frank L. Greenway4 
Published online: 15 April 2010


Low-level laser therapy (LLLT) is commonly used in medical applications, but scientific studies of its efficacy and the mechanism by which it causes loss of fat from fat cells for body contouring are lacking. This study examined the effectiveness and mechanism by which 635–680 nm LLLT acts as a non-invasive body contouring intervention method.

Forty healthy men and women ages 18–65 years with a BMI <30 kg/m2 were randomized 1:1 to laser or control treatment. Subject's waistlines were treated 30 min twice a week for 4 weeks. Standardized waist circumference measurements and photographs were taken before and after treatments 1, 3, and 8. Subjects were asked not to change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceride release.

Data were analyzed for those with body weight fluctuations within 1.5 kg during 4 weeks of the study. Each treatment gave a 0.4–0.5 cm loss in waist girth. Cumulative girth loss after 4 weeks was −2.15 cm (−0.78 ± 2.82 vs. 1.35 ± 2.64 cm for the control group, p < 0.05). A blinded evaluation of standardized pictures showed statistically significant cosmetic improvement after 4 weeks of laser treatment. In vitro studies suggested that laser treatment increases fat loss from adipocytes by release of triglycerides, without inducing lipolysis or cell lysis.

LLLT achieved safe and significant girth loss sustained over repeated treatments and cumulative over 4 weeks of eight treatments. The girth loss from the waist gave clinically and statistically significant cosmetic improvement.
Keywords  Cold laser - Fat reduction - Low-level laser therapy - Non-invasive laser
This study was supported by Meridian Medical, Inc., Vancouver, BC, Canada V6K 4L9.


Autologous Augmentation-Mastopexy After Bariatric Surgery: Waste Not Want Not
Aesthetic Plastic Surgery, 03/17/10
Daniel J. A. Thornton1, 2   and Le Roux Fourie1


The escalating trend in obesity is having major impact on health and the economy. As a result of NHS policies to reduce obesity, the number of patients losing weight following bariatric surgery is increasing rapidly. In addition to the systemic benefits to their general health, dramatic weight loss leads to marked changes in body habitus, with many patients seeking further “aesthetic” surgery to improve their appearance. We present our technique of autologous augmentation-mastopexy to address the problems of both skin excess and insufficient breast volume.

Our chosen method for mastopexy uses the Wise-pattern skin excision. Augmentation of the breast deficient in volume is provided by a pedicled subcutaneous lateral thoracic perforator-based flap raised via a vertical continuation of the lateral mastopexy incision superiorly, often in continuity with a simultaneous brachioplasty incision.

Thus far, six patients have undergone autologous augmentation mastopexy following massive weight loss (range = 36–79 kg, mean = 61 kg). Follow-up of these patients ranged from 1 to 18 months (mean = 12.5 months). Postoperative complications included a donor site seroma, haematoma, and scar contracture. All patients tolerated the procedure well and they felt that the improvement in breast and chest wall contour more than compensated for the donor site scar on the lateral chest wall.

Autologous augmentation-mastopexy provides a robust augmentation, giving more natural ptotic breasts while avoiding the cost and potential complications of implant augmentation. The increased lateral flank scarring is well tolerated by these patients, with the additional benefit of reducing flank fullness.
Keywords  Bariatric surgery - Augmentation-mastopexy - Autologous breast augmentation

Note: I have been doing autologous breast augmentation for over 20 years. It can be a realiable alternative to implants for selective patients. Free fat transplantation has limited long term results. Larry Weinstein,MD FACS

Prospective Assessment of Nutrition and Exercise Parameters before Body Contouring Surgery: Optimizing Attainability in the Massive Weight Loss Population
Plastic and Reconstructive Surgery:
April 2010 - Volume 125 - Issue 4 - pp 1242-1247

Koltz, Peter F. M.D.; Chen, Rui Ph.D.; Messing, Susan M.S.; Gusenoff, Jeffrey A.  M.D.

Background: A lower body mass index at the time of body contouring surgery can optimize surgical options and, ultimately, aesthetic results. With increased emphasis on preoperative evaluation of the massive weight loss patient, the interrelationships between nutrition and exercise on body mass indices have not been well defined.

Methods: One hundred thirty-three consecutive massive weight loss patients presented for body contouring. Two-week food logs, weekly exercise regimens, and body mass indices were measured. Outcome variables were assessed by univariate and multivariate analysis.

Results: One hundred fifteen women and 18 men presented, with a mean age of 46.5 ± 11.0 years, a maximum body mass index of 52.8 ± 10.6 kg/m2, current body mass index of 32.4 ± 8.6, change in body mass index of 20.4 ± 6.5, daily protein intake of 56.9 ± 18.5 g, and mean exercise of 3.7 days/week. The mean change in body mass index for the bariatric surgery group was 20.9 ± 6.4 versus 15.9 ± 6.8 for the self-weight loss group (p = 0.01). Age correlated directly with current body mass index (p = 0.0031) and inversely with exercise (p = 0.0003). Change in body mass index was related to younger age (p = 0.0455), maximum body mass index (p < 0.0001), and bariatric surgery (p = 0.0016), but not protein intake. Exercise five or more times per week was associated with a larger change in body mass index and lower current body mass index (p < 0.0036) than exercising two or fewer times per week (p = 0.0292).

Conclusions: Frequent exercise optimizes body mass index at the time of presentation for body contouring surgery. Further evaluation of the elements of diet will be required to determine its role. Thus, comprehensive post-bariatric surgery or lifestyle programs that promote exercise may increase surgical options and optimize results in body contouring surgery.

Note: All patients should diet and exercise to maximise their potential. larry Weinstein MD FACS

Plastic and Reconstructive Surgery: 9 March 2010                       
Longevity of SMAS Facial Rejuvenation and Support by Sundine, Michael J. M.D.; Kretsis, Vasileios M.D.; Connell, Bruce F. M.D

Background: One of the most common questions asked by patients when they present for facelift surgery is "How long will this last?" The answer to this question is not clear from the literature.

Methods: The purpose of the study is to review a series of secondary facelifts performed between 2001 and 2008 with both the primary and secondary facelift performed by a single surgeon. There were 42 patients with full records available for review. Data were collected in regards to timing, surgical technique, complications, and reasons for early revision

Results: The average age at the primary facelift was 50.2 years (34.9-69.9) and the average age at the secondary facelift was 61.9 years (43.6-77.2). The average age length of time from the primary to secondary facelift was 11.7 years. There were 9 patients who required a secondary facelift prior to 5 years from the primary facelift (21.4%). Reasons for early secondary facelifting (within 5 years of the primary) included: loss of skin elasticity (5 patients), increase in subplatysmal fat and skin neck folds due to weight gain (1 patient), loss of elasticity secondary to protease inhibitors for HIV infection (1 patient), loss of skin elasticity due to corticosteroid use (1 patient), and residual fullness of digastric and residual submental fat (1 patient). Conclusion: On average, a well performed SMAS flap facelift will last 12 years. Those patients who present with very poor skin elasticity secondary to sun damage may require an earlier secondary facelift.

Note: How long the reset of a face lift is determined by many factors. A second procedure under local is not a major procedure that can enhance a result. It is rare in my practice that someone's facelift does not last a lifetime. There are people in the limelight who may need more frequent nips and tucks. Larry Weinstein, MD FACS


Prophylactic mastectomy of healthy breast may boost survival in some women.

The Los Angeles Times (2/25, Kaplan) "Booster Shots" blog reported that, according to research appearing in the Journal of the National Cancer Institute, in "women under 50 with Stage 1 or Stage 2 breast cancer that was estrogen receptor negative," researchers found that "prophylactic removal of a healthy breast" boosted "their odds of being breast-cancer free after five years by 4.8 percentage points."

The Houston Chronicle (2/26, Ackerman) reports, however, that researchers "found no benefit among patients 60 or older undergoing a double mastectomy, and murky results among those aged 50 to 60." The study showed "that preventive surgery on the opposite breast had little survival benefit, save for the one subset, either because patients die from the cancer they already have, or from other medical conditions."

Experts attribute increasing rates of prophylactic mastectomies to "improved genetic and imaging techniques that give women a lot of information about their tumors," Time (2/25, Park) reported.

Note: The younger the patient at the time of diagnosis of breast cancer the more dangerous the tumor. The higher the chance the opposite breast could harbor disease. Patient's over 50 usually have a different disease. The actual pathology is important and can be used to advise someone , what is best. Reconstruction may increase survival. Larry Weinstein,MD FACS


Inferior Pedicle Autoaugmentation Mastopexy After Breast Implant Removal

Journal Aesthetic Plastic Surgery

Johannes Franz Hönig1, 2  , Hans Peter Frey3, Frank Michael Hasse1 and Jens Hasselberg1      21 February 2010

Abstract  A new method of autoaugmentation mammaplasty is presented to correct ptosis and to increase the projection and volume of the breast in patients who would like a reposition augmentation mammaplasty after breast implant removal but do not want a new implant. Methods   Between 1999 and 2007, a total of 27 patients (age = 54 ± 7.3 years) underwent mammaplasty using an inferior-based flap of deepithelialized subcutaneous and breast tissue modularized to its pedicle which was inserted beneath a superior pedicle used for correction of ptosis and to increase the projection and apparent volume of the breast.

Results   The results confirmed that autoaugmentation mammaplasty of the breast following removal of the implant yields longstanding results. It corrects ptosis and increases the projection and apparent volume of the breast when mastopexy is planned without use of a new implant. Twelve months after surgery the degree of descent of the inframammary fold generally parallels that of the nipple. The mean level of the inframammary fold was below the mean level of the nipple. Postoperatively, the optimum distance had been largely achieved.

Conclusion   The advantages of the technique presented here are that it minimizes the skin scar in cases using vertical mammaplasty techniques and optimizes the breast shape after breast implant removal in patients who do not want a new implant. Keywords  Capsular contracture - Breast implant - Autoaugmentation mammaplasty - Mastopexy 

Note: I have done a number of implant removals with mastopexy performed at the same time. There are many patients who look fine after removal without implants. Sometimes people gain weight, get pregnant, or hormonally change resulting in larger breasts then anticipated. Perky breasts are routinely achieved with breast lift or mastopexy. Larry Weinstein.MD FACS


Fleur-de-lis Abdominoplasty: A Safe Alternative to Traditional Abdominoplasty for the Massive Weight Loss Patient
Friedman, Tali MD,MHA; Coon, Devin MD; Michaels, Joseph V. MD; Purnell, Chad BS; Hur, Seung BA; Harris, Diamond N BS; Rubin, J. Peter MD

Background: Traditional abdominoplasty techniques often fail to adequately correct the complex contour deformities in the massive weight loss (MWL) patient. To correct these deformities, addition of a vertical skin resection to the traditional horizontal excision has become a popular procedure. We analyzed the impact of vertical (fleur-de-lis) excision on complications when compared to traditional transverse excision.

Methods: A review of MWL patients enrolled in an IRB-approved prospective registry was performed on consecutive patients undergoing abdominoplasty by a single surgeon. Patients were included if they underwent at least 50 lbs of weight loss. Demographic, procedural data and outcome measures were studied. Logistic regression and t-tests were performed to analyze differences in complication rates for both procedures and identify risk factors for complications.

Results: Four hundred ninety nine patients met inclusion criteria, of whom 154 (31%) had a fleur-de-lis (FDL) vertical component. The overall abdominal complication rate for all patients was 26.3% with a 5.6% rate of major complications. Transverse-only and FDL abdominoplasty had similar rates of complications with the exception of a higher rate of wound infection in the FDL group on multivariate analysis. Risk factors for abdominal wound complications with either procedure included male gender, seroma, high BMI, concurrent component separation and previous subcostal scars.

Conclusion: FDL abdominoplasty can be safely performed with complication rates comparable to traditional abdominoplasty techniques. Ideal candidates are patients with upper abdominal skin laxity who may not achieve an adequate aesthetic result with transverse-only excision. Note: In my website at I have several examples of patients who have had just lower abdominal incisions for tummy tuck. However there are a select group of patients who need the fleur de lis incision to control the extra skin or relieve tension on the lower abdominal wound. Larry Weinstein, MD FACS (C)2010American Society of Plastic Surgeons


Subfascial Breast Augmentation: A Comprehensive Experience
Aesthetic Plastic Surgery, 02/11/10 Joseph P. Hunstad1   and L. Shayne Webb2

Background  Subfascial breast augmentation, first performed in 1998, places the implant above the pectoralis muscle but below the pectoralis fascia. Graf documented that this approach resulted in less capsular contracture than subglandular implant placement and a more natural shape while eliminating implant animation with arm movement. In addition, implant edge visibility was decreased compared with subglandular implantation in all but the extremely thin patient. Because of the described benefits and high patient satisfaction, the authors began to perform this technique in 2006.

Methods  This report presents a comprehensive review of the aforementioned technique by describing a large series of subfascial augmentations (inframammary, periareolar, and endoscopic transaxillary) as primary procedures, secondary procedures, and operations with concurrent use of mastopexy performed by a single surgeon using multiple approaches. A patient satisfaction questionnaire was used in addition to a detailed clinical assessment.

Results  The results of this procedure were reproducible, controllable, and predictable. The study demonstrated a high degree of patient and surgeon satisfaction with few complications, a low rate of capsular contracture, no evidence of breast animation with arm movement, excellent lower pole coverage, and a brief recovery period.

Conclusions  Subfascial breast augmentation is a safe, effective procedure allowing for predictable results with excellent shape and longevity. For the properly selected patient, this approach provides the benefits of subglandular and submuscular placement without the disadvantages associated with each. Keywords  Breast augmentation - Implant - Subfascial  Note: I have used this technique many times for small breast augmentations it is good alternative. The results fail to show adequate cleavage, the implants are centered on the nipple and have more of an axillary placement then most patients desire. Larry Weinstein, MD FACS


Malposition Implant treated with capsular Flap Gyeol Yoo1 and Paik-Kwon Lee2

(1)  Department of Plastic Surgery, College of Medicine, The Catholic
University of Korea, # Yeouido-dong, Yeoungdeungpo-gu, Seoul, Korea
 31 December 2009

Abstract  Among the reasons for reoperation after augmentation mammaplasty is the malpositioned implant, especially a lowered inframammary fold or symmastia, which is difficult to repair. The peri-implant capsule, a physiologic response to a foreign body, is naturally formed and suitable for use as a flap because of its high vascularity. In addition, it is sufficiently tough for suspension of the implant. The authors introduce the idea that the capsular flap is very useful for the correction of symmastia or a lowered inframammary fold. In such situations, the capsular flaps are used to prevent migration of the implant after raising of the inframammary fold or defining of the midline with capsulorrhaphy. This technique successfully corrected the malpositioned implants in this study, and all the patients were satisfied. There was no recurrence of a lowered inframammary fold or symmastia. These findings suggest that the capsular flap should be considered an option for the management of malpositioned implants.

Keywords  Breast augmentation - Capsular flap - Implant malposition

Note: Implant malposition can often be treated with external manipulations and bandages. On a rare occasion is the surgical option needed. Capsulorraphy or adjusting the capsule with Contour thread sutures is a quick effective method of controling lateralization or double bubble problems. Flaps are an alternative for the tougher cases.
Larry Weinstein,MD FACS


Capsular contracture and possible implant rupture: is MRI useful?
AA, Paetau; SA, McLaughlin; RB, McNeil; E, Sternberg; SP, TerKonda; JC, Waldorf; G, Perdikis
Published Ahead-of-Print

Background: Currently, magnetic resonance imaging (MRI) is considered the gold standard to evaluate breast implant integrity.

Methods: To evaluate its utility in diagnosing ruptured silicone implants in the setting of capsular contracture and to correlate the preoperative assessment of implant integrity with or without MRI with operative findings, 319 capsulectomies (171 patients with capsular contractures) were retrospectively reviewed. 160 implants had preoperative MRI while the remaining 159 were evaluated using only physical exam and/or mammography (MMG). We analyzed our postoperative results to determine the sensitivity, specificity, and accuracy of preoperative MRI in comparison to clinical and/or MMG alone.

Results: Although occasionally valuable, overall preoperative MRI was no more accurate than clinical +/- MMG evaluation in predicting implant status: MRI 124/160 (78%), clinical 121/159 (76%); p=0.77.

Conclusions: In the setting of capsular contracture, physical exam with or without mammogram is as accurate as MRI in determining implant integrity. Although MRI is a sensitive diagnostic tool, in symptomatic patients with capsular contracture it cannot be viewed as infallible.

(C)2009American Society of Plastic Surgeons
Plastic and Reconstructive Surgery:
POST ACCEPTANCE, 1 December 2009
doi: 10.1097/PRS.0b013e3181cb6530
Article: PDF Only


Pre-operative Sizing in Breast Augmentation
Hidalgo, David A. M.D.; Spector, Jason A. M.D
Published Ahead-of-Print

Background: Implant size selection in breast augmentation patients is one of many variables to be determined prior to surgery. Few methods exist today that allow the patient to participate in this process and accurately determine optimal size. We describe a simple method of preoperative sizing using silicone implant samples.

Methods: A total of 567 patients underwent breast augmentation; 297 had surgery prior to implementation of pre-operative sizing, 270 patients were sized pre-operatively. Sizing consisted of fitting the patients with various size silicone implants in a larger bra at least twice prior to surgery in order to determine desired size. Surveys were sent to both groups to inquire about overall satisfaction, how many preferred a different size postoperatively, and how many ultimately underwent size change surgery.

Results: One hundred and two (34.3 percent) responses were obtained from the control group and 142 (52.5 percent) from the sized group. Sized patients received smaller implants (average 276.6 cc non-sized versus 246.4 cc sized, p< 0.001). Four patients (1.4%) in the control group underwent a size change procedure versus none in the sized group. In the sized cohort, 69% believe they are the size that the process predicted, 21% are smaller, 9% are larger, and 1% did not answer the question.

Conclusions: Sized patients were more satisfied than controls and fewer were interested in having a different size implant postoperatively. Sized patients indicated that preoperative sizing was both helpful and reasonably accurate in predicting final breast size.
(C)2009American Society of Plastic Surgeons


Patient Satisfaction and Health-Related Quality of Life Following Breast Reconstruction: A Comparison of Patient-Reported Outcomes Amongst Saline and Silicone Implant Recipients
Macadam, Sheina A. MS; Ho, Adelyn L. MD; Cook, E F. Jr SD; Lennox, Peter A. MD; Pusic, Andrea L. MHS
Published Ahead-of-Print

Background: In recent years, there has been a growing acceptance of the value of breast reconstruction. The majority of women who choose to proceed will undergo alloplastic reconstruction. The primary objective of this study was to determine if the type of implant used in alloplastic breast reconstruction has an impact upon patient-reported satisfaction and quality of life.

Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least one year prior to study initiation. Patients were contacted by mail: two questionnaires (BREAST-Q(C) and EORTC QLQC30 (Br23)(C)), a contact letter, and an incentive gift-card were included. Scores were compared between silicone and saline implant recipients.

Results: 75 silicone implant recipients and 68 saline implant recipients responded for a response rate of 58%. BREAST-Q(C) responses showed silicone implant recipients to have higher scores on all 9 subscales. This difference reached statistical significance on 4 of 9 subscales: overall satisfaction (p=0.008), psychological well-being (p=0.032), sexual well-being (p=0.05), and satisfaction with surgeon (p=0.019). Regression analysis adjusted for follow-up time, timing of surgery, unilateral vs. bilateral surgery, radiation and age. Results from the EORTC QLQC30 (Br23)(C) showed a statistically significant difference on 2 of 22 subscales: silicone recipients had higher overall physical function and saline recipients had higher systemic side effects.

Conclusions: This study has shown higher satisfaction with breast reconstruction in silicone gel implant recipients compared to saline recipients using the BREAST-Q(C). There was no difference in overall global health status between the two patient groups as measured by the EORTC-QLQC30(C).
(C)2009American Society of Plastic Surgeons

Benchmarking Outcomes in Plastic Surgery: National Complication Rates for Abdominoplasty and Breast Augmentation 'Outcomes Article] Alderman, Amy K. M.D., M.P.H.; Collins, E Dale M.D., M.S.; Streu, Rachel M.D.; Grotting, James C. M.D.; Sulkin, Amy L. M.P.H.; Neligan, Peter M.D.; Haeck, Phillip C. M.D.; Gutowski, Karol A. M.D.


Background: The authors evaluated the use of national databases to track surgical complications among abdominoplasty and breast augmentation patients.

Methods: Their study population included all patients with abdominoplasty or breast augmentation in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) and CosmetAssure databases from 2003 to 2007. They evaluated the incidence of hematoma, infection, and/or deep venous thrombosis/pulmonary embolism. Chi-square and t tests were used for the analyses.

Results: The TOPS and CosmetAssure databases included 7310 and 3350 patients with abdominoplasty and 30,831 and 14,227 patients with breast augmentation, respectively. In the TOPS and CosmetAssure populations, the complication rates for abdominoplasty were 0.9 percent and 0.5 percent with hematoma (p = 0.29), 3.5 percent and 0.7 percent with infection (p < 0.001), and 0.3 percent and 0.1 percent with deep venous thrombosis/pulmonary embolism (p = 0.05), respectively. The complication rates for breast augmentation in TOPS and CosmetAssure were 0.6 percent and 0.7 percent with hematoma (p = 0.21), 0.3 percent and 0.1 percent with infection (p < 0.001), and 0.02 percent and less than 0.01 percent with deep venous thrombosis/pulmonary embolism (p = 0.31), respectively.

Note: Less than 1% of patients have a complication as described in my practice. Quick care of these problems are critical.
Larry Weinstein,MD FACS

Endoscopically assisted limited-incision rhytidectomy: A 10-year prospective study ☆
Enzo Rivera Citarella, Aris Sterodimas, Alexandra Condé-Green  07 December 2009.



The ability to bring aesthetic harmony back into the ageing face requires the blending of surgical technique, anatomic knowledge and artistic sensitivity to individualise the surgical approach for each given patient. Since the advent of endoscopic techniques for facial rejuvenation, there has been an increase in the number of patients who seek alternative facial procedures, refusing a conventional face-lift.
Limited-scar rhytidectomies offer patients with mild-to-moderate facial ageing an alternative to traditional face-lift surgery. The authors present a prospective study using the endoscopically assisted limited-incision face-lifting technique.

Indications for using this technique include young patients with a relatively small amount of skin excess, older patients with thick skin and minimal skin redundancy, smokers and bald people. A set of incisions in the forehead, pre-auricular area, ear lobe and post-auricular area are done. Frontal and temporal endoscopic lifting is performed, followed by middle third and cervical undermining and transposition of a 2×5.5cm rectangular pre-auricular superficial musculo-aponeurotic system (SMAS) flap. Overall satisfaction with the facial appearance after this procedure was rated on a scale of 1 to 5.

A total of 54 patients were operated upon during January 1997 and January 2007, which represents 13% of the total number of face-lifting procedures performed during that period. Their age ranged from 28 to 55 years old (mean 38 years), and 35% of them were men. There were two cases of haematoma formation (1%) and four patients (2%) required further liposuction of the submental region. There were no cases of nerve injury or infection. Six patients (3%) requested revision surgery after 2–4 years after the first procedure (median 3.5 years). They underwent a secondary round of face-lifting. The mean follow-up period has been 5.5 years (range 1–9 years). Sixty-nine percent reported that their appearance after limited-incision rhytidectomy was ‘very good’ to ‘excellent’ and 22% responded that their appearance was ‘good’. Only 9% of patients thought their appearance was less than good.

This is not a mini-lift technique but rather a full face-lift performed through minimal incisions and assisted by the use of the endoscope.
Although the endoscopically assisted limited-incision rhytidoplasty is reserved for a specific category of patients and requires a learning curve, it appears to be a procedure with a low rate of complications and a high patient satisfaction.

Keywords: Endoscopic face-lifting, Limited-incision rhytidectomy, Facial rejuvenation, Short-scar face-lifting

Note: I have been doing short scar face lift for 20 years with results that have withstood the test of time. Endoscopic technique helps me get better results. Not everyone can benefit from mini incision technique.

Larry Weinstein,MD FACS


Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices Lina Triana, MD1, Carlos Triana, MD1, Carlos Barbato, MD1, Marco Zambrano, MD1 Accepted 13 May 2009.


The development of liposuction provided plastic surgeons with a safe and effective way to sculpt the human figure. The techniques and instrumentation used in the performance of liposuction have evolved significantly since its introduction.


The authors review their experience with different liposuction techniques over the past 25 years.


Data from patients who had undergone liposuction were collected from the personal databases of four different surgeons and from the database at the Corpus and Rostrum Plastic Surgery Clinic in Cali, Colombia. A retrospective review was conducted and the results from different liposuction techniques were compared.


A total of 26,259 patient charts were reviewed. The results showed that 5% of patients experienced a postsurgical seroma. Postsurgical fibrosis developed to some degree in 2.3% of patients. Anemia was present in 18% of all patients and in 60% of those patients who underwent dry liposuction. Ninety percent of patients reported postoperative pain.
The incidence of deep vein thrombosis was 0.03%, as was the incidence of pulmonary embolism. Mortality was 0.01% and was mainly caused by pulmonary embolism. Patient satisfaction was similar for all of the described techniques.


The incidence of anemia was reduced significantly in patients undergoing tumescent liposuction versus dry liposuction. However, the occurrence of seroma increased with the introduction of tumescent liposuction. The incidence of postoperative pain and fibrosis was similar for all liposuction techniques reviewed. The aesthetic results obtained using ultrasound- or laser-assisted liposuction were similar to those obtaining using other techniques.

Note: I have performed close to 1000 tumescent liposuctions with 2 seromas, 1 hematoma, no deep venous thrombosis, no pulmonary emboli, pain similar to after a tough work out and results of two to 12 inches of improvement.
Larry Weinstein,MD FACS


Management of Upper Abdominal Laxity After Massive Weight Loss: Reverse Abdominoplasty and Inframammary Fold Reconstructionabdominoplasty Aesthetic Plastic Surgery, 11/30/09


Background  Central to body contouring after weight loss surgery is treatment of the abdominal region, often through a circumferential abdominoplasty. This procedure, however, neglects the laxity of the lower thoracic/upper abdominal region. A reverse abdominoplasty with reconstruction of a new inframammary fold (IMF) corrects this deformity through removal of excess skin along the IMF. Since 2002, we have performed 88 reverse abdominoplasty procedures within the context of a single or staged total-body lift (TBL).

Methods  A retrospective chart review of 129 TBL cases indicated that
88 patients had a combined or staged reverse abdominoplasty and circumferential abdominoplasty. Complication rates were noted as localized or generalized.

Results  Fifty-three of our patients had combined reverse abdominoplasty and circumferential abdominoplasty and 35 had the reverse abdominoplasty during a second stage. The complication rates for both groups were about 5% per patient per procedure with differences that were not statistically significant. Also, the revision rates for reverse abdominoplasty and circumferential abdominoplasty were similar for both groups, indicating patient satisfaction with the procedures.

Conclusion  In selected patients, effective treatment of the abdominal region demands correction of both the upper and lower abdominal laxity and contour. This can be performed safely, effectively, and reliably by a reverse abdominoplasty with IMF reconstruction independently or simultaneously with circumferential abdominoplasty.

Keywords  Body contouring - Circumferential abdominoplasty - Inframammary fold reconstruction - Massive weight loss - Reverse abdominoplasty

Note: Old technique used for unusual situations. Larry Weinstein,MD FACS

Augmentation Mastopexy in Muscle-Splitting Biplane: Outcome of First 44 Consecutive Cases of Mastopexies in a New Pocket UD Kahn
Aesthetic Plastic Surgery, 11/24/09


Background   Augmentation with mastopexy is a commonly performed procedure and is done either simultaneously or in stages. The augmentation component can be accomplished by placing an implant in the subglandular, partial submuscular, or subfascial plane, and mastopexy can be performed using periareolar, vertical, or Wise pattern markings. These two components are independent of each other and any pocket can be combined with suitable external markings. The muscle-splitting submuscular biplane is a new pocket and is combined with conventional envelope reductions for mastopexy.

Methods   The submuscular biplane pocket was used in 44 consecutive patients for mastopexy and augmentation using vertical scar and periareolar markings. Of these, 13 had subglandular augmentation in the past. The mean age of the patients was 32.4 years (range = 21–46). Average blood loss was 44 g (range = 10–111 g). Drains were used selectively and the procedure was usually done as a day case.

Results   The follow-up period of the included cases ranged from 4 months to 3 years. No infection, hematoma, or wound problems were seen. Minor revision was required for periareolar puckering in one case and three had dog-ears after vertical scar mastopexy. One periareolar mastopexy required conversion into a vertical scar as a revision and one vertical scar mastopexy had superficial infection with bilateral minor skin breakdown which responded completely to antibiotics.

Conclusion   The submuscular biplane technique is a good option for breast augmentation with mastopexy as a single or staged procedure.

Keywords  Breast augmentation - Vertical scar mastopexy - Periareolar mastopexy - Submuscular biplane technique

Note: The Biplane technique is a basic technique of breast augmentation with or without lift. Recent refview of 554 case reveals similar results. No drains were used by me, no revisions of vertical scars because I do inverted Ts, crescent and or periareola approaches. Larry Weinstein, MD FACS

Plastic and Reconstructive Surgery:
November 2009 - Volume 124 - Issue 5 - pp 1375-1385
doi: 10.1097/PRS.0b013e3181b988c4

Breast: Original Articles
Breast Cancer Screening Prior to Cosmetic Breast Surgery: ASPS Members'
Adherence to American Cancer Society Guidelines Selber, Jesse C. M.D., M.P.H.; Nelson, Jonas A. B.A.; Ashana, Adedayo O. B.A.; Bergey, Meredith R. M.Sc., M.P.H.; Bristol, Mirar N. M.A.; Sonnad, Seema S. Ph.D.; Serletti, Joseph M. M.D.; Wu, Liza C. M.D.

Background: The goal of this study was to determine the self-reported breast cancer screening practices of American plastic surgeons and the degree to which those practices adhere to the American Cancer Society guidelines. An independent analysis of subgroups divided by gender, years in practice, and practice setting was performed and the implications of the results are discussed.

Methods: The authors conducted an online survey of the members of the American Society of Plastic Surgeons. Questions assessed practice composition, American Cancer Society guideline familiarity, and preoperative breast cancer screening in patients seeking aesthetic breast surgery. Responses were summarized, subgroup comparisons were made, and logistic regression was used to determine predictors of physician practices.

Results: The 1066 respondents were predominantly male (82 percent) and consisted largely of private practitioners (73 percent). In total, 47 percent appeared to follow the American Cancer Society guidelines, while 64 percent claimed familiarity. Being male predicted more accurate guideline knowledge, but being female resulted in more aggressive screening and possibly more diagnoses. Number of years in practice and familiarity with the American Cancer Society guidelines also resulted in more perioperative diagnoses.

Conclusions: Knowledge of the American Cancer Society guidelines is an essential component of effective cancer screening, but only two-thirds of plastic surgeons claim familiarity with them, and fewer than half report concordant practices. As plastic surgeons who often perform surgical procedures on the breast in women with no history of breast disease, we have an obligation to understand and apply consistent, reliable breast cancer screening practices to ensure the well-being of our patients. Note: The diagnosis of breast disease is extremely important in woman. I have found tumors that require treatment prior to cosmetic plastic surgery. Larry Weinstein,MD FACS


Abdominoplasty After Major Weight Loss: Improvement of Quality of Life and Psychological Status

Authors: Lazar, Calin1; Clerc, I.2; Deneuve, S.3; Auquit-Auckbur, I.4; Milliez, P.4

Source: Obesity Surgery, Volume 19, Number 8, August 2009 , pp.

Abdominoplasty provides a reconstructive but rarely aesthetic cosmetic solution after major weight loss. Few articles document quality of life (QOL) issues and the psychological impact of abdominoplasty on obese patients. We report a retrospective study of 41 abdominoplasties performed after an average weight loss of 40.2 kg. Data were obtained through review of patient medical files, double-blind surgical and psychological examinations, and two specifically designated questionnaires used to assess pre-abdominoplasty body perception and QOL, post-body contouring perception of improvement, and psychological status. To date, 14 patients have regained >10 kg; 84.6% have improved QOL; 86.5% have improved psychological status; 74% have better sexual relations; 53.9% admit liking their body; 76.9% are satisfied with the results of abdominoplasty; and 96.1% would be willing to undergo abdominoplasty again. Anterior dermolipectomy improves both QOL and psychological status. Provision of patient education, multidisciplinary management, and long-term follow up are necessary to obtain satisfactory results. Note: My experience with a similar number of patients has been extremely positive for this group of patients, Some had lost weight on there own with diet and exercise others had a banding procedure. A full extended abdominoplasty can change the waist by 4 to 8 inches. Men and woman are candidates for the procedure. Larry Weinstein,MD FACS


Management of Mons Pubis and Labia Majora in the Massive Weight Loss Patient

Gary J. Alter, MD

The high incidence of female obesity and weight loss has resulted in common complaints of a large, protuberant mons pubis and labia majora (outer labial lips) related to unsightly fat deposits and skin ptosis. The author presents a technique to correct the protuberant mons and pubic descent by performing a pubic lift, fat excision, and liposuction, and then tacking the superficial fibrofatty tissue to the rectus fascia. The labia majora enlargement is treated by fat excision and/or liposuction and skin excision. These techniques eliminate difficulties with sexual intercourse, poor hygiene, and discomfort, while also improving self-esteem. (Aesthet Surg J;29:432-442) Note: Most often I treat these problems at the same time as an extended abdominoplasty. A proper abdominoplasty addresses this issue but can be dealt with at a secondaary procedure. Dr. Larry Weinstein


Surgery potentially best option for severe migraine headaches

University Hospitals Case Medical Center researchers provide study results at ASPS conference

CLEVELAND – The disability from migraine headaches is an enormous health burden affecting over 30 million Americans.

In newly released research, 79 migraine sufferers were followed for at least five years after having undergone detection of migraine "trigger sites" and surgery. The new data finds promising outcomes for treating trigger sites surgically for migraine headaches resulting in elimination of pain for those afflicted with the condition.

Since the surgery, 10 of the 79 patients required additional surgeries for newly detected trigger sites and were eliminated from the final analysis. Sixty-one of the remaining 69 patients (88 percent) have maintained the initial positive response to the surgery. Twenty patients (29 percent) reported elimination of migraines entirely, 41 patients (59 percent) noticed a significant decrease, and only eight patients (11 percent) experienced less than 50 percent improvement or no change.

This new data provides strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate (cure) or reduce the frequency, duration, and/or intensity of migraine headaches with lasting results.

Bahman Guyuron, MD, Chairman of Plastic Surgery at University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, and an internationally recognized leader in the field of plastic surgery, will present new five-year research data that could potentially reveal a cure for migraine headaches on October 24, 2009, at the American Society of Plastic Surgeons annual meeting in Seattle.

"Migraine headaches are extremely disabling and this surgical option offers hope for migraine sufferers," says Dr. Guyuron. "Combined with the previous studies, this new five-year data has provided strong evidence that severe migraine headaches and their painful symptoms can be successfully treated with surgery with lasting results."

The impetus behind Dr. Guyuron's eight migraine headache research projects was his observation close to a decade ago that many patients who had undergone forehead rejuvenation noticed a disappearance in migraine symptoms following surgery.

For patients who suffer frontal migraine headaches, Dr. Guyuron removes the corrugator supercilii (frowning) muscle group in the forehead that is suspected to be a trigger point for headaches, compressing nerves and causing nerve inflammation. Temple migraine headaches are treated by removing a small branch of the trigeminal nerve. For those patients who suffer from occipital (back of the head) migraine headaches, a small piece of muscle encasing the nerve is removed and replace with a soft tissue flap. When the headaches are located behind eyes and are triggered by weather change, he works on the nose septum and surrounding structures. Dr. Guyruon has performed more than 1,000 of these procedures on more than 450 patients, since each patient has 2.5 trigger sites in average. Analysis of more recent results demonstrates a significantly higher elimination rate.

Note: Dr. Guyaron is a member of our Maxillofacial society, we have found a number of patients that benefit from Botox as well. The procedure can be done endoscopically through minimal incisions with great aesthetic cosmetic results. Larry Weinstein, MD FACS


Volume 29, Issue 5, (September2009)

Combination Hand Rejuvenation Procedures
Ava T. Shamban, MD1 Accepted 22 May 2009.

Although the hands age at the same rate as the face, the aging process differs and requires a combination treatment approach for optimal rejuvenation. Photoaging causes epidermal changes such as lentigines, actinic keratoses, fine wrinkles, and crepe-like textural change. Thinning of the dermis and subcutaneous fat occurs as a result of both ultraviolet light exposure and intrinsic aging. This process can lead to a skeletal appearance of the hands, with prominent veins and bulging tendons. The combination approach addresses all of these issues, employing lasers, intense pulsed light devices, fractional devices, fillers, peels, vein sclerotherapy, and an effective at-home skin care program as indicated for individual needs and concerns.

Note; Hand Rejeuvenation is a procedure I have done for years with LASER with very good results. Dr. Weinstein


Plastic and Reconstructive Surgery: September 2009 - Volume 124 - Issue 3 - pp 919-925
doi: 10.1097/PRS.0b013e3181b0389e    Cosmetic: Original Articles

Local Complications after Cosmetic Breast Augmentation: Results from the Danish Registry for Plastic Surgery of the Breast

Hvilsom, Gitte B. M.D.; Hölmich, Lisbet R. M.D., D.M.Sc.; Henriksen, Trine F. M.D., Ph.D.; Lipworth, Loren Sc.D.; McLaughlin, Joseph K. Ph.D.; Friis, Søren M.D.

Background: Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially.

Methods: The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/displacement of the implant, hematoma, and infection.

Results: During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant.

Conclusions: Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up.

Note: Incidence of complications with Dr. Weinstein is less. Hematoma 0.02%, none requiring surgery. Reoperation rate is less than 1% per year. Larry Weinstein, MD FACS


Plastic and Reconstructive Surgery: October 2009 - Volume 124 - Issue 4 - pp 1304-1311 doi: 10.1097/PRS.0b013e3181b455d0  Cosmetic: Original Articles

Intraoperative Use Bupivacaine for Tumescent Liposuction    Failey, Colin L. M.D.; Vemula, Rahul M.D.; B, Gregory L. M.D.; Hsia, Henry C. M.D.

Background: Bupivacaine anesthetic is commonly used as a wetting solution additive in tumescent liposuction, but its routine use remains controversial because of a lack of evidence in the current literature

Methods: In accordance with local institutional review board regulations, a retrospective chart review was conducted of liposuction cases performed from 1997 to 2007 at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. The primary endpoint was adverse perioperative events. Secondary endpoints included length of postanesthesia care unit stay and length of total postoperative hospital stay.

Results: Eighty-seven cases were analyzed and two subsets of patients were identified. In group 1, 24 patients were compared who underwent liposuction as the primary procedure and received bupivacaine, lidocaine, or no additive in their wetting solution. No adverse events were encountered and the average length of stay was not significantly different. In group 2, 20 patients were compared who underwent abdominoplasty and liposuction and received bupivacaine or no additive in their wetting solution. No adverse events occurred and patients receiving bupivacaine had a significantly shorter average length of stay, 19 hours versus 36 hours, compared with controls (p = 0.015)
                                                                 Conclusions: A review of the experience at Robert Wood Johnson University Hospital reveals that the intraoperative use of bupivacaine for tumescent liposuction in 27 cases appeared to be as safe as other tumescent additives. There did not appear to be a significant difference in the incidence of adverse events or postoperative length of stay for patients who underwent liposuction with bupivacaine compared with other wetting solutions. Among a subset of patients who underwent concurrent abdominoplasty and liposuction procedures, patients who received bupivacaine spent significantly less time in the hospital postoperatively than those who did not receive it. Conducting future prospective studies involving larger samples among multiple centers is an essential next step to confirm these findings.

Note: I have been using Bupivicaine a longer acting anesthetic for 20 years with minimal pain for most patients postoperatively. Larry Weinstein, MD FACS


Plastic and Reconstructive Surgery: October 2009 - Volume 124 - Issue 4 - pp 1285-1293 doi: 10.1097/PRS.0b013e3181b455b  Cosmetic: Original Articles

Lateral Orbicularis Oculi Muscle Plasty in Conjunction with Face Lifting for Periorbital Rejuvenation    Cabbabe, Samer W. M.D.; Andrades, Patricio M.D.; Vasconez, L, O. M.D.

Background: The purpose of this study was to evaluate the lateral orbicularis oculi muscle plasty as an alternative periorbital rejuvenation technique during face lift

Methods: The authors conducted a retrospective review of patients who underwent face lifts between 2004 and 2007. Postoperative follow-up, complications, aesthetic outcome, and patient satisfaction were recorded. The patients were further divided into four groups for the analysis: lateral orbicularis oculi muscle plasty with lower blepharoplasty (group 1), lower blepharoplasty without lateral orbicularis oculi muscle plasty (group 2), lateral orbicularis oculi muscle plasty without lower blepharoplasty (group 3), and neither lateral orbicularis oculi muscle plasty nor lower blepharoplasty (group 4).   

Results: A total of 76 patients were identified as having had a midface lift with or without lateral orbicularis oculi muscle plasty in the study period. Sixty-eight percent of the patients had a lateral orbicularis oculi muscle plasty procedure. Group 3 showed the lowest complication rate followed by group 4, but there were no statistical differences in complication rates among the study groups. The higher aesthetic result and patient satisfaction were obtained by groups 3 and 4 (p < 0.01). Group 2 had the highest complication rate and lowest overall outcomes.

Conclusion: The authors have been able to demonstrate that lateral orbicularis oculi muscle plasty is a safe technique that may be considered a good alternative for periorbital rejuvenation and may help in avoiding lower lid incisions or extensive dissections during face lifting in some cases.

Note: I have been using a lateral suspension procedure for many years, patient outcomes have been very acceptable. Larry Weinstein, MD FACS


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 722-736
doi: 10.1097/PRS.0b013e3181b179d2
Breast: Special Topics
Partial Breast Reconstruction: Current Perspectives

Losken, Albert M.D.; Hamdi, Moustapha M.D., Ph.D.

Summary: The popularity of breast conservation therapy for the management of women with breast cancer continues to rise. To preserve cosmesis or broaden the indications for breast conservation therapy in some situations, plastic surgeons are now being challenged with the reconstruction of partial mastectomy defects. Numerous techniques exist, either at the time of resection or following radiation, and the decision of which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects in smaller breasts will often benefit from volume replacement techniques, such as local fasciocutaneous or myocutaneous flaps, without the need for a symmetry procedure. Women with moderate or larger breasts (with or without ptosis) and the potential for an unfavorable result also have the option for volume displacement procedures using local tissue rearrangement techniques to reshape the breast mound. As these are volume reduction procedures, they often require a contralateral procedure for symmetry. The extent of resection (lumpectomy versus quandantectomy) will also influence the type of reconstruction. Patient selection, surgical technique, margin status, and appropriate follow-up are crucial to maximize both oncological safety and cosmesis. The reconstruction of partial mastectomy defects will likely gain popularity as we continue to demonstrate safe and effective treatment algorithms with larger series and longer follow-up in an attempt to minimize locoregional disease and maximize cosmetic outcome.

Note: I have been doing partial breast reconstructions for years using implants, fat injections, latissimus flaps and small TRAM flaps with acceptable results. I am not a puris, I will use what I feel is best for the patient be it implant or autologous tissue. Larry Weinstein, MD FACS Chester NJ USA


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 826-835
doi: 10.1097/PRS.0b013e3181b03749
Reconstructive: Head and Neck: Original Articles

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?
McCluskey, Paul D. M.D.; Constantine, Fadi C. M.D.; Thornton, James F. M.D.

Background: A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat.

Methods: The authors conducted a retrospective analysis of 55 consecutive patients who underwent reconstruction of lower third nasal defects with full-thickness skin grafts between 2002 and 2007 performed by the senior author (J.F.T.). All of the patients in this review underwent skin cancer ablation by means of Mohs' micrographic surgery.

Results: Good aesthetic results, based on preoperative and postoperative photographic analysis of contour and pigmentation, have been achieved in both the recipient and donor sites in 52 of 55 patients. Three patients, all of whom were smokers, experienced loss of the skin graft requiring alternative reconstructive techniques.

Conclusions: Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color.
Note: It is critical with grafts or flaps to get buy in from the patient to stop smoking. I have used full thickness skin grafts, alar wedge grafts, flaps, bone and cartilage grafts for nose reconstruction.                               Larry Weinstein, MD FACS Chester NJ USA


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 926-933
doi: 10.1097/PRS.0b013e3181b03880
Cosmetic: Original Articles

National Bariatric Surgery and Massive Weight Loss Body Contouring Survey

Warner, Jeremy P. M.D.; Stacey, D Heath M.D.; Sillah, Nyama M. M.D.; Gould, Jon C. M.D.; Garren, Michael J. M.D.; Gutowski, Karol A. M.D.

Background: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons.

Methods: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed.

Results: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery.

Conclusions: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified.

Note: Abdominoplasty, buttock lifts, arm lifts, breast lifts and augmentation have all been used with some amazing results. Options should be offered to patients by competent plastic surgeons.                          Larry Weinstein, MD FACS Chester NJ USA


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 899-906
doi: 10.1097/PRS.0b013e3181b03824
Pediatric/Craniofacial: Original Articles

Current Surgical Practices in Cleft Care: Cleft Palate Repair Techniques and Postoperative Care

Katzel, Evan B. B.A.; Basile, Patrick M.D.; Koltz, Peter F. M.D.; Marcus, Jeffrey R. M.D.; Girotto, John A. M.D.

Background: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery.

Methods: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients.

Results: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons' self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely.

Conclusions: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article. Note: I prefer a one stage procedure. Careful planing and skill are keys to success. Dr. Larry Weinstein


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 919-925
doi: 10.1097/PRS.0b013e3181b0389e
Cosmetic: Original Articles

Local Complications after Cosmetic Breast Augmentation: Results from the Danish Registry for Plastic Surgery of the Breast

Hvilsom, Gitte B. M.D.; Hölmich, Lisbet R. M.D., D.M.Sc.; Henriksen, Trine F. M.D., Ph.D.; Lipworth, Loren Sc.D.; McLaughlin, Joseph K. Ph.D.; Friis, Søren M.D.

Background: Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially.

Methods: The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/displacement of the implant, hematoma, and infection.

Results: During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant.

Conclusions: Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up. Note : I recently reviewed 500 of my cases with lower complication results then are reported bu the Danes. Careful planing and skill are keys to success. Dr. Larry Weinstein


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 926-933
doi: 10.1097/PRS.0b013e3181b03880
Cosmetic: Original Articles

National Bariatric Surgery and Massive Weight Loss Body Contouring Survey

Warner, Jeremy P. M.D.; Stacey, D Heath M.D.; Sillah, Nyama M. M.D.; Gould, Jon C. M.D.; Garren, Michael J. M.D.; Gutowski, Karol A. M.D.

Background: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons.

Methods: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed.

Results: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery.

Conclusions: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified. Note; Careful planing and skill are keys to success. Dr. Larry Weinstein


Plastic and Reconstructive Surgery:
September 2009 - Volume 124 - Issue 3 - pp 706-714
doi: 10.1097/PRS.0b013e3181b17a13
Breast: Original Articles

A Detailed Analysis of the Reduction Mammaplasty Learning Curve: A Statistical Process Model for Approaching Surgical Performance Improvement

Carty, Matthew J. M.D.; Chan, Rodney M.D.; Huckman, Robert Ph.D.; Snow, Daniel Ph.D.; Orgill, Dennis P. M.D., Ph.D.

Background: The increased focus on quality and efficiency improvement within academic surgery has met with variable success among plastic surgeons. Traditional surgical performance metrics, such as morbidity and mortality, are insufficient to improve the majority of today's plastic surgical procedures. In-process analyses that allow rapid feedback to the surgeon based on surrogate markers may provide a powerful method for quality improvement.

Methods: The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2007. Multiple linear regression analyses were conducted to determine the relative impact of key factors on operative time. Explanatory learning curve models were generated, and complication data were analyzed to elucidate clinical outcomes and trends.

Results: A total of 1068 procedures were analyzed. The mean operative time for bilateral reduction mammaplasty was 134 ± 34 minutes, with a mean operative experience of 11 ± 4.7 years and total resection volume of 1680 ± 930 g. Multiple linear regression analyses showed that operative time (R = 0.57) was most closely related to surgeon experience and resection volume. The complication rate diminished in a logarithmic fashion with increasing surgeon experience and in a linear fashion with declining operative time.

Conclusions: The results of this study suggest a three-phase learning curve in which complication rates, variance in operative time, and operative time all decrease with surgeon experience. In-process statistical analyses may represent the beginning of a new paradigm in academic surgical quality and efficiency improvement in low-risk surgical procedures.
Note: Breast Reduction in my practice is an outpatient procedure of same day surgery. No breast reduction patient in 21 years has required a transfusion in my hands. Careful planing and skill are keys to success. Dr. Larry Weinstein  

Plastic and Reconstructive Surgery:
August 2009 - Volume 124 - Issue 2 - pp 629-634
doi: 10.1097/PRS.0b013e3181addc68
Cosmetic: Original Articles

Protective Effect of Topical Antibiotics in Breast Augmentation

Pfeiffer, Philip M.D.; Jørgensen, Signe M.D.; Kristiansen, Thomas B. M.D.; Jørgensen, Anna M.D.; Hölmich, Lisbet R. M.D., D.M.Sc.

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Background: Previous studies indicate that antibacterial lavage and/or use of topical antibiotics may reduce infection in breast implant surgery and perhaps also reduce occurrence of capsular contracture. A retrospective analysis was performed to evaluate this effect.

Methods: The study participants included all women (n = 436) who underwent breast augmentation during two different time periods: 2000 to 2002 (n = 218) and 2005 to 2007 (n = 218). During the first period (2000 to 2002), cephalothin (Keflin), was added to the saline/epinephrine solution, which was used to irrigate the implant pocket and filled into the outer lumen of the saline/gel implants. In the second period (2005 to 2007), only saline/epinephrine was used. All women were operated on at the same clinic and by the same surgeon. Recorded postoperative complications included occurrence of infection, seroma, and capsular contracture.

Results: Medical records were identified for 414 women (94.9 percent): 2000 to 2002 (n = 203) and 2005 to 2007 (n = 211); 99.8 percent of all implants were placed in the submuscular position and 99.8 percent of all incisions were periareolar. Frequency of infection in the 2005 to 2007 cohort (12.8 percent) exceeded substantially the frequency among the 2000 to 2002 cohort (6.7 percent; p = 0.044), as did the frequency of seroma (7.6 percent versus 2.9 percent, respectively; p = 0.036). There was no significant difference in development of capsular contraction between the two groups (8.1 percent versus 5.9 percent; p = 0.393).

Conclusion: The authors' data support the use of topical antibiotics in cosmetic breast surgery, because significant increases of both infections and seroma were seen in patients not treated with topical antibiotics compared with a cohort of similar patients where topical antibiotics were used.

Note: I have always used antibiotic irrigation for my implants prior to use and tio irrigate the pocket created for the implant. My infection rate for breast augmentation in 20 years with over 600 cases is zero. Larry weinstein, MD FACS

Combined Use of Ultrasound-Assisted Liposuction and Limited-Incision Platysmaplasty for Treatment of the Aging Neck Aesthetic Plastic Surgery

Patrick P. G. M. Rooijens1 , Hans-Peter Zweep2 and Werner H. Beekman2

Many techniques have been introduced for the surgical treatment of the aging neck. In this study the combination therapy of ultrasound-assisted liposuction and limited-incision platysmaplasty for cervicofacial rejuvenation is presented.

Fifteen female patients (age = 43–75 years) were treated for grade II–III (n = 2), III (n = 6), and grade IV (n = 7) cervicomental angle deformity. The outcome of surgery was retrospectively evaluated by a panel.

Ultrasonic energy was applied for an average of 2 min (range = 45 s–6.5 min). The mean aspiration volume was 125 ml. No immediate or delayed adjuvant skin reduction was needed in any of the patients. No complications were encountered in this series. After treatment significant improvement of the cervicomental angle was observed.

For treatment of all grades of the aging neck we advocate the combination of UAL and limited-incision platysmaplasty. This combination therapy has little morbidity and leads uniformly to significant improvement of the cervicomental angle.
Keywords  Aging neck - Liposuction - Ultrasonic - Platysmaplasy

Limited procedures on the neck will give limited results and less likely to give long term results. We have the ultrasonic liposuction machine available at Morristown Memorial in Morristown New Jersey. I have performed multiple fat reductions of fatty necks with excellent results in younger patients. However in older patients a facelift necklift or string suspension is often necessary for optimal results. Larry Weinstein, MD FACS Chester, New Jersey


Lower Eyelid Aesthetics After Endoscopic Forehead
Midface-lift James C. Marotta, MD; Vito C. Quatela, MD Arch Facial Plast Surg. 2008;10(4):267-272.

To assess and quantitate the immediate effect of endoscopic forehead midface-lift on infraorbital hollowing and lower eyelid skin excision.

Twenty-five patients who underwent an endoscopic forehead midface-lift with a lower eyelid blepharoplasty or lower eyelid blepharoplasty without a midface-lift between January 1, 2005, and May 15, 2005, were included in the study. Preoperative and immediate postoperative measurements of the vertical height of the lower eyelid were taken in all patients. The change in the vertical height of the lower eyelid after endoscopic forehead midface-lift with blepharoplasty was compared with the change in lower eyelid height after either transconjunctival or lower eyelid skin pinch blepharoplasty or skin muscle flap blepharoplasty alone. The amount of lower eyelid skin excised after endoscopic forehead midface-lift with blepharoplasty was compared with both transconjunctival or lower eyelid skin pinch blepharoplasty and skin muscle flap blepharoplasty when a midface-lift was not performed.

The average change in the vertical height of the lower eyelid after the endoscopic forehead midface-lift was 5 mm. Lower eyelid blepharoplasty alone, whether transconjunctival with skin pinch or skin muscle flap, did not affect the vertical height of the lower eyelid.
The change in the vertical height of the lower eyelid with midface surgery over blepharoplasty alone was statistically significant (P < .001). The average amount of lower eyelid skin excised after endoscopic forehead midface-lift and lower eyelid skin pinch was 7.0 mm compared with 5.5 mm for both the transconjunctival lower eyelid skin pinch and the skin muscle flap techniques. The difference in skin excision when a midface-lift was performed compared with blepharoplasty alone was statistically significant (P = .008).

The endoscopic forehead midface-lift can reduce the vertical height of the lower eyelid by an average of 5 mm and allows more skin excision over blepharoplasty alone. The endoscopic forehead midface-lift is a powerful tool for decreasing the vertical height of the lower eyelid, lessening infraorbital hollowing, and improving dermatochalasis.

Suspension of the midface can be done under direct vision through the lower or upper blepharoplasty external lateral incision. The periosteum of the lateral orbit or zygomatic bone can be used to suspend midface adipose tissue and reduce thickened nasolabial folds.
Conservative resection of lower lid skin regardless of suspension is extremely important.
Larry Weinstein,MD FACS  Chester, New Jersey


 Landmark Five-Year Data

Artes Medical recently announced the publication of positive data from a long-term safety and efficacy study of ArteFill in the December 2007 "Special Issue: Fillers" of Dermatologic Surgery, a peer-reviewed publication of the American Society for Dermatologic Surgery.

Results from the study, led by Steven R. Cohen, MD, Clinical Professor, Division of Plastic Surgery, University of California, San Diego School of Medicine, showcase the safety and aesthetic outcomes over a five-year period in patients treated with ArteFill for nasolabial fold wrinkles. This 5-year follow-up study evaluated 145 patients who were treated with ArteFill in Artes Medical's U.S. pivotal clinical trial.

In addition to demonstrating the safety profile of ArteFill, the study showed statistically significant (p less than 0.001) improvement in patient wrinkle correction 5 years after the patient's last ArteFill treatment, and a statistically significant (p=0.002) improvement in wrinkle correction at the 5-year point compared to the 6-month evaluation period.

The "Rising-Sun-Technique" in Abdominoplasty

Annals of Plastic Surgery. 60(4):343-348, April 2008.
Momeni, Arash MD; Heier, Matthias MS; Bannasch, Holger MD; Torio-Padron, Nestor MD; Stark, G Bjorn MD


A multitude of studies has been published focusing on different technical aspects of abdominoplasty. However, rarely has attention been drawn to skin closure techniques and its implications on postoperative scar length and complication rate. A retrospective analysis was conducted comparing a new comprehensive approach to skin closure with conventional techniques. Patients in each study group were matched for race, body mass index, gender, medical history, and smoking habits. We focused on postoperative scar length and rate of wound healing problems. Forty-six patients were included in each study group. Patients in whom wound closure was achieved via the technique presented here displayed a mean scar length of 33.68 cm (vs. 49.92 cm) and wound healing problems in 8.7% (vs. 23.9%). A marked reduction of scar length and postoperative wound healing problems is achievable with application of the technique presented in this article.

Note: The smile incision I have used for 20 years is hidden very well in the panty line. The length of the incision varies on the amount of tissue to be removed. A tension free closure is more important to get a barely visible scar then any other factor. Refraining from smoking is very important to get a reasonable result. Larry Weinstein, MD FACS Cosmetic plastic surgeon - Chester, New Jersey

Abdominoplasty Can Be Performed Successfully as an Outpatient Procedure With Minimal Morbidity

Annals of Plastic Surgery. 60(4):349-352, April 2008.
Chattar-Cora, Deowall MD *; Okoro, Stanley A. MD +; Barone, Constance M. MD +


Since abdominoplasty has been shown to have a positive impact on patient's self-image and quality of life, it is no surprise that the annual number of these procedures performed has continued to increase. Historically, because of concerns with patient safety the majority of these operations have been performed on an inpatient basis. The breast reduction experience has shown that with proper patient selection and operative technique, this procedure can be performed on an outpatient basis without compromising safety. We retrospectively reviewed the senior author's experience to see if abdominoplasties can be safely performed as an outpatient procedure. Forty-five patients underwent abdominoplasties as an outpatient with only 1 patient required operative reexploration; the other complications were minor wound problems that did not require operative intervention. Proper patient selection and operative technique can allow a successful abdominoplasty with minimal morbidity.

Note: I have been doing Abdominoplasty or tummy tucks on an outpatient basis for 20 years with no mortality and minimal secondary problems. Larry Weinstein, MD FACS cosmetic Plastic surgeon Chester, New Jersey

EMLA Cream Application Without Occlusive Dressing Before Upper Facial Botulinum Toxin Injection: A Randomized, Double-Blind, Placebo-Controlled Trial

Annals of Plastic Surgery. 60(4):353-356, April 2008.
Kashkouli, Mohsen Bahmani MD; Salimi, Shabnam MD; Bakhtiari, Pejman MD; Parvaresh, Mohammad Mehdi MD; Sanjari, Mostafa Soltan MD; Naseripour, Masood MD

A randomized, double-blind, placebo-controlled clinical trial was conducted among 44 subjects to assess the efficacy of EMLA cream application without occlusive dressing on pain on needling (PN) and pain on injection (PI) felt during multiple botulinum toxin type A (BTA) injections for correction of hyperkinetic upper facial lines. Mean PN score was less than PI score with high correlation and no significant difference. Although both PN and PI scores (visual analog) were less in the EMLA than placebo group, the difference was only statistically significant for PN score. Time intervals between the cream application and BTA injections beyond 60 minutes did not show lower pain score in either type of the pain.

Note: I have been using ice packs and EMLA or liocaine cream for over 10 years with strong patient appreciation. Larry Weinstein, MD FACS Cosmetic Plastic surgeon Chester NJ

Botox Euphoric effects on Nueorotoxins in the Brain

- A new scientific study on rats suggests that the anti-wrinkle treatment Botox may be able to move from the skin into the brain, degrading proteins and acting on nerves. The study, which was headed up by Matteo Caleo of the Italian National Research Council's Institute of Neuroscience, is said to show for the first time that the botulinum toxin may affect the brain.The rat study showed that only a fraction of the toxin was carried through to the proteins and nerves in the brain, with the rest remaining at the injection site.

But despite the fact that the tiny amount of toxin that was transferred to the brain area during the injection process having no noticeable affect on the rats' behaviour, Caleo said.
The study, which was published in the Journal of Neuroscience this week, entailed rats being injected with botulinum neurotoxin around the whisker muscles of the face.Three days after the injections the team assessed the impact the injections had had on the connected brain areas, finding that diluted amounts of the toxins had reached the related brain cells.
As well as having specific medical applications such as the treatment of facial ticks, Botox has seen huge worldwide growth as a non-invasive anti-wrinkle treatment.

"These findings reveal a novel pathway of botulinum trafficking in neurons and have important implications for the clinical uses of this neurotoxin," the study concluded.
Although the study findings might have some positive applications for research into the treatment of overactive brain neurons.

Note: The Italians of the Nueoroscience Institute of Pisa are clearly working on full tilt. They have found that nueroreceptors in the brain have been affected by Botox without affecting the animal behavior.  Could it be the receptors are effected by the muscle relaxation of nerve receptors to the muscles in the face? No mortality or significant observable effects were noted other then the paralysis of movement of the rat whiskers. Are rats more attractive if they can't move their whiskers? Certainly elimination of crow's feet, 11 lines, smoking lip lines among others make the brains of over a 1000 of my patients feel better, even euphoric.
Larry Weinstein,MD FACS

Assessment of Breast Aesthetics

Plastic & Reconstructive Surgery. 121(4):186e-194e, April 2008.
Kim, Min Soon M.S.; Sbalchiero, Juliano C. M.D.; Reece, Gregory P.
M.D.; Miller, Michael J. M.D.; Beahm, Elisabeth K. M.D.; Markey, Mia K.

Summary: A good aesthetic outcome is an important endpoint of breast cancer treatment. Subjective ratings, direct physical measurements, measurements on photographs, and assessment by three-dimensional imaging are reviewed and future directions in aesthetic outcome measurements are discussed. Qualitative, subjective scales have frequently been used to assess aesthetic outcomes following breast cancer treatment. However, none of these scales has achieved widespread use because they are typically vague and have low intraobserver and interobserver agreement. Anthropometry is not routinely performed because conducting the large studies needed to validate anthropometric measures (i.e., studies in which several observers measure the same subjects multiple times) is impractical. Quantitative measures based on digital/digitized photographs have yielded acceptable results but have some limitations. Three-dimensional imaging has the potential to enable consistent, objective assessment of breast appearance, including properties (e.g., volume) that are not available from two-dimensional images. However, further work is needed to define three-dimensional measures of aesthetic properties and how they should be interpreted.
(C)2008American Society of Plastic Surgeons

Note: Breast aesthetics or cosmetic results are extremely subjective measures. More important then objective analysis is patient satisfaction. It is most important to satisfy the patient needs which are related to breast symmetry, Breast cup size, breast shape and how natural they look and feel and proportional to the rest of the body proportions. Patient satisfaction should also focus on number of procedures to get to an acceptable outcome as well as well as down time, morbidity and mortality. Larry Weinstein,MD FACS board certified plastic surgeon Chester, New Jersey

Treating the Abdominotorso Region of the Massive Weight Loss Patient: An Algorithmic Approach.

Plastic & Reconstructive Surgery. 121(4):1431-1441, April 2008.
Wallach, Steven G. M.D.


Summary: There has been tremendous growth in the number of patients seeking body contouring procedures after massive weight loss. Most patients desire improvement of the abdominotorso region first. After massive weight loss, there is enormous variability of body proportions, and therefore there have been many surgical options proposed based on the quality of the skin, subcutaneous fat component, and location of the lax tissue. Each area needs to be assessed to see whether there is a significant lower abdominal component, an upper midline abdominal component, or contributions from the buttocks and flanks. An algorithm for treatment is presented to simplify the decision-making process.  Patient examples are also shown to demonstrate the usefulness of the algorithm.
(C)2008American Society of Plastic Surgeons

Note: Assessing the skin texture, underlying fascia and adjacent tissue components are critical to acceptable results. Taking into account proportions, excess adjacent skin and planning appropriate length procedures are critical to safe results. The real risk of deep venous thrombosis ( leg clots) and pulmonary emboli must be explained to these patients.  The algorithm as explained is an acceptable method that may help some junior surgeons approach these cases.  Larry Weinstein,MD FACS board certified plastic surgeon Chester, New Jersey


Advances in Facial Rejuvenation: Botox, Hyaluronic Dermal Fillers, and Combinations--Consensus Recommendations

COSMETIC  Plastic & Reconstructive Surgery. 121(5) SUPPLEMENT:5S-30S, May 2008.
Carruthers, Jean D. A. M.D.; Glogau, Richard G. M.D.; Blitzer, Andrew M.D., D.D.S.; the Facial Aesthetics Consensus


Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures, and patient demographics.  Clinicians can tailor treatments to individual patients, treating multiple facial areas, and using combinations of products to optimize outcomes. Methods: A multidisciplinary group of aesthetic people convened to review the uses of botulinum toxin type A (BoNTA) and hyaluronic acid fillers and to update consensus recommendations for facial rejuvenation using these two types of products. The group considered paradigm shifts in facial aesthetics; optimal techniques for using BoNTA and hyaluronic acid fillers alone and in combination; the influence of patient sex, ethnicity, cultural ideals, and skin color on treatment; general techniques; patient education and counseling; and emerging trends and needs in facial rejuvenation.
Results: The group provided specific recommendations by facial area, focusing on relaxing musculature, restoring volume, and recontouring using BoNTA and hyaluronic acid fillers alone and in combination. For the upper face, BoNTA remains the cornerstone of treatment, with hyaluronic acid fillers used to augment results. These fillers are central to the midface because of the need to restore volume. BoNTA and hyaluronic acid in combination can improve outcomes in the lower face.  Conclusions: Optimal outcomes in facial aesthetics require in-depth knowledge of facial aging and anatomy, an appreciation that rejuvenation is a three-dimensional process involving muscle control, volume restoration, and recontouring, and thorough knowledge of properties and techniques specific to each product in the armamentarium.

Note: This appears to be an Allergan picked panel. radiesse and Artefil are other alternatives for fillers that offer advantages over hyaloronics in some cases. Surgical ablation of muscles that cause wrinkles is ignored but very effective in many cases. Resurfacing by peels via acids or LASER are another alternative to help control wrinkles.
Larry Weinstein, MD FACS board certified plastic surgeon Chester, New Jersey


The Influence of Forehead, Brow, and Periorbital Aesthetics on Perceived Expression in the Youthful Face.
COSMETIC Plastic & Reconstructive Surgery. 121(5):1793-1802, May 2008.
Knoll, Bianca I. M.D.; Attkiss, Keith J. M.D.; Persing, John A. M.D.


The purpose of this study was to characterize the relative influence of eyebrow position and shape, lid position, and facial rhytides on perceived facial expression as related to blepharoplasty, with a specific focus on the perception of tiredness.  Methods: A standardized photograph of a youthful upper face was modified using digital imaging software to independently alter a number of variables: brow position/shape, upper/lower lid position, pretarsal show, and rhytides. Subjects (n = 20) were presented with 16 images and asked to quantify, on a scale from 0 to 5, the presence of each of seven expressions/emotions as follows: "surprise," "anger," "sadness,"
"disgust," "fear," "happiness," and "tiredness." 

Statistically significant values for tiredness were achieved by changes of increasing and decreasing the pretarsal skin crease, lowering the upper eyelid, and depressing the lateral brow. Happiness was perceived by elevation of the lower lid or the presence of crow's feet. Brow shape had a greater influence than absolute position on perceived expression. Elevation of the lateral brow was perceived as surprise, whereas depression of the medial brow and rhytides at the glabella were perceived as anger and disgust. Elevation of the medial brow elicited a minimal increase for sadness.

This study showed that the perception of tiredness is most affected by the length of pretarsal lid height (e.g., ptosis).  Surprisingly, simulating the skin resection of an upper blepharoplasty results in a paradoxical increase in the perception of tiredness as well. Modifications of brow contour elicit profound changes in perceived facial mood to a greater degree than absolute brow position.(C)2008American Society of Plastic Surgeons
Note: Extreme elevation of the brow is to be avoided, it gives a surprised look. However hooding can be corrected with a brow lift.   Finesse in this operation is critical to a well received outcome.  Larry Weinstein,MD FACS board certified plastic surgeon Chester, New Jersey

Outcomes After Breast Reduction: Does Size Really Matter?
Annals of Plastic Surgery. 60(5):505-509, May 2008.
Spector, Jason A. MD *; Singh, Sunil P. BA +; Karp, Nolan S. MD ++

There is no doubt that reduction mammoplasty (RM) results in significant improvement in a myriad of patient macromastia-related symptoms and other macromastia-related quality of life factors. Whether this improvement is correlated with the amount of tissue resected remains unknown because no previous study of RM has stratified patients by the amount of breast tissue resected. In this study, all patients were given a custom-designed questionnaire designed to evaluate their macromastia-related symptoms and other macromastia-related quality of life issues. Patients were then provided the same questionnaire at their final postoperative visit between 3 and 12 months after surgery. A total of 188 patients completed pre- and postoperative surveys. Before the initiation of this study, patients were stratified by the total weight of breast tissue resected into the following cohorts: 1000 g or less (66 patients), 1001 to 1500 g (55 patients), 1501 to 2000 g (30 patients), and greater than 2000 g (37 patients). RM resulted in significant improvement in all macromastia-related symptoms and quality of life factors analyzed (P < 0.000001). There were no significant differences (P > 0.05) in pre- and postoperative macromastia-related symptoms across our 4 groups with the exception of lower back pain (preoperative P = 0.026), shoulder pain (preoperative P = 0.014), and painful bra strap grooves (preoperative P = 0.0059). Analysis of the symptomatic burden of macromastia on several quality of life factors showed no significant differences (P > 0.05) in either the pre- or postoperative symptom scores across all groups in any of the categories assessed. This study demonstrates that women seeking breast reduction have a similar preoperative symptom burden across a wide range of breast sizes. Furthermore, the symptomatic improvement derived from RM is not significantly different between women of different breast sizes.

Improving Esthetics and Safety in Abdominoplasty With Broad Lateral Subcostal Perforator Preservation and Contouring With Liposuction
Annals of Plastic Surgery. 60(5):491-497, May 2008.
Kolker, Adam R. MD, FACS

Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.


Should a Panniculectomy/Abdominoplasty After Massive Weight Loss Be Covered by Insurance?
Annals of Plastic Surgery. 60(5):502-504, May 2008.
Sati, Shawkat MD; Pandya, Sonal MD

Body contouring after massive weight loss (MWL) is a rapidly growing area in Plastic Surgery. Panniculectomy/abdominoplasty is primarily a cosmetic procedure with some functional benefits (a large pannus may hamper mobility, prevent further weight loss, and cause recurrent skin infections) and hence many insurance companies are changing their guidelines to include this as a medical procedure. This study assesses reimbursements for a large academic institution in Massachusetts for panniculectomies/abdominoplasties performed in MWL patients. We performed a retrospective review of charges and reimbursements for panniculectomy/abdominoplasty in MWL patients performed at Lahey Clinic. Records for patients who underwent a "medical" panniculectomy by a single surgeon from August 2002 to August 2006 were reviewed with special emphasis on the charges, reimbursements, insurance carriers, and prior preauthorizations. Fifty-two patients underwent a medical panniculetomy/abdominoplasty (Current Procedural Terminology code 15831) for laxity of skin/pannus as a result of MWL. All patients except Medicare required and obtained precertification for the procedure. Patient ages ranged from 35 to 59 years, which included 42 females and 10 males (n = 52). Forty-three underwent bariatric surgery; their procedures were performed between 13 and 62 months after their initial surgery. Weight loss ranged from 65 to 345 pounds. Body mass index at the time of the surgery ranged from 22 to 48. The standard surgical charge for a medical panniculectomy at Lahey Clinic is $3,086. The range of reimbursements was zero to the full amount with the mean reimbursement of $615 and the median being $899. Reimbursements for panniculectomies are remarkably low and in many instances (35% in our series) absent despite obtaining prior precertification of medical necessity. Although insurance companies have extended their indications for panniculectomy/abdominoplasty, we think that it is a cosmetic procedure. Plastic surgeons must bear these reimbursements in mind when faced with a patient requesting this. (C) 2008 Lippincott Williams & Wilkins, Inc.


The Retaining System of the Face: Histologic Evaluation of the Septal Boundaries of the Subcutaneous Fat Compartments

Plastic & Reconstructive Surgery. 121(5):1804-1809, May 2008.
Rohrich, Rod J. M.D.; Pessa, Joel E. M.D.


Background: Because the concept of subcutaneous fat compartments has many significant implications for cosmetic and reconstructive surgery, it is important to verify the original findings and validate the concept. The authors studied the histology of the septal boundaries between several adjacent fat compartments.

Methods: Eighteen hemifacial cadaver specimens were used (five male and four female cadavers; age range, 39 to 87 years). Tissue marking dye was injected into the central forehead and the medial, middle, and lateral temporal cheek compartments. Dye was allowed to diffuse for 4 hours until a skin blush was noted, at which point dye-setting solution was injected to fix the dye. En bloc transverse specimens were harvested and stored in formalin overnight. Standard histologic processing was performed.

Results: Each compartment partitioned dye in a consistent and reproducible manner. A fibrous condensation of connective tissue formed the diffusion barriers. These septa originated from underlying fascia and inserted into the dermis of the skin. A septal barrier originated from the fascia of the frontalis muscle, so these septal barriers are not necessarily related to the superficial musculoaponeurotic system but can occur anywhere between superficial fascia and skin.

Conclusions: These findings support the concept that subcutaneous fat is compartmentalized, specifically by fascial condensations that travel from superficial fascia to dermis. These septa form an interconnecting framework that limits shearing forces on the face. This framework provides a "retaining system" for the human face. Implicit in this concept is the suggestion that the face ages three dimensionally, with separate compartments changing relative to one another by both position and volume.

(C)2008American Society of Plastic Surgeons

The Influence of Forehead, Brow, and Periorbital Aesthetics on Perceived Expression in the Youthful Face.

Plastic & Reconstructive Surgery. 121(5):1793-1802, May 2008.
Knoll, Bianca I. M.D.; Attkiss, Keith J. M.D.; Persing, John A. M.D.


Background: The purpose of this study was to characterize the relative influence of eyebrow position and shape, lid position, and facial rhytides on perceived facial expression as related to blepharoplasty, with a specific focus on the perception of tiredness.

Methods: A standardized photograph of a youthful upper face was modified using digital imaging software to independently alter a number of variables: brow position/shape, upper/lower lid position, pretarsal show, and rhytides. Subjects (n = 20) were presented with 16 images and asked to quantify, on a scale from 0 to 5, the presence of each of seven expressions/emotions as follows: "surprise," "anger," "sadness," "disgust," "fear," "happiness," and "tiredness."

Results: Statistically significant values for tiredness were achieved by changes of increasing and decreasing the pretarsal skin crease, lowering the upper eyelid, and depressing the lateral brow. Happiness was perceived by elevation of the lower lid or the presence of crow's feet. Brow shape had a greater influence than absolute position on perceived expression. Elevation of the lateral brow was perceived as surprise, whereas depression of the medial brow and rhytides at the glabella were perceived as anger and disgust. Elevation of the medial brow elicited a minimal increase for sadness.

Conclusions: This study showed that the perception of tiredness is most affected by the length of pretarsal lid height (e.g., ptosis). Surprisingly, simulating the skin resection of an upper blepharoplasty results in a paradoxical increase in the perception of tiredness as well. Modifications of brow contour elicit profound changes in perceived facial mood to a greater degree than absolute brow position.

(C)2008American Society of Plastic Surgeons


Outcome Analysis of Combined Lipoabdominoplasty versus Conventional Abdominoplasty

Plastic & Reconstructive Surgery. 121(5):1821-1829, May 2008.
Heller, Justin B. M.D.; Teng, Edward B.S.; Knoll, Bianca I. M.D.; Persing, John M.D.


Background: Abdominoplasty and liposuction have traditionally been separate procedures. The authors performed a retrospective cohort study to evaluate the outcomes of a novel single-stage approach combining extensive lipoplasty with a modified transverse abdominoplasty.

Methods: One hundred fourteen patients were evaluated for abdominal contouring. Patients were categorized into four groups: group I (n = 20) received abdominal liposuction only, group II (n = 33) traditional W-pattern incision line abdominoplasty, group III (n = 30) modified transverse incision abdominoplasty, and group IV (n = 31) combined procedure involving widely distributed abdominal liposuction accompanied by inverted V-pattern dissection abdominoplasty. Wound complications, patient satisfaction, and revision rates were compared statistically.

Results: Group I (liposuction alone) experienced an overall complication rate of 5 percent; two patients were dissatisfied (10 percent) and underwent further revision with full abdominoplasties. Group II (traditional W-pattern abdominoplasty) had a complication rate of 42 percent, a dissatisfaction rate of 42 percent, and a revision rate of 39 percent. By comparison, group III (modified low transverse abdominoplasty) had a complication rate of 17 percent, a dissatisfaction rate of 37 percent, and a revision rate of 33 percent. Group IV (combined liposuction plus abdominoplasty) had significantly lower complication, dissatisfaction, and revision rates (9, 3, and 3 percent, respectively).

Conclusions: Modified transverse abdominoplasty combined with extensive liposuction and limited paramedian supraumbilical dissection produced fewer complications and less dissatisfaction than did traditional abdominoplasty. This may be attributable to a reduced tension midline closure in the suprapubic region, less lateral undermining in the upper abdomen, and greater preservation of intercostal artery blood flow to the flap.

(C)2008American Society of Plastic Surgeons

Wound Infections in Aesthetic Abdominoplasties: The Role of Smoking.


Plastic & Reconstructive Surgery. 121(5):305e-310e, May 2008.
Araco, Antonino M.D.; Gravante, Gianpiero M.D.; Sorge, Roberto M.D.; Araco, Francesco M.D.; Delogu, Daniela; Cervelli, Valerio M.D.

Background: In this prospective study, the authors followed patients who underwent aesthetic abdominoplasty to determine the influence of smoking on the occurrence of postoperative wound infections.

Methods: Patients who underwent aesthetic abdominoplasty were considered eligible for the study. The authors excluded postbariatric patients, those with ongoing clinical infections, those receiving a recent antibiotic course, and those with systemic diseases such as arteriosclerosis and diabetes mellitus. Smokers were advised to quit smoking at least 4 weeks before surgery.

Results: Starting in February of 2004, the authors enrolled 84 patients. Postoperative infections were present in 13 patients (15.5 percent) and were superficial in 10 (77 percent). All but one occurred in smokers. These had a certain number of cigarettes smoked per day, years of smoking, and higher estimated overall number of smoked cigarettes when postoperative infections were present. The relative risk of smoking on infections was 12. A cutoff value of approximately 33,000 overall cigarettes smoked determined 3.3 percent false-positive and 0 percent false-negative rates.

Conclusions: Smoking is an important issue in aesthetic surgery that needs to be accurately addressed during the preoperative interview. In the future, the analysis of smoke-related, easy-to-gather variables such as the estimated overall number of cigarettes smoked until surgery could help stratify patients according to their risk of manifesting infections.

(C)2008American Society of Plastic Surgeons

Maturation of the Human Scar: An Observational Study.
Plastic & Reconstructive Surgery. 121(5):1650-1658, May 2008.
Bond, Jeremy S. M.R.C.S. (Ed.); Duncan, Jonathan A. L. M.R.C.S.(Ed.); Sattar, Abdul Ph.D.; Boanas, Adam B.Sc.; Mason, Tracey Ph.D., C.Stat.; O'Kane, Sharon B.Sc. (Hons.), Ph.D.; Ferguson, Mark W. J. D.D.S., Ph.D.

Background: The natural history of scar maturation in humans has never been formally described from either a clinical or a histologic standpoint. Methods: The maturation of incisional scars was observed in 58 healthy male volunteers who each had 2 x 1-cm incisional wounds created on the inner aspect of both upper arms. The resulting scars were photographed digitally at monthly intervals for 12 months and excised for histologic analysis at specific time points. All histologic specimens were stained using Masson's trichrome and reviewed together with the corresponding digital clinical scar images to produce macroscopic and microscopic descriptions of the maturation process. Results: Three distinct groups, each displaying a different rate of longitudinal progression of scar maturation, were identified from within the study group. The majority of volunteers belonged to a "representative" subset but distinct "poor" and "excellent" subsets were also identified. The poor subset invariably contained volunteers younger than 30 years of age, whereas the majority of the excellent subset comprised subjects older than 55 years of age. Conclusions: Scar maturation occurs as a series of defined macroscopic and microscopic stages over the course of 1 year. The rate of scar maturation varied within the study group, with older subjects (>55 years) displaying accelerated maturation, whereas a prolonged high turnover state and a retarded rate of maturation were observed in younger subjects (<30 years).
(C)2008American Society of Plastic Surgeons

Note: Estrogen and other hormonal influences cannot be underestimated in their effects on wound healing. Older patients do better then younger patients. Maturation of scars can take 2 years. Redness can last 2 years as well. Larry Weinstein, MD FACS Chester, New Jersey

The Tripod Theory of Nasal Tip Support Revisited The Cantilevered Spring Model
Richard W. Westreich, MD; William Lawson, MD, DDS              Arch
Facial Plast Surg. 2008;10(3):170-179.

Objective:  To extrapolate on the tripod concept to create a more universal and multiethnic model that includes common anatomical configurations and strategies to avoid certain unwanted surgical outcomes.
Methods  Analysis of current surgical methods, scientific studies, and predominant theories to produce a new model of nasal tip support based on the biomechanical properties of the nasal cartilages.
Results  The nasal tip acts as a cantilevered spring that associates with other rigid and semirigid regions of the nose. Application of these concepts resulted in preservation of projection and tip rotation in appropriately selected patients.

Conclusion:  The cantilevered spring tripod provides a more universal model for explaining nasal tip dynamics in a contemporary multiethnic population of patients seeking functional or cosmetic rhinoplasty correction.

Note:  A new technique I have been using is a Quill suture applied to the lower lateral cartilages of the tip that would thin the tip and give it more projection. This technique I have developed will be submitted for publication shortly.

A Clinical Review of Total Body Lift Surgery
Aesthetic Surgery Journal, 05/28/08

Hurwitz DJ et al. - TBL is customized for individuals who desire a comprehensive approach to improvement of their loose skin. The rate of complications was high and comparable to other published series. There was no difference between the complications of the single-and two-stage patients. While there was an observable reduction in deformity and a high rate of satisfactory aesthetic outcomes, this high number of complications indicates a need to improve clinical performance.

Note: Body lift surgery has potential complications that must be understood by candidates requesting these procedures. I tend to be more conservative then Dr. Hurwitz. I prefer to do one sided surgery at a time. Larry Weinstein, MD FACS board certified plastic surgeon Chester, New Jersey

Facial Dermal Fillers: Selection of Appropriate Products and Techniques
Steven H. Dayan MD & Benjamin A. Bassichis MD
Accepted 6 March 2008.  Available online 15 May 2008

Over the last decade, there has been a shift in the way aesthetic surgeons approach facial rejuvenation. With recognition of the value of volume enhancement in achieving a more youthful appearance, as well as the ease of office procedures offering minimal downtime and predictable results, there has been a concomitant explosion in the soft tissue filler market. Given the vast array of filler products currently available, the decision of which facial filler to use in specific situations can be complicated and confusing. A physician's selection of facial filler(s) should be based on a solid understanding of the various filler products, appropriate patient selection, and the physician's proficiency in injection techniques. We present a review of the most widely used fillers, offering guidance on patient selection and effective injection techniques.

Note: Facial fillers and the aging process are very important as an adjunct for facial rejuvenation. The key is Selecting the Most Appropriate Filler. Considerations to the following Products is given by Larry Weinstein, MD FACS board certified plastic surgeon at morristown Memorial in Morristown New Jersey.

Hyaluronic Acids last 6 to 12 months
Calcium Hydroxylapatite lasts 1 to 2 years
Collagen-Based Products 1 to 3 months
Silicone not safe
Polymethylmethacrylate lasts 2 to 5 years
Poly-L-lactic acid for AIDS
Fat Transfer unpredictable

Facial Rejuvenation with SMASectomy and FAME Using Vertical Vectors
Aesthetic Plastic Surgery Wednesday, May 28, 2008
Ruth Graf, Anne Karoline Groth, Daniele Pace and Lincoln Graça Neto

(1)  Department of Plastic and Reconstructive Surgery, Federal University of Parana and Pietà Medical Center, Rua Solimoes 1175, Curitiba, PR, 80810-070, Brazil

Received: 3 March 2008  Accepted: 18 April 2008  Published online: 28 May 2008

Abstract:  The quest for better results in the midface after a face lift has led to the repositioning of a structure called the malar fat pad. Finger-assisted malar elevation (FAME) consists of detaching the malar fat pad from the underlying SMAS, which allows for the elevation of this structure. Two hundred five patients (189 females and 16 males) from January 2002 to August 2007 underwent a facial rejuvenation procedure comprising short-scar rhytidoplasty, SMASectomy, and FAME, with or without a simultaneous endobrow, blepharoplasty, and lipofilling. The midface fixation technique consisted of a stitch from the malar fat pad and SMAS flap to the periosteum at the zygomatic arch which was performed in every case. Elevation of the midface and improvement of the nasolabial fold and the mandible contour were obtained in all cases. Facial aging should be evaluated as a global process instead of a segmented one. Aging occurs in every structure of the face in different ways, depending on the vector of descent, thereby treatment must be individualized. We have observed improvement of the midface when using the FAME procedure in a rhytidoplasty with SMASectomy with deep fixation.

Predicting the Results of Rhinoplasty Before Surgery: Easy Noses versus Difficult Noses
Canadian Journal of Plastic Surgery - Original Articles Summer 2008, Volume 16 Issue 2: 69- 75
N Fanous, VJ Brousseau, N Karsan & A Fanous

A major problem for many rhinoplastic surgeons is the ability to predict, before surgery, the difficulty of the procedure (whether the rhinoplasties will be technically easy or technically difficult to perform) and the success rate of the result (whether the rhinoplasty will likely give good results or poor ones).

The present paper outlines a systematic approach to nasal analysis, allowing the surgeon to consistently estimate, before surgery, the degree of technical difficulty of each rhinoplasty, as well as predicting its future result in terms of patient satisfaction. This preoperative evaluation is based on the analysis of the skin texture and the osteo-cartilagenous framework on lateral and frontal views. It allows for the nose to be classified as green (easy), yellow (moderate) or red (difficult), depending on two factors: the degree of surgical difficulty and the expected patient's satisfaction with the result.

The essence of the present paper is to introduce a simple, systematic approach to assist the novice rhinoplastic surgeon to assess the complexity, the risks and the expected outcome of a rhinoplasty in the preoperative period, rather than postoperatively.

Note: Rhinoplasty or nosejob can often have a predictable outcome based on the supporting structures, 3 dimensional relationship and covering skin. Some rhinoplasty cosmetic surgery is more difficult then others.The thicker the skin and the more oil prouduced the more difficult the outcome. Postoperative swelling is common and the result often cannot be assessed until one year after surgery. Larry Weinstein,MD FACS Chester, New Jersey

Considering plastic surgery? Check credentials Updated 11/20/2007 7:18 AM | Donda West, the mother of hip-hop star Kanye West, died the day after having cosmetic surgery. The case is still under investigation.

By Rita Rubin, USA TODAY

Sometimes, says physician Stephen Miller, people spend more time and effort shopping around for a car mechanic than they do for a plastic surgeon.
The death of rapper Kanye West's mother, Donda West, on Nov. 10 serves as a reminder that cosmetic surgery is not merely a beauty treatment, so patients need to examine doctors' qualifications before choosing a surgeon, medical experts say. West, 58, died a day after having cosmetic surgery in Los Angeles.

An autopsy has been performed on West, but the cause of death has been "deferred" pending the results of additional toxicology tests, which won't be available for five or six weeks, Fred Corral, a spokesman for the Los Angeles coroner's investigation division, said Monday.

A spokesman for plastic surgeon Jan Adams told the Associated Press that Adams, who has appeared on Oprah and had his own series on Discovery Health, operated on West.

A quick check of information available on the Internet showed that Adams is not board-certified and that the Medical Board of California is seeking to revoke or suspend his license to practice because of multiple criminal convictions for alcohol-related offenses. The medical board filed a complaint against Adams in April, months before West's surgery.

Noone's board is one of 24 that make up the American Board of Medical Specialties, or ABMS, of which Miller is president and CEO. "Probably 85% of all licensed U.S. physicians are certified by one of our boards," Miller says.

Besides Noone's board, three ABMS boards require plastic surgery
training: the American Board of Otolaryngology, the American Board of Ophthalmology and the American Board of Dermatology.

To become certified by the American Board of Plastic Surgery, doctors must complete a minimum of five years' residency training, including three years in basic surgery and at least two in plastic surgery, Noone says. They must also have letters of recommendation and hospital privileges and pass an examination.

"You want to know all kinds of things about the doctor, but, at the very least, you want to make sure that doctor is certified by an ABMS board and is concentrating on an area you want him to be concentrating on," Miller says. So even if doctors are board-certified, make sure they are certified by the relevant board. For example, Miller says, board-certified ophthalmologists are trained in eyelid surgery but not tummy tucks.

To see whether a doctor is certified by an ABMS board, call 866-ASK-ABMS or log onto

Note: Physicians without appropriate training cannot become board certified in Plastic Surgery. Many physicians with little formal experience and training in cosmetic plastic surgery are setting up shop and holding themselves up as plastic surgeons. I know of a dermatologist who holds himself out as a plastic surgeon with less then acceptable results on an observed basis. There are high risk gynecologists who are abandoning obstetrics to attempt cosmetic surgery. Someone maybe board certified in ENT or Gynecology which in no way implies they have expertise in Plastic or Cosmetic surgery.
Always check credentials to be certain a physician is board certified in the area you plan on being cared for, especially plastic surgery.
Larry Weinstein,MD FACS

Temporal and Demographic Factors Influencing the Desire for Plastic Surgery after Gastric Bypass Surgery.

Plastic & Reconstructive Surgery. 121(6):2120-2126, June 2008.
Gusenoff, Jeffrey A. M.D.; Messing, Susan M.A., M.S.; O'Malley, William M.D.; Langstein, Howard N. M.D.

An increasing number of gastric bypass patients desire plastic surgery after massive weight loss. However, the timing of interest and factors influencing the desire for body contouring have not been studied.

Methods: Two thousand five hundred one gastric bypass patients were surveyed. Outcome measures included years since gastric bypass, laparoscopic versus open procedures, body mass indexes, income, prior plastic surgery, desire for body contouring, and need for a payment plan. Multiple variables were assessed by univariate and multivariate analysis.

Results: Nine hundred twenty-six patients (817 women and 109 men; mean age, 47.2 years) responded. Eight hundred eleven patients were considering body contouring: 685 patients (84.5 percent) desired body contouring after gastric bypass and 126 wanted no further surgery (15.5 percent). Desire was inversely related to age (p < 0.0001), years since gastric bypass (p = 0.052), and open versus laparoscopic gastric bypass (p = 0.04), but was two times more likely in women (p = 0.008) and divorced versus married individuals (p = 0.04). Patients desiring a payment plan were younger (p = 0.0210) and had lower post-gastric bypass body mass indexes (p = 0.007). Age was inversely related to desire for a payment plan but directly related to the inability to afford or lack of desire for body contouring (p = 0.02).
Conclusions: A majority of post-bariatric surgery patients desire body contouring; younger, divorced, female patients who had laparoscopic gastric bypass voiced the strongest interest in body contouring. Thus, efforts should be directed toward facilitating body contouring in this subpopulation because they appear the most motivated.

Note: Many patients with over 100 pound weight loss have benefited from full abdominoplasties, extended abdominoplasty tummytuck, full body lift, arm lifts, facelift and thigh lift in my hands. Providing good health is exhibited a safe procedure is possible in an appropriate safe environment. Larry Weinstein, MD FACS Chester, New Jersey

Calf Augmentation with Autologous Tissue Injection.

Plastic & Reconstructive Surgery. 121(6):2127-2133, June 2008.
Erol, O Onur M.D.; Gurlek, Ali M.D.; Agaoglu, Galip M.D.

Lean or asymmetric calves may cause body image problems.
These deformities can be corrected by inserting a silicone calf prosthesis or silicone injection, and also through the use of an autologous fat or tissue cocktail.

Methods: Thin and asymmetric parts of the leg are marked while the patient is standing. Depressed areas are observed at the anteromedial part of the tibia from the knee to the ankle. Fat tissue harvested under general anesthesia, using a syringe and a 4-mm cannula, is centrifuged to eliminate blood and lipids, antibiotic is added, and small amounts of fat grafts are injected into different layers using a cannula 15 or 26 cm in length and 3 mm in diameter. For the preparation of the tissue cocktail, tissue (dermis, fascia, fat) was cut into very small pieces measuring 0.5 mm to be passed through 16-gauge needles.
The amount injected depends on the severity of deformity and the size of the legs. Rather than overcorrecting, injections are repeated if necessary, two to four times at 3-month intervals.

Results: Between 1992 and 2003, 77 patients underwent calf augmentations with autologous fat and tissue cocktail injections, with follow-up from 1 to 8 years. Outcome was satisfactory in most patients, with moderate improvement in 10 patients (13 percent) and good improvement in 67 (87 percent). In 12 patients, small irregularities or asymmetries were seen after the first injection and were corrected with a second injection. No infection was reported in any case.

Conclusion: Autologous augmentation and shaping offers scar-free, long-lasting results, with no late complications, and with the possibility of touch up.
(C)2008American Society of Plastic Surgeons Note Fat injection maybe better tolerated then silicone implant calf augmentation. Larry Weinstein,MD FACS

Abdominoplasty with two fusiform plications
Journal Aesthetic Plastic Surgery
Publisher Springer New York
ISSN 0364-216X (Print) 1432-5241 (Online)
Issue Volume 20, Number 3 / May, 1996

Américo Marques1, Elizabeth Brenda1, Max Domingues Pereira1, Myrian de Castro1 and Antonio Carlos Abramo1

Abstract:  Two-fusiform plications are recommended for contouring the abdomen to produce a slimmer waistline in abdominoplasty, rather than the classical median xiphoid-pubic fusiform plication. This procedure was accomplished in 11 patients. After the dermoadipose flap was undermined, two fusiform shapes were marked at the transition of the sheaths of the rectus abdominis muscles with the external obliques. The slimmer waistline produced intraoperatively was maintained during the late postoperative period (mean 20 months), without loss of the natural contour between the rectus muscles. Maintenance of the natural contours of the abdominal muscles is of fundamental importance to reduce the embarrassment of a postabdominoplasty flat abdomen. Key words  Plastic surgery - Abdominoplasty - Abdominal wall

Note: There are 10 to 20 examples of abdominoplasty results on my websites which involve plication of the diastasis rectus and tightening the musculopaoneurotic fascia. The actual technique described is interesting not applicable to all cases. Larry Weinstein MD FACS a board certified plastic surgeon practicing cosmetic surgery in Chester, New Jersey and Chief of Plastic Surgery at Morristown Memorial Hospital in Morristown New Jersey.

Who should get gastric banding? 
By Martin Hutchinson 

Fern Britton has shed three stone since the band was fitted Television presenter Fern Britton has caused controversy after it was revealed that her recent weight loss followed a "gastric band" operation, and was not simply down to dieting and exercise.

But how does a gastric band work, who should receive them, and is there still a stigma attached?

For some obese people, attempts at conventional dieting and exercise will fail, and their weight means a far higher risk of health problems later in life.

It is at this point that their doctor may suggest gastric banding.

The principle is a simple one. Most people eat when they feel hungry, and when their stomachs are full, they stop.

A fluid-filled balloon is clipped around the upper end of the stomach with a band. This restricts the flow of food into the lower stomach, making the patient feel full sooner. The band can be adjusted via the reservoir which is sited beneath the skin.

The operation leaves a silicone loop tightened about three-quarters of the way up the stomach, creating a much smaller space at the top, with a tiny gap leading to the rest of the stomach.

Much less food is needed to fill up this little "pouch" at the top, at which point the person feels full.

The "pouch" then slowly empties through the gap into the rest of the stomach, and appetite returns.

Dr Ian Campbell, Medical Director of the charity Weight Concern, said: "If you reduce the volume of food you can comfortably put in your stomach, you'll eat less."

The NHS does offer gastric banding, but many people choose to have the operation privately, at a cost of around £7,000.

On average, people will lose up to 50% of their excess weight in the two years after they have one, almost immediately cutting the risk of diabetes, heart disease or high blood pressure.

But it is not recommended to all obese people - guidelines from the National Institute of Clinical Excellence say that it should be considered only after other, non-surgical solutions, have been fully exhausted, and patients need to be free of psychological problems, and receive the correct advice and counselling.

New lifestyle

The reason it is not recommended to all overweight people are the small, but significant risks of having a band, which are normally balanced against the health risks of obesity.

BBC Breakfast discussion on the issue of gastric bands.

Although the band is normally placed using "keyhole" surgery, having a general anaesthetic still carries a risk, especially to an obese patient. There is also the chance of infection, or a problem with the band, such as leakage, which will require a second operation to correct.

Dr Campbell insists it is no easy option. Patients will need to change what they eat - the new stomach shape may not cope well with food which comes in large chunks, causing vomiting, and lavish dinner parties may be a thing of the past.

"You need to break off your love affair with food. You simply can't sit down to a three course meal with your friends any more."

Despite that, the stigma remains, despite the fact that thousands of gastric banding operations are carried out each year in the UK.

Fern Britton chose to keep her operation private, and was criticised for doing so by newspaper columnist Carole Malone.

 I'm of the opinion that no-one should need that drastic an intervention

Dr Funke Baffour

"She is a public persona, but she is making money out of her weight. She also has made a career out of being a trustworthy person - a person that people look up to.

"She shares lots of parts of her life with the viewing public, and she gets paid an awful lot of money for that. She has made a little bit of a career out of dieting."

Psychological need

Some psychologists are also not convinced that the rising numbers of operations is a good thing.

Dr Funke Baffour, who specialises in the psychology of weight management, suggested that would-be patients should first be dealing with the underlying emotional issues which helped cause the weight gain.

"People aren't using their willpower, they're looking for a quick fix, but this will not resolve the psychological problems they may have.

"I'm of the opinion that no-one should need that drastic an intervention.

"I have had patients who are thinking about it, tell me they have done everything they can to lose weight, but, after discussing it, they haven't."

Dr Campbell, however, is adamant that the public perception of weight loss surgery is a false one. He said: "It's seen as a cop-out, a cowardly way of dealing with it.

"But what we have here is a perfect example, someone who is an intelligent, very able person, who has tried everything, over many years, without success. "The forces that make her overweight cannot be overcome just by willpower." 
Note: There are some patients who would benefit with diet and exercize alone. Weight watchers is helpful for many wayward obese people. Liposuction and tummy tucks abdominoplasty is sometimes helpful in getting people back on track. Larry Weinstein MD FACS is a board certified plastic sugeon in Chester New Jersey practicing cosmetic surgery as chief of plastic surgery at Morristown Memorial hospital in Morristown New Jersey.

Psychosocial Effects of Otoplasty in Children with Prominent Ears
Aesthetic Plastic Surgery, 06/13/08 Published online: 6 June 2008

Abstract:  This study aimed to investigate changes experienced by children during the pre- and postoperative periods of prominent ear corrective surgery. A total of 30 patients with prominent ears, sometimes called “lop ears” or “cup ears,” ranging in age from 6 to 14 years were consecutively enrolled in this study. Half of the patients (n = 15, 50%) were male. The inclusion criteria specified children with prominent ears and reports of evident anatomic deformity. Clinical evaluations, routine laboratory tests, and interviews were performed in the pre- and postoperative periods. To assess the dissatisfaction or social maladjustment caused by the prominent ears, questionnaires, which are used routinely in psychological and psychiatric practices, were applied in the pre- and postoperative periods. The tests used were the Child Behavior Check List, the State-Trait Anxiety Inventory for Children, and the Children’s Depression Inventory. The patients themselves and their parents or guardians reported improvements in terms of anatomic aspect. For the psychological tests, improvements in almost all the assessed items were observed. In conclusion, psychological problems caused by anatomic deformities, such as prominent ears, can be improved by adequate corrective surgery. Psychological support is necessary for the patients.

Keywords  Plastic surgery - Prominent ears - Psychological aspects

Note: The ears are 85% full growth at 3 years of age. So, children at the age of 5 before kindergarten can have their ears fixed. Prominent ears and cup ear deformity I commonly fix ages 5 to 10. When I was in India I had children of all ages with very difficult ear abnormalities. I have fixed many adults male and females with great success. Larry Weinstein MD FACS a board certified plastic surgeon in Chester, New Jersey.

Eyelash Reconstruction With Strip Composite Eyebrow Graft.
Annals of Plastic Surgery. 60(6):649-651, June 2008.
Kasai, Kenichiro MD


Abstract:  Eyelash hairs have certain unique properties such as parallel direction, limited length, and tapering, which makes eyelash reconstruction considerably difficult. Several methods for eyelash reconstruction have been reported. Among them, strip composite eyebrow graft is the most suitable because the properties of eyebrow hairs are very similar to those of the original eyelash hairs. A rich blood supply in the eyelid ensures a good survival of the graft. Careful selection of the donor strip harvesting site is critical for preserving a good direction of hairs. The thickness of the graft strip should be determined considering the optimal thickness of hairs being obtained. When suturing the graft strip to the recipient bed, the burying method is suitable for preventing the protrusion of the graft. A well-performed surgical procedure results in a postoperative outcome that closely resembles the natural eyelashes. 

Note: Eyebrow and eyelash reconstruction I have done with strip or individual hair follicle grafts. Larry Weinstein MD FACS Chester New Jersey board certified plastic surgeon

Breast Reconstruction: Complication Rate and Tissue Expander Type
Aesthetic Plastic Surgery, 06/13/08

Abstract:  Background  Limited literature exists regarding complication rates among women undergoing breast reconstruction and the association of these rates with tissue expander types (anatomic, round and Becker).

Methods:  A historical cohort study investigated all breast reconstructions performed at Hadassah Medical Center for 140 consecutive women. Analyses were performed using both logistic and Poisson regression multivariate methods.

Results:  At least one major complication occurred in each of the following groups: anatomic (41%), round (20%), and Becker (11.7%) (p = 0.015). Women reconstructed with anatomic expanders were at increased risk for at least one complication (odds ratio [OR], 3.96; 95% confidence interval [CI], 1.18–13.3; p = 0.026) and an average increase of 331% (95% CI, 102–817%; p = 0.0002) in the number of major complications.
Conclusion  The results of this study suggest that integrated-valve expanders are associated with more complications than the distant inflation port. The benefits of an anatomic shape may perhaps be better exploited using devices with a distant port.
Keywords  Breast reconstruction - Complication - Tissue expanders
C) 2008 Lippincott Williams & Wilkins, Inc.

Note: I have exclusively used distal fill ports for tissue expanders for over 20 years.
Larry Weinstein MD FACS Chester New Jersey board certified plastic surgeon

The Influence of Anger Expression on Wound Healing

Jean-Philippe Gouina, b, , , Janice K. Kiecolt-Glasera, b, c, William B. Malarkeyb, c, d and Ronald Glaserb, e aDepartment of Psychology, The Ohio State University, USA bInstitute for Behavioral Medicine Research, Ohio State University College of Medicine, USA cDepartment of Psychiatry, Ohio State University College of Medicine, USA dDepartment of Internal Medicine, Ohio State University College of Medicine, USA eDepartment of Molecular Virology, Immunology, and Medical Genetics, Ohio State University College of Medicine, USA
Received 1 August 2007;   accepted 17 October 2007.  Available online
19 December 2007.

Certain patterns of anger expression have been associated with maladaptive alterations in cortisol secretion, immune functioning, and surgical recovery. We hypothesized that outward and inward anger expression and lack of anger control would be associated with delayed wound healing. A sample of 98 community-dwelling participants received standardized blister wounds on their non-dominant forearm. After blistering, the wounds were monitored daily for 8 days to assess speed of repair. Logistic regression was used to distinguish fast and slow healers based on their anger expression pattern. Individuals exhibiting lower levels of anger control were more likely to be categorized as slow healers. The anger control variable predicted wound repair over and above differences in hostility, negative affectivity, social support, and health behaviors. Furthermore, participants with lower levels of anger control exhibited higher cortisol reactivity during the blistering procedure. This enhanced cortisol secretion was in turn related to longer time to heal. These findings suggest that the ability to regulate the expression of one’s anger has a clinically relevant impact on wound healing.

Anger expression; Anger control; Wound healing; Cortisol; Hostility; Negative affect; Social support; Health behaviors; Psychoneuroimmunology Note I have seen two incidences in which wound healing was delayed. One in a woman who yelled at her rambuxious child and developed a hematoma and another who suffered isolation in his healing when he expressed anger at his wife. Larry Weinstein,MD FACS


Tighter Plastic Surgery Rules Sought
Los Angeles Times (2008-05-26) P. B1; Lin II, Rong-Gong

California lawmakers are pushing for tougher standards for clinics and surgeons that perform cosmetic surgery. The call for stricter patient safety protections comes in the wake of the high-profile death of Donda West, the 58-year-old mother of Kanye West, who died following cosmetic surgery. A coroner's report indicated that West died from heart disease. A physical exam conducted prior to surgery would have revealed her condition, but West's surgeon did not perform one, according to her family. AB 2968 would force cosmetic surgery candidates to have a physical exam before undergoing surgery. Another bill pending in the California state Senate would require inspections of outpatient facilities once every three years. But some physicians argue that the additional regulations will not change how cosmetic surgeons practice. "There's no way to control surgical judgment," says American Society of Plastic Surgeons Vice President Dr. Michael F. McGuire, who recommends instead tougher disclosure requirements for cosmetic surgeons. McGuire says all healthcare providers should be required to divulge data about their educational background and training before performing surgery. He supports laws that would allow only board-certified plastic surgeons to perform surgery.

Note: Dr Larry Weinstein a board certified plastic surgeon is an ambulatory surgery facility inspector. Dr. Weinstein is involved in patient safety initiatives in the Morristown Memorial hospital in Morristown New Jersey, in the Chester Ambulatory Surgery Center and in surgical facilities nationwide.

Draining After Breast Reduction:

A Randomised Controlled Inter-Patient Study
Leonard U.M. Corion, Mark J.C. Smeulders, Paul P.M. van Zuijlen, Chantal M.A.M. van der Horst Received 27 June 2007; accepted 5 January 2008. published online 19 June 2008.


One hundred and seven bilateral breast reductions were prospectively randomised during surgery to receive or not receive wound drains. Fifty-five patients were randomised to have a drain and 52 to not have a drain. There was no statistical difference in the number of complications between the drained and undrained group (P=0.092; student's t-test for independent observations). Twenty-two of the 55 patients in the drained group had a complication, 12 of the 52 patients in the undrained group had a complication. The hospital stay was significantly shorter (P<0.001) in the undrained group. The main discomfort score due to the presence of the drains was 5.62, which can be qualified as high.

This study demonstrates that breast reduction without postoperative draining does not increase the risk of complications, increases the patient's comfort and significantly reduces hospital stay.
Keywords: Breast reduction, Drain, Complication, Hospital stay

Note: For 20 years I have done breast reduction as an outpatient  same day surgery without drains. There are some surgeons who still use drains for this procedure. In a smoker or someone oozing I would consider the option. Larry Weinstein,MD FACS

3D Stereophotogrammetry Quantitative Lip Analysis Aesthetic Plastic Surgery
06/30/08 Adam R. Sawyer1 , Marlene See1 and Charles Nduka1 Abstract Background  Reduction in lip volume is a stigmata of the aging face.

There are many lip augmentation techniques but very few studies analyzing how these techniques change the three-dimensional structure of the lips. Furthermore, there is no consensus about whether the lip position should be standardized to either the lips closed or parted.
The aim of this study was first to obtain a three-dimensional quantitative analysis of the lips in adults and to look for sexual dimorphism and, second, to compare whether more consistent measurements of the oral region can be obtained with the mouth open compared with it closed.
Methods  Seventy young Caucasian volunteers underwent lip dimension analysis using 3D stereophotogrammetry with lips parted and closed.

Parameters measured for consistency of results were linear distances (e.g., mouth width, total lip height, upper lip height), surface distances (e.g., upper vermilion), areas (e.g., vermilion upper and lower lip, total vermilion), and volumes (upper and lower lip volume, total lip volume). Analysis also compared lip dimensions between male and female subjects.

Results:  Consistent and reproducible results were seen with the lips closed compared with lips apart. All lip parameters (distances, areas, and volumes) were larger in men than in women. The following measurements had significant differences between males and females:
mouth width, upper lip height median, upper white lip height median, upper white lip height lateral, lower vermilion surface distance, and area of vermilion (p < 0.05).

Conclusion:  We present a novel technique for aesthetic assessment of the lips that is objective and achieves consistency with the lips in the closed position. Males have greater lip dimensions compared with females.

Keywords:  Lip augmentation - Stereophotogrammetry - Lip measurement - Lip volume

Note: Lip volume can predictably be increased with current hyaloronic fillers. Restylane and Juvederm are products that I use for this purpose. Men have fuller lips then woman. Lips should not be over done to avoid masculanization.

Larry Weinstein,MD FACS

Facial Dermal Fillers: Selection of Appropriate Products and Techniques

Steven H. Dayan MD1, ,  and Benjamin A. Bassichis MD2

Accepted 6 March 2008.  Available online 15 May 2008.

Over the last decade, there has been a shift in the way aesthetic surgeons approach facial rejuvenation. With recognition of the value of volume enhancement in achieving a more youthful appearance, as well as the ease of office procedures offering minimal downtime and predictable results, there has been a concomitant explosion in the soft tissue filler market. Given the vast array of filler products currently available, the decision of which facial filler to use in specific situations can be complicated and confusing. A physician's selection of facial filler(s) should be based on a solid understanding of the various filler products, appropriate patient selection, and the physician's proficiency in injection techniques. We present a review of the most widely used fillers, offering guidance on patient selection and effective injection techniques.

Note:The dermal fillers I have had good reliable reponse with are Juvederm, Restylane, Radiesse and artefill. They last from 6 months to 5 years dependent on location and product. Larry Weinstein, MD board certified plastic surgeon Chester, New Jersey

Unusual Distribution of the Lower Body Fatty Tissue: Classification, Treatment, and Differential Diagnosis.

Aesthetic Surgery -  Annals of Plastic Surgery. 61(1):2-8, July 2008.
El-Khatib, Hamdy A. MD - Abstract:

Unusual fat distribution of the lower part of the body is clinically characterized by massive symmetric and diffuse fat deposition in the trochanters, groins, buttocks, hips, and lower extremities, which contrasts sharply with the normal upper part of the body. The massive lipomatoses of the lower part of the body can be classified into 3 types:

type 1: the familial symmetrical lipomatosis that affects the groins, trochanters, hips, buttocks, and thighs;

type 2: the bilateral peritrochanteric familial lipomatoses; and

type 3: the unilateral peritrochanteric lipomatosis. This unusual adiposity runs in families and predominantly exists in the Mediterranean region, and seems, however, to be common in North Africa.

It is rarely reported in the literature. In this regard, a differential diagnosis is presented regarding the lipomatosis and lipodystrophies-described syndromes to familiarize plastic surgeons with these unique deformities. Between 2000 and 2006, 50 women with abnormal diffuse fat deposits in the lower part of the body were investigated and treated with conventional liposuction; patients' ages ranged between 20 to 46 years.

Laboratory examination includes the serum concentrations of lipoprotein, cholesterol, triglycerides, uric acid, fasting glucose, and other routine laboratory tests. Endocrinologic tests include serum estradiol and testosterone levels, and thyroid function tests.

Histologic examination of the lipoaspirate was performed. All cases were treated with liposuction. For type 1 cases liposuction was performed in stages; the maximum amount of lipoaspirate per setting was 3,000 to 4,000 mL, and for type 2 and type 3 a single stage liposuction was undertaken.
Laboratory examination showed normal values and routine parameters were within normal limits. Endocrinologic investigations revealed no abnormalities and histologic examination of lipoaspirate showed normal subcutaneous fatty tissue. The esthetic outcome of all individuals was satisfactory.
Abnormal swelling of the lower half of the female body caused by deposition of subcutaneous fat is determined by heredity and seems to be common in North Africa. It is often accompanied by a psychological reaction due to the disturbed body image. A clinical classification is reported in the current study. The traditional liposuction is the treatment of choice for these esthetic deformities.

Note: There are many women of different ethnic backgrounds with excess fatty tissue of the lower extremities and buttocks. I have found liposuction always to be effective treatment in healthy patients.   Larry Weinstein,MD FACS

Use of 2-Octyl-Cyanoacrylate Skin Adhesive (Dermabond) for Wound Closure following Reduction Mammaplasty: A Prospective Randomized InterventionStudy.          
BREAST Plastic & Reconstructive Surgery. 122(1):10-18, July 2008.
Nipshagen, Martine D. M.D.; Hage, J Joris M.D., Ph.D.; Beekman, Werner H. M.D., Ph.D.

Background: 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure. However, its use in plastic surgery has not been properly assessed. Methods: The authors conducted a prospective, randomized, controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure. Bilateral reduction mammaplasty was performed in 50 patients. The method of closure (sutures versus skin adhesive) applied to each breast was determined randomly, using each patient as her own control. Scars were assessed by the patient and by a blinded panel, at 1 week, 6 weeks, and 6 months after surgery, using a visual analogue scale, the modified Hollander Wound Evaluation Scale, and the Patient and Observer Scar Assessment Scale. Results: Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery. Patients' visual analogue scale scores for scar comfort and scar appearance and panelists' visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months (p < 0.05), as was the total Hollander Wound Evaluation Scale score of the panelists after 6 weeks (p < 0.02). The total Patient and Observer Scar Assessment Scale score after 6 months was significantly better for the adhesive side according to the patients (p < 0.01), but not according to the panelists (p = 0.11). Conclusion: The authors conclude that 2-octyl-cyanoacrylate is a sound alternative for wound closure. (C)2008American Society of Plastic Surgeons

Note: Tissue glues are an alternative to sutures close to or over the skin. Most plastic surgeons as Dr. Weinstein use subcuticular sutures with steristrips as an effective method of wound closure. The Quill suture maybe a method more favorable to wound healing. Larry Weinstein, MD FACS

Botulinum Toxin for Treatment of Glandular Hypersecretory Disorders
☆ T.A. Lainga, M.E. Laingb, S.T. O'Sullivana 11 July 2008.

Summary:  The use of botulinum toxin to treat disorders of the salivary glands is increasing in popularity in recent years. Recent reports of the use of botulinum toxin in glandular hypersecretion suggest overall favourable results with minimal side-effects. However, few randomised clinical trials means that data are limited with respect to candidate suitability, treatment dosages, frequency and duration of treatment. We report a selection of such cases from our own department managed with botulinum toxin and review the current data on use of the toxin to treat salivary gland disorders such as Frey's syndrome, excessive salivation (sialorrhoea), focal and general hyperhidrosis, excessive lacrimation and chronic rhinitis.

Keywords:   Botulinum toxin, Glandular hypersecretory disorders, Frey's syndrome, Hyperhidrosis, Sialorrhoea, Epiphora

Note:  I have been using botox fo sweaty palms and armpits for five years with uniform success. Larry Weinstein,MD FACS

Geriatrics and Aging                                                                 Volume 11, Number 5, June 2008, Pages 276-280                                                                  Facial Rejuvenation in the Aging

Jeffrey A. Fialkov, MD, MSc, FRCSC, Assistant Professor, Division of Plastic Surgery, Department of Surgery, University of Toronto; Staff Plastic Surgeon, Sunnybrook Health Sciences Centre, Toronto, ON.  This article reviews surgical and nonsurgical rejuvenation techniques as they relate to the anatomic changes that occur with facial aging. An understanding of the changes that occur to the facial soft tissues and their support structures over time and with exposure to the elements facilitates individualized treatment optimization for older adults seeking facial rejuvenation. In addition, treatment optimization must account the patient’s underlying medical status and personal psychosocial concerns. Key words: facial rejuvenation, cosmetic surgery, facial aging, noninvasive rejuvenation,facelift, photoaging.

Note: Taking into account the patient's age, health condition and medications are very important to planing a facial rejeuvenation procedure such as a facelift z-lift neck lift or thread lift. Alternative procedures other then surgery are options that maybe best for certain geriatric patients. Larry Weinstein, MD FACS

Brachioplasty and Concomitant Procedures after Massive Weight Loss: A Statistical Analysis from a Prospective Registry Plastic and Reconstructive Surgery
07/15/08 Gusenoff JA et al.

Brachioplasty is a safe and effective method of treating upper arm deformity in the massive weight loss patient. Although patients with greater weight loss are likely to present for longer contouring procedures and are at highest risk for wound-healing complications, these complications occur most frequently in areas other than the arms.

Note: I have done many Brachioplasties for hanging skin of the arm. Excess skin and fat of the arm is a common problem, the scar from this surgery is not always invisible. It can be placed on the posterior brachial line at the back of the inside of the arm. The axillary incision has limited applicability especially in the massive weight loss patient. Larry Weinstein,MD FACS
Chester, New Jersey

Volumetric short scar rhytidectomy – indications, technique and outcomes
Barry M. Jones, a, , Damian D. Maruccia and Gary L. Rossa aKing Edward VII's Hospital, Beaumont Street, London W1G 6AA, UK Received 24 September 2007;  accepted 13 November 2007.  Available online 15 May 2008.

Procedures combining a short scar with superficial musculoaponeurotic system (SMAS) manipulation are increasingly popular for patients with early signs of mid- and lower-facial laxity seeking rhytidectomy. We present the senior author's experience with a short scar volumetric malar imbrication rhytidectomy, which avoids post-auricular incisions and sub-SMAS dissection.

Patients and methods
Between January 2004 and April 2007, 54 patients underwent a short scar volumetric rhytidectomy (9.6% of all facelifts). These procedures were primary in 38 and secondary in 16 patients, at a mean age of 49 years (range 35–77 years). Average operating time was 90 min. Resultant vertical and horizontal skin movement at the helical root was recorded. Concurrent procedures included blepharoplasty, canthoplasty, endoscopic forehead rejuvenation and fat grafting. Minimum follow up was 3 months. Pre- and 3 month postoperative photographs of 25 randomly selected patients were rated by three independent surgeons. A seven-point scale was used to grade the improvement in the malar eminence, melolabial fold, jowls and cervicomental angle. The overall aesthetic result was assessed using the MDACS gradin g system. Statistical analysis was performed using Student's t-tests and general estimation equations where appropriate.

There were no significant complications. Three patients developed minor cheek swellings which all settled with antibiotics. Mean postoperative aesthetic outcomes were rated as ‘Good’ using the MDACS scale (mean score 0.64), with no ‘Poor’ results. Vertical skin lifting was significantly greater than the horizontal skin lifting (P < 0.001).
Mild postoperative improvements were noted in the malar eminence soft tissue volume, nasolabial fold diminishment, jowl diminishment and cervicomental angle.

In the appropriately selected face, short scar volumetric malar imbrication rhytidectomy is a straightforward, safe and effective procedure for improving the early signs of ageing.

Keywords: Short scar rhytidectomy; SMAS imbrication

Note: The proof is in the pudding. Last week I performed four of these procedures short scar rhytidectomy facelift with all patients pleased with the results. There is no question in the right hands this procedure can produce excellent short term and long term result of facial rejuvenation. In specific helping reduce nasolabial folds, eliminating jowls and correcting neck deformities such as turkey gobbler neck.  Larry Weinstein,MD FACS Chester New Jersey


Abdonminoplasty tummy tuck Panniculectomy
Annals of Plastic Surgery. 61(2):188-196, August 2008.
Cooper, Joshua M. MD *; Paige, Keith T. MD, FACS +; Beshlian, Kevin M. MD, FACS +; Downey, Daniel L. MD, FACS +; Thirlby, Richard C. MD, FACS *

We reviewed our experience with 3 operative techniques for abdominal panniculectomies to determine differences in complication rates and levels of patient satisfaction. Methods: This retrospective study included 92 consecutive patients who underwent abdominal panniculectomies over a 9-year period. Patients underwent one of 3 panniculectomy techniques: fleur-de-lis (n = 25), transverse incisions with minimal undermining (n = 30), or transverse incisions with extensive undermining (n = 37). Postoperatively, patient satisfaction surveys were completed. Results: Median pannus weight was 4.4 kg (range, 1.6-20.5). Sixty-eight patients (73.9%) had a previous gastric bypass. Median body mass index (BMI) was 38 kg/m2 (range, 22-66.9). Median follow-up for complications was 8.1 week (range, 1-235). Forty of 92 patients (43%) suffered wound complications. The reoperation rate was 13%. Postoperative complication rates were higher among hypertensive patients (61% vs. 36%; P = 0.04). There was a trend towards increased complications among those with higher BMI and pannus weights. There was not a significant relationship between operative technique and overall complication rate. Mean length of follow-up for patient questionnaire completion was 2 years, 11 months (range, 1-9 years). Eighty-one percent of those responding to the mailed questionnaire were satisfied with their operative results. There were no statistically significant differences between the technique used and patient satisfaction level. Concomitant hernia repair was performed in 47% of patients without increased wound complications.

Conclusions: Patients were satisfied with the results of their panniculectomy, although complications were common. Higher BMI, larger pannus size, and hypertension were correlated with increased complication rates. The minimal undermining, extensive undermining, and the fleur-de-lis panniculectomy techniques result in similar patient satisfaction rates and complication rates.
Note: High satisfaction rate is the rule in my experience, the heavier the patient the rougher the recovery. Larry Weinstein MD FACS Chester New Jersey 

The Anatomic Replication Technique (ART): A New Approach in Saddle Nose Correction.
Annals of Plastic Surgery. 61(2):169-177, August 2008.        Mutaf, Mehmet MD

Correction of major saddle nose deformities is one of the greatest challenges in nasal surgery. Here, a new approach for the correction of major saddle nose deformities in which the missing parts of the nasal skeleton are replaced with their anatomic replicas sculptured from an autogenous osteocartilagineous rib graft is presented. Since 1998, this new technique has been used in 17 patients (11 females and 6 males) with major saddle nose deformities. The age range was between 19 and 37 years. The etiology of saddle nose deformity was iatrogenic in 11 and traumatic in 2 patients. In the remaining 4 patients, saddle nose was a part of ethnic facial features. During a mean follow-up of 2 years, the sculptured nasal frame maintained its form and resistance. There was no patient with recurrent nasal collapse or airway obstruction. The nasal tip was naturally mobile in all patients. Replacing the missing parts of the nasal skeleton with their anatomic replicas created from autogenous tissues, this new technique restores all anatomic and functional features of the nose. It efficiently corrects saddle nose deformity and eliminates associated functional deficiencies.

Note: I have had extensive experience with saddle nose reconstruction using cranial bone graft and ear cartilage with excellent results for traumatic, congenital and iatrogenic nose reconstruction.
Larry Weinstein, MD FACS Chester New Jersey

Satisfaction With and Psychological Impact of Immediate and Deferred Breast Reconstruction
J. Fernández-Delgado1, M. J. López-Pedraza2, J. A. Blasco2, E. Andradas-Aragones3, J. I. Sánchez-Méndez4, G. Sordo-Miralles1 and M. M. Reza2,* 

Background: The present work assesses the effect of immediate breast reconstruction (IBR), deferred breast reconstruction (DBR), and no breast reconstruction on the psychological impact. Patients and methods: Standard questionnaires were used to determine the psychological impact suffered by patients who underwent IBR, DBR and no reconstruction, their degree of satisfaction with the results achieved, and their postprocedure opinions regarding reconstruction options. Results: A total of 526 women underwent mastectomy. The response rate to the questionnaires was 71.67%. A significantly greater proportion of the women who underwent no reconstruction suffered psychological problems than those who underwent reconstruction of some type (P = 0.01). Some 94.77% of the women who underwent IBR maintained a postprocedure preference for this option; in contrast, some 87.27% of the DBR and 56.14% of the no-reconstruction patients declared a postprocedure preference for IBR. In all, 63.49% of the women who underwent reconstruction were moderately very satisfied with the aesthetic results achieved, while only 22.80% of the no-reconstruction patients declared such satisfaction (P = 0.0001).  

Conclusions: The women who underwent no breast reconstruction suffered more emotional problems than those who underwent a reconstruction procedure. In general, all groups reported a postprocedure preference for IBR in their questionnaire answers. The aesthetic results achieved by IBR seem to be those best accepted.     Key words: breast neoplasm, breast/surgery, mammaplasty, mastectomy, patient satisfaction, plastic surgery

Note: Since my Sloan Kettering New York New York days I have been acutely aware of the need for breast reconstruction in the breast cancer patient. The job is not finished until the patient is satisfied. Larry Weinstein, MD FACS Chester New Jersey.

Correction for the Iatrogenic Form of Banana Fold and Sensuous Triangle Deformity
Aesthetic Plastic Surgery, 07/31/08   Luiz Haroldo Pereira1  and Aris Sterodimas2            

Abstract:  The “banana fold,” or the infragluteal fold, is a fat deposit on the posterior thigh near the gluteal crease and parallel to it. The “sensuous triangle” is found at the junction of the lateral buttocks, the lateral thigh, and the posterior thigh. The iatrogenic forms of banana fold and sensuous triangle deformity are produced by excessive liposuction. The authors’ experience using autologous fat transplantation to treat tissue defects led them to use this technique for correcting iatrogenic forms of banana fold and sensuous triangle deformity. The simplicity of the procedure, the low incidence of complications, and the high satisfaction rate makes autologous fat transplantation an attractive option for correcting iatrogenic complications of liposuction.

Keywords:  Liposuction - Banana fold - Sensuous triangle deformity - Fat transplantation 

Note: Indentation deformities, wavy skin, and indented areas can be treated under local anesthesia with a tiny incision to release them with a forked cannula. Fat deposition is sometimes helpful for this rarly seen problem in the USA. Larry Weinstein MD FACS Chester New Jersey USA

Breast Reduction: Safe in the Morbidly Obese?

Plastic & Reconstructive Surgery. 122(2):370-378, August 2008.
Roehl, Kendall M.D.; Craig, E Stirling M.D.; Gomez, Victoria B.A.; Phillips, Linda G. M.D.


Background: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to >=40 kg/m2) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions.

Methods: Retrospective investigation of 179 reduction mammaplasty patients was performed out to determine whether reduction mass, age, body mass index, smoking, method used (i.e., vertical pedicle, inferior pedicle/central mound, or free nipple graft), and comorbidities influenced complication rates. The patients were categorized by size of reduction, age, and body mass index.

Results: The overall complication rate was 50 percent. There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively). Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072). There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07).

Conclusion: It is as safe to perform large-volume breast reductions in the morbidly obese patient with comorbidities as in anyone else.

Note: I find it difficult to believe this study. The larger the patient the greater the risk for open wounds, fat necrosis, deep venous thrombosis and pulmonary emboli. A 50% incidence of complications may explain their insignificant difference in the study chort. In private practice a 50% incidence of complications is not compatible with a viable practice. In a city hospital with only third party payors, not in New York. Larry Weinstein, MD FACS Chester, New Jersey

Options in Reconstructing the Irradiated Breast.

Plastic & Reconstructive Surgery. 122(2):379-388, August 2008.
Spear, Scott L. M.D.; Boehmler, James H. M.D.; Bogue, David P. M.D.; Mafi, Amir A. B.S.


Background: As radiation therapy becomes more prevalent in the treatment of breast cancer, more patients requesting breast reconstruction for mastectomy defects will have a history of radiation therapy.

Methods: A retrospective chart review study was performed of a single surgeon's 5-year experience with reconstruction of the irradiated breast.

Results: Sixty-six primary patients and 13 secondary patients were treated over a 5-year period (2001-2005). Of the 66 primary patients, 25 (38 percent) presented for reconstruction after recurrence following prior breast conservation therapy: 12 had prosthetic based reconstructions (with or without a latissimus flap) and 13 had autologous reconstructions. Twenty-five patients (38 percent) presented after mastectomy followed by radiation therapy: six had prosthetic-based constructions and 19 had autologous reconstructions. Twelve patients (18 percent) had their reconstructions performed before radiation therapy: nine had implant-based reconstructions and three had autologous reconstructions. Four patients (6 percent) presented for corrections of breast conservation therapy deformities. One hundred seventy-five total operations were performed for the primary patients, with an average of 2.65 operations per patient. Thirteen patients were treated secondarily after previous reconstruction at other institutions with a variety of reconstruction methods used. Twenty-eight total operations were performed for the secondary patients, with an average of 2.2 operations per patient. Capsular contracture rates using the prosthetic score are reported.

Conclusions: Because of the variability of presentation of the irradiated breast cancer patient, there is no one method of reconstruction ideally suited for all irradiated patients. In this 5-year review, the authors found that with careful patient evaluation and selection, good results can be attained regardless of reconstructive method.

Note: Breast reconstruction is complicated by radiation. There is significant vascular and cellular changes that predispose to capsular contracture, firmness of implants and fibrosis or fat necrosis of flaps. Larry Weinstein, MD FACS Chester New Jersey

(C)2008American Society of Plastic Surgeons

Early Surgical Intervention for Proliferating Hemangiomas of the Scalp: Indications and Outcomes.

Plastic & Reconstructive Surgery. 122(2):457-462, August 2008.
Spector, Jason A. M.D.; Blei, Francine M.D.; Zide, Barry M. D.M.D., M.D.


Large hemangiomas of the scalp, though uncommon, present unique challenges to the reconstructive surgeon. If not treated early, these lesions can result in large areas of alopecia, distortion of the hairline, or deformation of the ear. Given these potential complications and the relative pliability and redundancy of the infant scalp before 4 months of age, the authors propose early surgical excision.

Methods: A retrospective review of the senior author's (B.M.Z.) patient records was performed; over a period of 4 years, six infants were identified who underwent resection of a large scalp hemangioma. The surgical planning and execution of each case and follow-up are detailed.

Results: All six hemangiomas were excised completely. In five cases, the excisions were performed in one stage at or before 4 months of age. In a sixth case, a tissue expander was placed before excision and closure in an 18-month-old infant. In three cases, significant ear malposition was corrected by removal of the deforming mass. There were no complications.

Conclusions: The authors have demonstrated that by taking advantage of the greater elasticity of the infant scalp, large hemangiomas of the scalp can be aggressively and successfully treated with surgical intervention, often in one operation. Beyond the usual indications, early surgical excision of scalp hemangiomas may be advantageous and warranted to prevent the development of large alopecic areas or the permanent distortion of the hairline and aural anatomy.

Note: Tissue expansion in infants is well tolerated and can be used as I have for several enormous hemangiomas over the last 20 years. Larry Weinstein, MD FACS Chester New Jersey

The Effect of Weight Loss Surgery and Body Mass Index on Wound Complications After Abdominal Contouring Operations.
Aesthetic Surgery

Annals of Plastic Surgery. 61(3):235-242, September 2008.
Greco, Joseph A. III MD *; Castaldo, Eric T. MD +; Nanney, Lillian B.
PhD *; Wendel, J Jason MD *; Summitt, J Blair MD *; Kelly, Kevin J. MD *; Braun, Stephane A. MD *; Hagan, Kevin F. MD *; Shack, R Bruce MD *


Abdominal contouring operations are in high demand after massive weight loss. Anecdotally, wound problems seemed to occur frequently in this patient population. Our study was designed to delineate risk factors for wound complications after body contouring. Our retrospective institutional analysis was assembled from 222 patients between 2001 and 2006 who underwent either abdominoplasty (N = 89) or panniculectomy (N = 133). Weight loss surgery (WLS) before body contouring occurred in 63% of our patients. Overall the wound complication rate in these patients was 34%: healing-disturbance 11%, wound infection 12%, hematoma 6%, and seroma 14%. WLS patients had an increase in wound complications overall (41% vs. 22%; P < 0.01) and in all categories of wound complications compared with non-WLS-patients by univariate methods of analysis. In a multivariate regression model, only American Society of Anesthesiologists Physical Status Classification was a significant independent risk factor for wound complications. In conclusion, WLS patients are at increased risk for wound complications and American Society of Anesthesiologists Physical Status Classification is the most predictive of risk.


I wonder how significant these postoperative complications were. Minor wound disturbances, small fluid collections are easily handled in the office. However significant problems that require admission and treatment in the hospital is rare. More important is ambulation after surgery to help prevent deep venous thrombosis of the legs and the rare pulmonary embolus. Some patients with risk factors need heparin or lovenox as a preventive measure of DVT.
Larry Weinstein,MD FACS

Patterns of Plastic Surgical Use after Gastric Bypass: Who Can Afford It and Who Will Return for More.

COSMETIC Plastic & Reconstructive Surgery. 122(3):951-958, September 2008.
Gusenoff, Jeffrey A. M.D.; Messing, Susan M.A., M.S.; O'Malley, William M.D.; Langstein, Howard N. M.D.


More patients are undergoing plastic surgery after gastric bypass. Socioeconomic factors influencing the decision to have body contouring after gastric bypass have not been studied in the current literature. Methods: In this study, 2501 consecutive gastric bypass patients were surveyed. Outcome variables were assessed by univariate and multivariable analyses.
Results: Nine hundred twenty-six patients (817 women and 109 men) responded (40.3 percent of the 2296 surveys that at least may have been received), with a mean follow-up of 2.4 years. One hundred five (11.3 percent) underwent body contouring. Thirty-four patients assumed all costs for body contouring, and of these, 47 percent had multiple operations. Sixty-eight patients had some insurance coverage; 26 percent of these patients personally paid for additional body contouring. Having multiple procedures was not explained by any variables in our model. Body contouring was related to years since gastric bypass (p < 0.0001), post-gastric bypass body mass index (p < 0.03), change in body mass index (p < 0.0001), open versus laparoscopic gastric bypass (p < 0.0001), and income category greater than $20,000 (p < 0.03). Expenditures for body contouring were greater if the patient assumed costs versus had some insurance (p < 0.03), but were not related to income. Patients who assumed all costs of body contouring had lower pre-gastric bypass and post-gastric bypass body mass indexes (p < 0.007).

Conclusions: A minority of patients underwent body contouring. Patients assuming the costs of body contouring were twice as likely to have additional surgery. These results suggest that socioeconomic factors play an important role in the decision to have body contouring but may not predict who will have concomitant or additional procedures.

Note: Insurance does not cover most available procedures to correct massive hanging skin post weight loss from gastric bypass or diet and exercise. I have done many abdominoplasty or tummy tucks on massive weight loss patients with worthwhile results. They are not without risk. Larry Weinstein MD FACS Chester NJ

Comparison of Breast Implant Deflation for Mentor Anterior and Posterior Valve Designs in Aesthetic and Reconstructive Patients.

BREAST Plastic & Reconstructive Surgery. 122(3):685-692, September 2008.
Levi, Benjamin M.D.; Rademaker, Alfred W. Ph.D.; Fine, Neil A. M.D.; Mustoe, Thomas A. M.D.     


Background: Saline breast implant rupture remains problematic after implantation. Company reports and previous studies implicate the valve as a common site of implant failure. This study evaluates the rupture rate of the Mentor posterior valve compared with the anterior valve in breast augmentation and reconstruction. Methods: This is a retrospective analysis of consecutive breast implantations performed between 1992 and 2004 by two surgeons. All but two implants were filled at or above the manufacturer-recommended volume. Data were collected by chart review, telephone survey, and Mentor Corp. reports. Kaplan-Meier and Mantel-Haenszel analyses were used to compare rupture rate and relative risks, respectively.

Results: Sufficient data were available for 516 implants in 325 women (average follow-up, 6.04 years). Overall, those implants with posterior valves had a lower rupture rate (0.007 versus 0.022). In the reconstructive cohort, the posterior valve implants had a lower rupture rate (0.011 versus 0.036), and the relative risk of rupture using an anterior valve versus a posterior valve was 3.387 (p = 0.0154). There was no significant difference in rupture rate between valve types in breast augmentation. A multivariate analysis showed that implant texture did not affect rupture rate.

Conclusions: The authors found a statistically significant decrease in implant rupture for Mentor posterior valve implants in the reconstructive cohort and no difference in the augmentation cohort. Thus, the authors conclude that at worst, the posterior valve is not more prone to rupture than the anterior valve model. Furthermore, the authors believe that the postoperative flexibility of the posterior valve implants makes them more useful clinically.

Note: 23 years ago I did research on the posterior valvee with no failures in an experimental model. Occasional the valve mechanism can be cracked if the fist technique is used to deflate the implant to remove air. I advocate gentle suction prior to saline injection do avoid this problem. The posterior valve is less palpable and can be used as an adjustable implant device. Larry Weinstein MD FACS Chester NJ  C)2008American Society of Plastic Surgeons

Botulinum toxin for treatment of glandular hypersecretory disorders     T.A. Lainga, , , M.E. Laingb and O'Sullivana                                                               

The use of botulinum toxin to treat disorders of the salivary glands is increasing in popularity in recent years. Recent reports of the use of botulinum toxin in glandular hypersecretion suggest overall favourable results with minimal side-effects. However, few randomised clinical trials means that data are limited with respect to candidate suitability, treatment dosages, frequency and duration of treatment. We report a selection of such cases from our own department managed with botulinum toxin and review the current data on use of the toxin to treat salivary gland disorders such as Frey's syndrome, excessive salivation (sialorrhoea), focal and general hyperhidrosis, excessive lacrimation and chronic rhinitis.   

Botulinum toxin; Glandular hypersecretory disorders; Frey's syndrome; Hyperhidrosis; Sialorrhoea; EpiphoraUpdate on perioral cosmetic enhancement.     Facial plastic surgery            

I have used Botox for Hypersecretory activity with resounding success in the palms of the hands and armpits. Larry Weinstein, MD FACS Chester, NJ

Current Opinion in Otolaryngology & Head & Neck Surgery. 16(4):347-351, August 2008.Suryadevara, Amar 

Purpose of review: As our understanding of the perioral region advances and procedures available for its treatment increase, we are more able to successfully treat the aged perioral otchemodenervation, soft tissue fillers, fat grafting, and dermabrasion. The present article will review the most recent literature regarding the use of these techniques for various perioral age-related changes, including rhytids, labiomental folds, nasolabial folds, lip-cheek grooves, and thinning lips. Often, these modalities are combined to give the most natural aesthetic result.

An increase in our armamentarium of techniques and general understanding of the complex perioral region allows us to treat the area quite effectively with minimal risk. Volume loss, a key component of perioral aging, is best addressed with soft tissue fillers and autologous fat. In addition, botulinum toxin helps rest some of the key muscles responsible for perioral rhytids. Facial resurfacing techniques are still crucial adjuncts in the rejuvenation of this area, and they may be the only treatment that adequately addresses multiple deeper perioral rhytids. (C) 2008 Lippincott Williams & Wilkins, Inc.        

Multimodal therapy of the perioral area is key to significant improvement. Chemical or LASER peels, Fillers ( Juvederm - Restylane Hyaloronic Acid, Radiesse Hydoxyappetite crystals or Artefill ) and Botox are all effective modalities to enhance the perioral areas. Larry Weinstein, MD FACS

Practice profiles in breast reduction: A survey among Canadian plastic surgeons
RA Nelson, SM Colohan, LJ Sigurdson, DH Lalonde

Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons.

The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes.

METHOD: Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software.

 There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient.

Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.

I have used the inverted T incision with 98% satisfaction ratio. I have experienced rare dehiscence which have been treated with local wound care. Washing with Dove soap in the shower and applying Silvadene antimicrobial or bacitracin or Hydrogel PRN to maximize the healing environment. Larry Weinstein, MD FACS Chester, NJ

Does Abdominoplasty With Liposuction of the Love Handles Yield a Shorter Scar? An Analysis With Abdominal 3D Laser Scanning.

Aesthetic Surgery Annals of Plastic Surgery. 61(4):359-363, October 2008.
Rieger, Ulrich M. MD *+; Erba, Paolo MD *; Wettstein, Reto MD *; Schumacher, Ralf M. Eng ++; Schwenzer-Zimmerer, Katja MD, DDS *; Haug, Martin MD *; Pierer, Gerhard MD *+; Kalbermatten, Daniel F. MD *[S] Abstract:

The aim of this study was to evaluate the combination of abdominoplasty with liposuction of both flanks with regards to length of scar, complications, and patient's satisfaction. A retrospective analysis of 35 patients who underwent esthetic abdominoplasty at our institution between 2002 and 2004 was performed. Thirteen patients underwent abdominoplasty with liposuction of both flanks, 22 patients underwent conventional abdominoplasty. Liposuction of the flanks did not increase the rate of complications of the abdominoplasty procedures. We found a tendency toward shorter scars in patients who underwent abdominoplasty combined with liposuction of the flanks. Implementation of 3-dimensional laser surface scanning to objectify the postoperative outcomes, documented a comparable degree of flatness of the achieved body contouring in both procedures. 3-dimensional laser surface scanning can be a valuable tool to objectify assessment of postoperative results. (C) 2008 Lippincott Williams & Wilkins, Inc.


I have always done liposuction of the flanks when doing abdominoplasty with unusually short scars considering the extent of skin resection. The hydrostatic technique allows for same day surgery and quick recovery. Larry Weinstein, MD FACS Chester, NJ USA

Scars: A Review of Emerging and Currently Available Therapies.


Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008.
Reish, Richard G. M.D.; Eriksson, Elof M.D., Ph.D.


Background: With the investigation and potential introduction of several novel scar-reducing therapies to the market within the next several years, it is germane to review both the pathophysiology of scarring and the safety and efficacy of currently available and emerging therapeutic agents.

Methods: An extensive review of the English-language literature was conducted using the MEDLINE database.
Results: A comprehensive review of the pathophysiology of scarring and scar management, including both emerging and currently available therapies, was completed. Current clinical studies are limited by small sample sizes, lack of well-designed controls, and lack of standardized scar outcome measurement parameters.

Conclusions: A prominent challenge in the study of scar management is the paucity of well-designed, large, randomized, controlled studies examining existing scar-reducing techniques. The greatest improvement in scar-reducing protocols likely entails a polytherapeutic strategy for management. Further investigation into the role of inflammation in scarring is paramount to the development of improved scar-reducing agents. There is a need for large controlled trials using a polytherapeutic strategy that combines existing and novel agents to provide a standardized evidence-based evaluation of efficacy.
(C)2008American Society of Plastic Surgeons

Note: Control of scars is a constant vigilant interest of plastic surgeons. The redness of wounds takes 6 months to mature and improve, the thickness of a wound can take longer and may improve with external modalities. Larry Weinstein MD FACS Chester NJ USA

Maximizing the Aesthetic Result in Panniculectomy after Massive Weight Loss.


Plastic & Reconstructive Surgery. 122(4):1214-1224, October 2008.
Leahy, Paul J. M.D., M.A.; Shorten, Scott M. B.S.; Lawrence, W Thomas M.P.H., M.D.


Background: Plastic surgical consultation for abdominal contouring following massive weight loss is becoming increasingly prevalent, especially with the popularity of surgical weight loss procedures. The authors reviewed their experience with a novel panniculectomy technique that generally combines horizontal and vertical tissue excision to generate the best contour possible while providing effective relief of symptoms related to a dependent abdominal panniculus.

Methods: A retrospective chart review was conducted of 100 consecutive patients who underwent panniculectomy using the authors' technique over a 5-year period. Demographic and procedural data were collected, and outcome measures were analyzed.

Results: Eighty-seven women and 13 men with an average weight loss of 133 lb underwent abdominal panniculectomy. A total of 37 ventral hernias were repaired concomitantly. Mean clinical follow-up was 16 months. Hospital length of stay averaged 4 days, and the most common complications were blood transfusion requirement (n = 39), fluid collections (n = 32), tissue necrosis requiring debridement (n = 18), and contour irregularities requiring revision (n = 15). Overall, 56 patients had a completely uncomplicated recovery. Greater amounts of tissue resection were associated with higher rates of transfusion (p < 0.01).

Conclusions: The panniculectomy technique described can be performed safely and reproducibly. It yields an excellent abdominal contour and is effective in alleviating many symptoms of the dependent abdominal panniculus. It also provides exposure for improved evaluation and repair of concomitant ventral hernia defects. (C)2008American Society of Plastic Surgeons

Note: Massive Panniculectomy or extended abdominoplasty are performed by me at Morristown Memorial hospital in Morristown NJ USA with little down time and relatively quick recovery. I usually require a stress test preop for these morbidly obese patients. Larry Weinstein, MD FACS Chester NJ USA

Improvement of Physical and Psychological symptoms after breast reduction

M. Rogliani, P. Gentile, L. Labardi, A. Donfrancesco, V. Cervelli published online 24 October 2008.

JPRS Summary This study suggests that women who underwent breast reduction showed a significant improvement in both physical and psychological symptoms associated with macromastia and in their overall quality of life, 12 months postoperatively. Comparing pre- with postoperative scores obtained with the Body Dysmorphic Disorder Examination Self-Report (BDDE-SR23), the Short Form-36 Health Survey and the Symptom Inventory Questionnaire, the study objectively proves that breast reduction increases patient's satisfaction with their body image and improves their lives from both a psychological and relational point of view.

Keywords: Breast reduction, Psychological symptoms

Note: My patients with breast hypertrophy DD and above complain of back pain, neck pain, shoulder pain, breast pain, painful hands (ulnar nerve dysesthesias), difficulty exercising, and psychological effects. All of my patients have been pleased with the improvement or complete resolution of their physical problems and 96% have been very pleased with their aesthetic cosmetic results. Larry Weinstein,MD FACS

Panniculectomy and Redundant Skin Surgery in Massive Weight Loss
Patients: Current Guidelines and Recommendations for Medical Necessity Determination.

Review Article

Annals of Plastic Surgery. 61(6):654-657, December 2008.
Gurunluoglu, Raffi MD, PhD


There is certain insurance coverage criteria for panniculectomy and redundant skin surgery that every plastic surgeon participating in the surgical treatment of massive weight loss patients should be familiar with to accurately document and present the clinical findings of their patients. This article reviews the medical necessity guidelines used by most third-party payers for panniculectomy in massive weight loss patients after bariatric surgery. In addition, insurance coverage criteria for redundant skin surgery and panniculectomy recommended by American Society of Plastic Surgeons (ASPS) for third-party payers were reviewed. Although the criteria used by third-party payers are conceptually similar to those recommended by ASPS, in practice they are harder to meet by most weight loss patients. This discrepancy leads to a group of denied patients who would otherwise be authorized for plastic surgery after massive weight loss, when actual ASPS recommendations are taken into consideration. Furthermore, our search demonstrated that there are no established criteria or guidelines used for different body parts such as inner arms and medial thighs, other than the pannus among third-party payers. This review article points out to the fact that there is a need for development of new set of guidelines for those sites and for modification of current guidelines for medical necessity determination of panniculectomy used among third-party payers, according to actual ASPS recommendations.

(C) 2008 Lippincott Williams & Wilkins, Inc. Insurance carriers are not covering tummy tucks. This is really a cosmetic procedure that is not usually a need. Fungal inflammations and infected cysts in skin folds are reasons for skin removal which is very different then a cosmetic tummy tuck.
Larry Weinstein,MD FACS

Body Taping for body Contouring
Daniel Felix Kalbermatten1, 2 , Reto Wettstein3, Paolo Erba1, Ulrich Michael Rieger4, Gerhard Pierer4 and Wassim Raffoul2

Received: 20 May 2008  Accepted: 7 October 2008  Published online: 22 November 2008 Abstract Background  Preoperative marking is of primary importance in body contouring and when precise simulation of skin excisions is difficult.

Because the “cut as you go” principle can be delicate, especially in patients after massive weight loss, a simple and quick method is needed for preoperative planning. We suggest an approach that helps visualize the optimal skin incision lines and simulates the postoperative result by body taping.
Methods  Twelve patients who underwent abdominal contouring, including classic and vertical abdominoplasties as well as dog ear and scar revision, were prospectively analyzed. The skin to be excised was preoperatively folded, taped, and then marked. The area marked was measured and compared with the actual intraoperatively resected area and the postoperative result was evaluated after 1 year by the patients and three surgeons.


With body taping, an 83% congruence between the preoperative planning and the surgery was obtained and only two patients had additional skin resected. No wound dehiscence and flap necrosis occurred and patients as well as surgeons scored the final body contour positively.


Body taping is a simple, quick, and economic method for planning contour surgery with high accuracy as demonstrated by the low rate of intraoperative changes of the planned resection and low complication rate.


Skin resection - Tissue mobility - Obesity surgery - Abdominoplasty - Post-bariatric surgery - Body contouring


Preoperative planning is critical to best results in abdominoplasty. I use the pinch technique to determine the amount of free excess skin. I check and recheck as I go.
Larry Weinstein,MD FACS

A Management Algorithm and Practical Oncoplastic Surgical Techniques for Repairing Partial Mastectomy Defects. BREAST Plastic & Reconstructive Surgery. 122(6):1631-1647, December 2008.
Kronowitz, Steven J. M.D.; Kuerer, Henry M. M.D., Ph.D.; Buchholz, Thomas A. M.D.; Valero, Vicente M.D.; Hunt, Kelly K. M.D.


Background: In patients undergoing a partial mastectomy, choosing the best method with which to repair the defect is essential to optimizing outcomes and minimizing the potential for postoperative complications.

Methods: The authors present a management algorithm for repairing partial mastectomy defects based on clinically relevant parameters to allow clinicians to better select the most appropriate indications for the various reparative oncoplastic procedures. The clinicopathologic factors considered in surgical decision-making for reconstruction after partial mastectomy include timing of reconstruction in relation to radiation therapy, status of the tumor margin, extent of breast skin resection, breast size, and whether the cosmetic outcome would be better after a total mastectomy with immediate breast reconstruction, thereby avoiding the need for radiation therapy.

Results: Most patients with medium or large breasts will likely benefit from immediate repair, whereas some with small breasts may not. Immediate repair of partial mastectomy defects is preferred with the use of local breast tissue (local tissue rearrangement or breast reduction techniques) because of the simplicity of these approaches and because techniques using local tissue maintain the color and texture of the breast. Waiting to repair a large deformity until after whole-breast radiation therapy usually necessitates a complex transfer of a large volume of autologous tissue, which many patients who undergo breast conservation therapy are not willing to pursue. Use of lower abdominal flaps to repair partial breast defects is generally discouraged.

Conclusion: Although the authors' management algorithm and practical oncoplastic techniques should prove useful, it is up to the multidisciplinary breast team and the patient to determine the best approach. (C)2008American Society of Plastic Surgeons  Note: Limited reconstruction for breast cancer after partial mastectomy is an alternative available at Morristown Memorial hospital in Morristown, NJ and at Hackettstown Regional medical center in Hackettstown, NJ . Larry Weinstein, MD FACS

Pros And Cons Of Gastric Bypass Surgery For Severe Obesity

ScienceDaily (Dec. 2, 2008) — Severely obese patients who underwent two different gastric bypass techniques had lost up to 31 per cent of their Body Mass Index (BMI) after four years, with no deaths reported among the 50 study subjects, according to the November issue of the British Journal of Surgery.decreased from high blood pressure fell by 76 per cent, diabetes fell by 90 per cent and cases of dyslipidaemia – abnormal concentrations of lipids or lipoproteins in the blood – fell by 77 per cent. However 29 complications were reported in 27 patients, including minor wound infections and narrowing of the anastomotic suture, and ten patients had to be operated on again in the four-year period after surgery. Surgeons at the University Hospital Zurich, Switzerland, carried out the study to compare two techniques and find out whether varying the length of the small bowel limb during surgery could offer superior weight loss. It had been suggested by several studies that a longer length would reduce the body’s ability to absorb certain sugars and fats. As a result of the four-year study, they now perform proximal gastric bypass as the operation of first choice, having decided that the distal gastric bypass technique, with its longer alimentary limb, doesn’t offer any significant advantages but does have a number of drawbacks. “There has been an ongoing debate about whether having a longer limb offers the patient greater weight loss and we decided to compare both techniques” explains Dr Markus Muller from the University’s Department of Visceral and Transplant Surgery. Fifty patients having laparoscopic gastric bypass surgery were match-paired, with 25 undergoing the proximal technique and 25 undergoing the distal technique. The alimentary limb length in the proximal surgery group was 150cm and this increased to between 200cm and 400cm in the distal group. The study subjects’ BMIs averaged 45.9 in the proximal group and 45.8 in the distal group. All had been obese for more than five years and had failed to lose weight using conventional methods for at least two years. Forty were female, their average age was 38 and their average weight was 126kg.

Key findings included:

  • BMI decreased from 45.9 to 31.7 in the proximal group (31 per cent) and from 45.8 to 33.1 in the distal group (28 per cent).
  • Average operating time was significantly longer in patients undergoing distal than proximal bypass surgery (242 minutes versus 170 minutes) and distal patients stayed in hospital longer (nine days versus eight days).
  • Over the four-year follow-up, 29 complications were reported in 11 patients in the proximal group and 16 patients in the distal group. 12 repeat operations were necessary, four in the proximal group and eight in the distal group. Two patients - one in each group - had two operations for both early and late complications.
  • Sixteen early complications were reported in the first 30 days after surgery - eight in each group. Eight of these were wound infections, there were two cases each of internal hernia, narrowing of the anastomotic suture and pulmonary embolism and one case each of staple-line bleeding and intra-abdominal abscess. Three reoperations and two endoscopic dilatations were required.
  • Thirteen late complications were reported 48 months after surgery, including seven internal hernias and three cases where the anastomotic suture had narrowed. There was also one case each of anastomotic ulcer, foreign body (part of a suction drain) and severe malnutrition. Nine reoperations and three endoscopic dilatations were required.
  • Before they received their gastric bypass, 29 patients had been suffering from high blood pressure. Two years after surgery this had dropped to seven patients (from 14 to two in the proximal group and 15 to five in the distal group).
  • Diabetes declined from 19 patients to two (from ten to two in the proximal group and nine to zero in the distal group).
  • The number of patients with dyslipidaemia – abnormal concentrations of lipids or lipoproteins in the blood – fell from 39 to nine (from 20 to four in the proximal group and 19 to five in the distal group).

“Our study found that both laparoscopic and distal bypass operations were feasible and safe with no deaths” says Dr Muller. “There were no significant statistical differences between the two techniques when it came to weight loss or reducing health issues such as high blood pressure or diabetes.

“However, we were very concerned that one of the distal patients developed severe protein malnutrition, because malnourished patients have high complication rates after surgery. A further operation was carried out to convert the distal bypass to a proximal bypass.

“As a result we now perform proximal gastric bypass surgery as the operation of first choice in morbidly obese patients.”

Note: Obesity kills. 30 minutes of aerobic exercize daily can make a difference. Low calorie diet, keeping carbohydrates to the minimum, no or little bread, no pasta, no rice, no cereals, no potatoes can help. Drinking water several times a day. Eating green vegetables. Weight watchers helps many people. If these don't work, bypass is an option. Liposuction is good for those unresponsive fat deposits. Larry Weinstein, MD FACS

Overresection of the Lower Lateral Cartilages
Wolfgang Gubisch1 and Jacqueline Eichhorn-Sens1: 27 November 2008


Background:  Overresection of the lower lateral cartilages to narrow the tip in individuals with thick skin is a common mistake with functional and aesthetic consequences. The most frequent deformities are external valve dysfunction, alar retraction, alar pinch, tip asymmetry, lack of tip definition, and parrot beak deformity resulting from drooping of the tip.
Methods  In 82 patients who underwent revision surgery from 1998 to
2007 the lower lateral cartilages were missing. To restore function of the external nasal valve and correct aesthetic deformities it is essential to rebuild the anatomical structure. Tip deformities were analyzed pre- and postoperatively based on clinical evaluation and standardized photographs. Patient satisfaction was evaluated subjectively.

Results:  Improvement of the poorly defined tip, the underprojected tip, the overrotated tip, and alar pinch was accomplished in all patients (100%). The function of the external nasal valve was restored in all patients (100%). The postoperative results showed a clear improvement in tip asymmetry (95.0%), tip deviation (76.5%), alar retraction (87.0%), and tip ptosis (85.7%). The average follow-up period was 13.8 months. Forty-eight patients (59.8%) rated the result as “excellent,” 27 (32.9%) as “very good,” 5 (6.1%) as “good,” 1 as 8 0not satisfied” (1.2%).

Conclusion:  Overresection of the lower lateral cartilages to narrow the tip in individuals with thick skin is frequently followed by dysfunction of the external nasal valve and aesthetic deformities. We completely rebuild the structure of the nasal tip. Only an anatomically correct configuration correlates with ideal aesthetics and physiologic function.

Keywords:  Secondary rhinoplasty - Nasal surgery - Lower lateral cartilage - Bending technique
Note: The superior portion of the lower lateral nasal cartilages can be removed to better define the tip. Full removal of these cartilages can cause major problems. The authors results in reoperative cases is interesting. Larry Weinstein,MD FACS

A Novel Bioabsorbable Device for Facial Suspension and Rejuvenation
P. Daniel Knott, MD; James Newman, MD; Gregory S. Keller, MD; David B. Apfelberg, MD

Arch Facial Plast Surg. 2009;11(2):129-135.

To evaluate the safety and efficacy of a novel bioabsorbable suspension device made of a polymer of polylactic acid and polyglycolic acid (Endotine Ribbon), we performed a retrospective multi-institutional case study of 21 patients who underwent minimally invasive or open rhytidectomy with the use of the device in an ambulatory surgery center setting. Twelve patients had an excellent result, 7 a good result, and 2 a fair result. Early complications were corrected with technical modifications. Patient satisfaction was high. The Ribbon is a safe and effective adjunct for performing both minimally invasive and open rhytidectomy and cervical lifting.

Note: I have used this ribbon device with varied success. It can be visualised in the early healing period and while it is dissolving. It offers limited long term improvement as a solitary instrument for face lift. If combined with a zlift face lift results have been appreciated by all my patients. Larry Weinstein MD FACS Chester, NJ

Plastic and Reconstructive Surgery:Volume 123(4)April 2009pp 1321-1331 Factors Contributing to the Facial Aging of Identical Twins

Guyuron, Bahman M.D.; Rowe, David J. M.S., M.D.; Weinfeld, Adam Bryce M.D.; Eshraghi, Yashar M.D.; Fathi, Amir M.D.; Iamphongsai, Seree M.D.
Cleveland, Ohio; and Temple, Texas

From the Department of Plastic Surgery, University Hospitals, Case Western Reserve University; and Division of Plastic Surgery, Texas A & M Health Science Center College of Medicine.Received for publication July 31, 2008; accepted November 12, 2008.

Disclosure: The authors have no financial interests to disclose in relation to the content of this article. Bahman Guyuron, M.D., Department of Plastic Surgery, University Hospitals, Case Western Reserve University, 29017 Cedar Road, Lyndhurst, Ohio 44124, Abstract

Background: The purpose of this study was to identify the environmental factors that contribute to facial aging in identical twins.

Methods: During the Twins Day Festival in Twinsburg, Ohio, 186 pairs of identical twins completed a comprehensive questionnaire, and digital images were obtained. A panel reviewed the images independently and recorded the differences in the perceived twins' ages and their facial features. The perceived age differences were then correlated with multiple factors.
Results: Four-point higher body mass index was associated with an older appearance in twins younger than age 40 but resulted in a younger appearance after age 40 (p = 0.0001). Eight-point higher body mass index was associated with an older appearance in twins younger than age
55 but was associated with a younger appearance after age 55 (p = 0.0001). The longer the twins smoked, the older they appeared (p < 0.0001). Increased sun exposure was associated with an older appearance and accelerated with age (p = 0.015), as was a history of outdoor activities and lack of sunscreen use. Twins who used hormone replacement had a younger appearance (p = 0.002). Facial rhytids were more evident in twins with a history of skin cancer (p = 0.05) and in those who smoked (p = 0.005). Dark and patchy skin discoloration was less prevalent in twins with a higher body mass index (p = 0.01) and more common in twins with a history of smoking (p = 0.005) and those with sun exposure (p = 0.005). Hair quantity was better with a higher body mass index (p = 0.01) although worse with a history of skin cancer (p = 0.005) and better with the use of hormones (p = 0.05).

Conclusion: This study offers strong statistical evidence to support the role of some of the known factors that govern facial aging.

Note: Healthy diet, no smoking and avoiding prolonged sunexposure make a huge difference in facialaging. Larry Weinstein,MD FACS

Safe and Consistent Outcomes of Successfully Combining Breast Surgery and Abdominoplasty: An Update

W. Grant Stevens, MD, Remus Repta, MD, Salvatore J. Pacella, MD, MBA, Marissa J. Tenenbaum, MD, Robert Cohen, MD, Steven D. Vath, MD, David A. Stoker, MD
Background: Combined cosmetic procedures have become increasingly popular. One of the most common combinations of cosmetic procedures includes abdominoplasty and cosmetic breast surgery. The shortened recovery and financial savings associated with combined surgery contribute to the increased demand for these combined surgeries.

Objective: The goal of this study was to evaluate the safety and efficacy of combined abdominoplasty and breast surgery at a single plastic surgery practice that performs a large volume of these cases. This is an update to a study published in 2006.

Methods: A retrospective review was performed for patients who underwent combined abdominoplasty and cosmetic breast surgery during the last 10 years at a single outpatient surgery center. Abdominoplasty inclusion criteria were defined as lower, mini, full, reverse, or circumferential abdominoplasty. Cosmetic breast surgery inclusion criteria were defined as augmentation, mastopexy, augmentation-mastopexy, reduction, or removal and replacement of implants. Pertinent preoperative and intraoperative data were recorded along with complications and revisions.

Results: There were 268 patients during the 10-year period between 1997 and 2007. There were no cases of death, pulmonary embolism, deep venous thrombosis, or other life-threatening complications. The overall complication rate was 34%. Abdominoplasty seroma and scars requiring revision comprised 68% (n = 74) of the complications. The total revision rate was 13%.

Combined abdominoplasty and cosmetic breast surgery was safe and effective in this large series of cases performed at a single plastic surgery practice. The complication and revision rates of the combined surgery were similar to those reported for individually staged procedures. (Aesthetic Surg J 2009;29:129–134.) Note: In my personal experince of 32 abdominoplasties combined with breast augmentation there have been no significant complications. Larry Weinstein, MD FACS

Efficacy of Lidocaine for Pain Control in Subcutaneous Infiltration During Liposuction

Daniel A. Hatef, MD, Spencer A. Brown, PhD, Avron H. Lipschitz, MD, Jeffrey M. Kenkel,

MDBackground: Liposuction remains the most commonly performed aesthetic surgical procedure in the United States. Preoperative infiltration of the subcutaneous tissues with a wetting solution has become standard. These solutions typically contain some amount of lidocaine for pain control. High doses of lidocaine have been demonstrated to be safe, but large amounts of this cardioactive agent during elective cosmetic procedures may be unnecessary.                                                                                 

Objective: A study was designed to examine the effects of wetting solutions with lower concentrations of lidocaine on perioperative pain.  
Methods: Seventeen patients were prospectively randomized to subcutaneous infiltration with one of 3 different lidocaine concentrations: 10 mg/kg, 20 mg/kg, or 30 mg/kg. Intra- and postoperative lidocaine and monoethylglycinexylidide (MEGX) plasma concentrations were measured and the total intraoperative inhalation gas requirements and minimum alveolar concentrations were recorded. Postoperative pain medication requirements were recorded and morphine equivalents were calculated. Patient pain level was subjectively assessed by using a visual analog pain scale.

Results: There was no difference in the intraoperative lidocaine or MEGX concentrations between any of the 3 groups. There was also no statistical difference between the 3 groups when comparing intraoperative inhalational gas requirement, postoperative morphine equivalence requirements, or subjective pain using the visual analog.

Conclusions: Decreasing concentrations of lidocaine in infiltrative wetting solutions did not significantly affect intraoperative anesthesia requirements or postoperative pain with liposuction. Lower concentrations of lidocaine can effectively be used, use of any lidocaine may be unnecessary. Future investigations may examine whether total elimination of lidocaine yields similar results in terms of anesthesia requirements and postoperative pain. (Aesthetic Surg J 2009;29:122–128.)

Note: There is a toxicity from Lidocaine which has been seen in Liposuction patients with excessive doses of Lidocaine administered. This study underlines the waste of this medication and unnecessary risk. Larry Weinstein, MD FACS

Asymmetry Correction in the Irradiated Breast: Outcomes of Reduction Mammaplasty and Mastopexy After Breast-Conserving Therapy

Michael S. Chin, Glen S. Brooks, MD, Kristin Stueber, MD, Anoush Hadaegh, MD, John Griggs, MD, Melissa A. Johnson, MD

Background: There is relatively scant evidence concerning radiation effects on reduction mammaplasty and mastopexy, two procedures which are often used in the irradiated breast to restore symmetry following breast-conserving therapy (BCT). Objective: The purpose of this study is to further examine outcomes of reduction mammaplasty and mastopexy in breast cancer patients previously treated with BCT and radiation. 

Methods: A retrospective search at Baystate Medical Center (Springfield, MA) identified 12 patients who had received external beam radiation and either reduction mammaplasty or mastopexy. Overall radiation doses, including tumor bed boost, ranged from 5000 to 6600 cGy. The mean time between completion of radiation therapy and asymmetry correction was 63 months (range, 5 to 169 months). An overall average of 910 g of tissue was removed from the irradiated breast (range, 180 to 2925 g). The average length follow-up after asymmetry correction was 9 months (range, 1 to 44 months).

Results: In our patients, there were no major complications such as flap loss, tissue necrosis, heavy scarring, infection, or severe deformity. Minor complications in the irradiated breast occurred in 25% of patients and included prolonged edema (n = 1), delayed wound closure (n = 1), and minor scarring (n = 1). Histopathology was unremarkable except for one patient who was found to have recurrent ductal carcinoma in situ.    Conclusions: In the cases reviewed, we did not observe any complications commonly associated with operating in an irradiated field. Good cosmesis and acceptable symmetry were achieved in all patients. Our data suggest that reduction mammaplasty and mastopexy after radiation therapy are relatively safe procedures with risks not significantly higher than either operation performed in patients without radiation. (Aesthetic Surg J 2009;29:106–112.)

Note: Respect for a radiated breast is important. Gentle technique is critical to good outcome. Larry Weinstein, MD FACS

Safety and Effectiveness of Mentors MemoryGel Implants at 6 Years
Aesthetic Plastic Surgery, 05/19/09 Bruce Cunningham1  and Jonathan McCue1

(1) Division of Plastic and Reconstructive Surgery, University of Minnesota Medical School, Mayo Memorial Bldg., 420 Delaware Street SE, Minneapolis, MN 55455, USA

Received: 26 March 2009  Accepted: 14 April 2009  Published online: 13 May 2009


Background  In November 2006, the FDA approved the Premarket Approval PMA applications for the round, cohesive, silicone gel-filled breast implants of Mentor (MemoryGel) and Allergan. Since that time, the devices have been widely available to plastic surgeons and their use is rapidly eclipsing that of the saline breast implants. Patients in the Core clinical studies supporting these approvals continue to be followed through for 10 years, with comprehensive annual patient and physician-reported evaluations of safety and efficacy.

Methods  One thousand and eight (1,008) female patients had data collected on 1,898 implants, and were enrolled at 48 sites. Key complication rates were recorded with Kaplan–Meier estimated cumulative incidence calculation for each.


Rupture rate, suspected and confirmed, for primary augmentation was 1.1% (95% CI, 0.3–4.3), and that for primary reconstruction patients was 3.8% (95% CI, 1.4–9.8). Capsular contracture rates for clinically significant Baker III/IV contracture for primary augmentation was 9.8% (95% C I, 7.6–12.7), and that for primary reconstruction was 13.7% (95% CI, 9.7–19.1). The reoperation incidence for primary augmentation and primary reconstruction was 19.4 and 33.9%, respectively, with explantation and replacement with a study device in 3.9% of primary augmentations and 10.4% of primary reconstructions.


Mentor MemoryGel Silicone Breast implants represent a safe and effective choice for women seeking breast augmentation or breast reconstruction following mastectomy. Keywords  Mentor - Silicone breast implants - Safety - Effectiveness - Outcomes - Follow-up - Rupture - Complications

Aesthetic Plastic Surgery, 05/21/09
Charles Hsu1 , Ronald P. Gruber1, 2 and Amarjit Dosanjh2

(1) Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, 770 Welch Road, 4th Floor, Palo Alto, CA 94304, USA
(2) Division of Plastic and Reconstructive Surgery, University of California (SF), San Francisco, CA, USA
Received: 12 January 2008  Accepted: 22 January 2008  Published online: 19 May 2009


Background  Patients considering a facelift (facial rhytidectomy) need some means of predicting their surgical outcomes. This will help them decide whether to proceed with the operation.


A total of 50 consecutive patients were asked to examine themselves with a hand-held mirror while lying supine on an examining table to give them a reasonable approximation of their postoperative result.


The tissues of the face redrape in a very aesthetic manner when lying completely supine. The appearance that the patient sees of himself or herself during the “supine test” correlated very well with the actual postop result after rhytidectomy consisting of subcutaneous undermining, SMAS plication, and platysmaplasty.


This supine test may be useful in helping patients preoperatively predict their facelift outcomes and may serve as a good adjunct to imaging.

Keywords  Face-lift - Meloplasty - Prediction - Rhytidectomy


Survey Shows Majority of Respondents Openly Discuss Use of BOTOX® Cosmetic and Hyaluronic Acid Dermal Fillers

NEW YORK, NY (June 1, 2009) — Despite what some may think, people
aren’t hiding their use of BOTOX® Cosmetic and hyaluronic acid dermal
fillers.  In fact, according to survey statistics released today by The
Aesthetic Surgery Education & Research Foundation (ASERF), the research
arm of the American Society for Aesthetic Plastic Surgery (ASAPS),
nearly nine out of 10 respondents (87 percent) openly discuss their
BOTOX® Cosmetic and hyaluronic acid dermal filler treatments with
others, with seven out of ten (70 percent) receiving support from the
people they told.

“In a similar survey issued four years ago, we dispelled the myth that
Hollywood and corporate wives were the typical BOTOX® Cosmetic
patient,” says ASERF President Laurie Casas, MD, a plastic surgeon
practicing in suburban Chicago. “Now, demographic and perception data
trends show us that aesthetic injectable treatments have continued to
evolve into mainstream and accepted options for the everyday woman.”

Survey results found that the typical aesthetic injectable patient is a
married, working mother betw
een 41-55 years of age with a household
income of under $100,000.  The survey also found that women receiving
aesthetic injectable treatments are health-conscious and philanthropy
minded, with the majority incorporating exercise (95 percent) and
healthy eating habits (78 percent) into their lives, and many
volunteering with charitable organizations that matter to them (32
percent).   In addition, nearly seven out of 10 respondents believe
that BOTOX® Cosmetic (72 percent) and hyaluronic acid dermal fillers
(65 percent) are important parts of their aesthetic routine.

“Interestingly, among BOTOX® Cosmetic patients, nearly seven out of 10
respondents also received treatment with hyaluronic acid fillers,” says
Dr. Casas.  “Most people have great success with BOTOX® Cosmetic and
dermal fillers; however, we need to make patients aware that even
though injectables are not ‘surgery,’ their administration is a medical
procedure with risks that depend on the training and experience of the
clinician, the clinical setting and the technique used.”

Additional findings of the survey found that 72 percent of respondents
received BOTOX® Cosmetic injections to treat their glabellar lines –
also referred to the “11” – the frown lines in between the brows, while
63 percent of those surveyed received hyaluronic acid dermal filler
injections to treat their na
solabial folds – also known as the
“parentheses” – the lines around the nose and mouth.  A few of the most
frequently cited reasons to receive treatment with BOTOX® Cosmetic was
“to look more relaxed, less stressed” while patients reported choosing
treatment with hyaluronic acid dermal fillers to “look more

Based on its annual survey of U.S. physicians performing cosmetic
procedures, ASAPS recently reported that BOTOX® Cosmetic injections
have remained the most frequently performed procedure since FDA
approval of the product in 2002.  Hyaluronic acid dermal fillers ranked
as the third most popular procedure performed last year.  ASERF
conducted this follow-up survey to quantify the characteristics and
opinions of the patients who receive the treatment to help its members
and the public obtain a better understanding of these important

Survey Methodology

To conduct this survey, ASERF, the charitable, not-for-profit research
arm of American Society for Aesthetic Plastic Surgery (ASAPS), retained
the services of Industry Insights, Inc. an independent research and
consulting firm headquartered in Columbus, Ohio.

In March 2009, a two-page questionnaire, designed by ASERF in
conjunction with Industry Insights, was distributed to 1,818 ASAPS
members to distribute to their BOTOX® Cosmetic and/or hyaluronic acid
=0 Adermal filler patients.  A total of 687 completed and useable forms
were received in time for processing and analysis.  Based on 687
presumably random responses, this study has a +/- 3.7% margin of error
at a 95% level of confidence.  A margin of error of +/- 5% is typically
accepted as the “standard” in association research, so this study’s
+/-3.7% figure indicates a stronger than typical level of statistical

Cosmetic Surgery Fashion Show Makes It's Debut in NYC (2009-05-15) ; Smith, Sonya

Fashion shows in New York are not an uncommon sight but a recent event, hosted by "A Little Nip/A Little Tuck" author, broke the mold on May 14. Instead of clothes, models showed off the latest plastic surgery procedures. The event also included discussion of current topics important to the plastic surgery community including mommy-makeovers, divorce packages, and the introduction of the doc's recession buster package for job seekers looking to remain competitive in the face of the tumultuous economy. Proceeds for the event will benefit LI cares, a local charity that provides food to those in need.

FDA Okays Alternative To Botox
Washington Post (DC) (2009-05-26) ; Mailander Farrell, Jodi

Dysport has been approved by the Food and Drug Administration as a sound injectable treatment. The FDA has mandated Dysport, along with its competitor Botox, to have black-box warning labels detailing the grave risks associated with receiving the injections. Possible side effects of both Dysport and Botox include trouble swallowing or breathing; Botox has been used for therapeutic usage in patients with eyelid spasms, excessive sweating, and cervical dystonia, while Dysport has been approved for use in frown lines and cervical dystonia. Dysport is a derivative of botulinum toxin and has been used as a cheap dermal filler in Europe in previous years. The FDA has said that complications arising from botulinum injectables has been due to misuse of the treatment for conditions such as limp spasticity that have not been FDA-sanctioned.

Draining after breast reduction: a randomized controlled inter-patient study
Leonard U.M. Corion, a, , Mark J.C. Smeuldersa, Paul P.M. van Zuijlena and Chantal M.A.M. van der Horsta aDepartment of Plastic, Reconstructive and Hand Surgery, Academic Medical Centre, Amsterdam, The Netherlands

Received 27 June 2007;  accepted 5 January 2008.  Available online 18 June 2008.


One hundred and seven bilateral breast reductions were prospectively randomized during surgery to receive or not receive wound drains. Fifty-five patients were randomised to have a drain and 52 to not have a drain. There was no statistical difference in the number of complications between the drained and undrained group (P = 0.092; student's t-test for independent observations). Twenty-two of the 55 patients in the drained group had a complication, 12 of the 52 patients in the undrained group had a complication. The hospital stay was significantly shorter (P < 0.001) in the undrained group. The main discomfort score due to the presence of the drains was 5.62, which can be qualified as high.

This study demonstrates that breast reduction without postoperative draining does not increase the risk of complications, increases the patient's comfort and significantly reduces hospital stay.

Keywords: Breast reduction; Drain; Complication; Hospital stay

Note: In over 200 breast reductions I have not found it necessary to use a drain. Larry Weinstein, MD FACS

Experience with the Mentor Contour Profile Becker-35 expandable implants in reconstructive breast surgery


Round expander-implants (Beckers 25 and 50) and anatomical expander-prostheses filled with firm cohesive gel (McGhan Style 150) are established choices for single-stage expander breast reconstruction. Because of their drawbacks we selectively adopted the anatomical Becker-35 expander-implant filled with soft cohesive gel from January 2005.

Patients and methods

All patients undergoing reconstructive breast surgery using the Contour Profile® Becker-35 expandable implant over a two-year period were retrospectively reviewed with respect to indication, implant sizes, inflation details, complications and outcomes.


36 patients, mean age 48.9 years (r=14–69), received 39 anatomical Becker-35 expanders (three bilaterally). Three quarters of these implants (29) were used for immediate breast reconstruction while the remainder was equally divided between delayed postmastectomy reconstruction (5) and correction of congenital breast asymmetry (5). Half of the patients had simultaneous latissimus dorsi myocutaneous flap coverage of the implants.

The median numbers of inflations and deflations needed to achieve the target expansion size and shape were 3 (r=0–7) and 0 (r=0–4), respectively. The mean time from expander insertion to completion of reconstruction was 4.6 months (r=0–13 months). Four patients required surgical intervention for haematoma, implant infection, severe capsular contracture, and palpable rippling. Additionally there were three injection port adjustments, giving a 20% overall revisional surgery rate (8/39 breasts) after a median follow-up of 20 months (r=6–38 months). Four implants (10%) developed significant but asymptomatic rippling. The significant capsular contracture rate was 21% (8/39 breasts), which was related to chest wall radiotherapy.


In this short-term study, the Becker-35 expander was successfully used for single-stage prosthetic breast reconstruction with an incidence of early complications comparable to alternative prostheses. Although it has expanded the range of implants available to the breast surgeon, its exact role in reconstructive breast surgery has yet to be established.

Keywords: Becker-35 expandable implant, Reconstructive breast surgery, Silicone breast implants, Permanent tissue expanders, Prosthetic breast reconstruction, Latissimus dorsi flap

 Nipple-Sparing Mastectomy

Spear, Scott L. M.D.; Hannan, Catherine M. M.D.; Willey, Shawna C. M.D.; Cocilovo, Costanza M.D.Background: The debate over nipple-sparing mastectomy continues to evolve. Over the past several years, it has become more widely accepted, especially in the setting of prophylactic mastectomy, but its role in the treatment of breast cancer has only recently been reexamined.

Methods: Two indications for the procedure are discussed: prophylactic, for the high-risk patient; and the more controversial topic, therapeutic nipple-sparing mastectomy, for the patient with breast cancer. A review of the literature suggests that certain breast cancers may be amenable to retaining the nipple if they meet specific oncologic criteria: tumor size 3 cm or less, at least 2 cm from the nipple, not multicentric, and with clinically negative nodes. Moreover, newer technologies such as magnetic resonance imaging and preoperative mammotome biopsy may make the procedure even safer in this setting. Practical and technical aspects of the procedure are discussed, including patient selection.

Results: The accumulating data from multiple series of nipple-sparing mastectomy show that properly screened patients have a low risk of local cancer recurrence, that recurrences occur rarely in the nipple, and that recurrences in the nipple can be managed by removing the nipple.

Conclusions: Despite continued controversy and the need for more long-term outcome data, nipple-sparing mastectomy is a procedure that is gaining increasing visibility and acceptance. Provided that certain oncologic and practical criteria are applied, it has the potential for allowing less invasive surgery and improved cosmetic outcomes without increased oncologic risk in appropriately selected patients.

Plastic and Reconstructive Surgery:
July 2009 - Volume 124 - Issue 1 - pp 134-143
Reconstructive: Head and Neck: Original Articles

Liposuction and Lipoinjection Treatment for Congenital and Acquired Lipodystrophies in Children
Giugliano, Carlos M.D.; Benitez, Susana M.D.; Wisnia, Pamela M.D.; Sorolla, Juan Pablo M.D.; Acosta, Silvana M.D.; Andrades, Patricio M.D.

Background: The purpose of this clinical study was to establish liposuction and lipoinjection as a noncosmetic procedure in children to correct lipodystrophies.

Methods: Liposuction, fat injection, or a combination of both was performed on 30 patients between 1994 and 2006 at Roberto del Rio Hospital or Clinica Alemana, Santiago, Chile. Liposuction was indicated in patients with excessive amounts of fatty tissue or tumor-like swelling. Combined liposuction and lipoinjection was performed on patients with deficit and excess in soft tissues. Lipoinjection was used for patients with soft-tissue insufficiencies. Samples of fat obtained by liposuction were submitted to histopathologic examination. Traditional tumescent technique was used for liposuction. The supernatant obtained by simple filtration was used for fat injection. Short- and long-term postoperative follow-up included registration of complications and assessment of aesthetic and functional outcome. The kappa test was used for statistical analysis.

Results: Thirty patients, nine boys and 21 girls, were operated on, with an average age of 11 years (range, 4 to 17 years). A total of 43 procedures were performed: 27 liposuctions, 10 lipoinjections, and six combined procedures. Average hospital stay was 1.1 days. Of a total 20 patients who underwent liposuction, six required revision. Histopathologic study showed 19 lipomatoses and one lipoblastomatosis. Cosmetic outcomes based on Strasser scale were as follows: six excellent, 19 good, four mediocre, and one poor.

Conclusions: Liposuction and lipoinjection as sole or combined procedures are safe methods for the pediatric population. They are well tolerated, with a low rate of complications and satisfactory aesthetic results.

Shaping the Breast in Aesthetic and Reconstructive Breast Surgery: An Easy Three-Step Principle. Part III-Reconstruction following Breast Conservative Treatment
Hijjawi, John; Depypere, Herman; Roche, Nathalie; Van Landuyt, Koenraad; Blondeel, Phillip N.

Plastic and Reconstructive Surgery. 124(1):28-38, July 2009.

Summary: Of the relatively few studies that exist regarding the cosmetic satisfaction of patients following breast conservation therapy, several indicate significant dissatisfaction in many patients. Breast conservation often results in some of the most challenging and complex reconstructive problems. Indeed, even defining the problem or analyzing the defect can be difficult for the junior surgeon. For the more seasoned reconstructive surgeon, analyzing the problem and applying solutions may be less difficult, but clearly communicating the defects typically seen after an aggressive lumpectomy and radiotherapy can be difficult, especially with trainees or junior surgeons. The goal of this article, the third in a four-part series, is to provide a template for the analysis and surgical reconstruction of defects resulting from breast conservation therapy utilizing a systematic three-step method. Part I of this series described the three main anatomical features of the breast-the footprint, the conus of the breast, and the skin envelope-and how they interact. By systematically analyzing the breast with this three-step method, a "problem list" based in specific anatomic traits of the breast can be generated, allowing the surgeon to then generate an appropriate surgical plan for reconstruction. Surgical approaches based on the percentage of breast parenchyma resected are suggested, with a focus on glandular rearrangement, breast reduction techniques, and locoregional flaps. The three-step method of breast analysis, evaluating the anatomical deformation of the breast footprint, conus, and skin envelope, remains the fundamental "fall-back" principle of this approach.

(C)2009American Society of Plastic Surgeons

The Impact of Partial Breast Reconstruction Using Reduction Techniques on Postoperative Cancer Surveillance
Losken, Albert; Schaefer, Timothy G.; Newell, Mary; Styblo, Toncred M.

Plastic and Reconstructive Surgery. 124(1):9-17, July 2009.

Abstract: Background: Partial breast reconstruction using reduction techniques has recently increased in popularity. Some fear that combining breast conservation therapy with partial breast reconstruction alters the architecture and will affect patterns of local recurrence and make postoperative cancer surveillance more difficult. The purpose of this series was to evaluate long-term postoperative cancer surveillance.

Methods: The authors retrospectively reviewed the charts and mammograms of patients (n = 17; average follow-up, 6.3 years) who underwent the oncoplastic reduction technique before 2004. Mammography sensitivity was determined by measuring breast density, qualitative changes, and time until mammographic stabilization was determined. These data were compared with those of a control group from the same time period who underwent breast conservation therapy alone (n = 17; average follow-up, 5.9 years).

Results: Typical mammographic findings, including architectural distortion, cysts, and calcifications, were similar between the two groups. There was no significant difference in breast density scores. The oncoplastic reduction group had longer times to mammographic stabilization (21.2 versus 25.6 months, p = 0.23). There was a trend toward a greater number of postoperative mammograms and ultrasounds in the study group when indexed per follow-up year. The rate of tissue sampling in the study group was significantly higher (53 percent) than that in the control group (18 percent).

Conclusions: The oncoplastic reduction technique remains safe and effective, without significantly affecting postoperative surveillance. Mammographic findings were similar to those observed in patients with breast conservation therapy alone, and sensitivity was not affected. It takes longer to achieve mammographic stability and more patients in the oncoplastic group will require additional diagnostic testing.

(C)2009American Society of Plastic Surgeons

Plastic and Reconstructive Surgery:
August 2009 - Volume 124 - Issue 2 - pp 356-363
doi: 10.1097/PRS.0b013e3181aee9a3
Breast: Original Articles

Salvage of Tissue Expander in the Setting of Mastectomy Flap Necrosis: A 13-Year Experience Using Timed Excision with Continued Expansion
Antony, Anuja K. M.D.; Mehrara, Babak M. M.D.; McCarthy, Colleen M. M.D.; Zhong, Toni M.D.; Kropf, Nina M.D.; Disa, Joseph J. M.D.; Pusic, Andrea M.D.; Cordeiro, Peter G. M.D.

Background: Mastectomy flap necrosis after immediate tissue expander placement can have profound implications, resulting in prosthetic infection necessitating tissue expander removal. The purpose of this investigation was to evaluate the safety and efficacy of timed, surgical excision during continued serial expansion in the setting of mastectomy flap necrosis and to identify an algorithm for surgeons faced with the management of this difficult problem.
Methods: Consecutive patients in whom documented mastectomy flap necrosis developed following immediate tissue expander placement from 1995 to 2008 were identified. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database. Medical records were then retrospectively reviewed to further characterize the extent of mastectomy flap necrosis and its management.

Results: Over the 13-year study period, 178 patients with documented mastectomy flap necrosis following immediate tissue expander were identified. In 58 patients (33 percent), surgical excision of the mastectomy flap necrosis was performed. Surgical excision occurred a mean 36 days (range, 8 to 153 days) after tissue expander placement. Mean surface area of eschar excised was 42.5 cm 2 (range, 2.5 to 240 cm2). In nine (15.5 percent) of the 58 patients, resection of such an extensive area of mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure (local advancement flaps, n = 8; latissimus flap, n = 1). Of the remaining patients, only three (6 percent) developed a subsequent infection necessitating the premature removal of a tissue expander.

Conclusions: Timed excision with continued expansion is a straightforward procedure associated with a low incidence of failure. This approach allows for salvage of a significant percentage of threatened tissue expanders and may be coordinated with adjuvant oncologic therapy without excessive delays.


Surgical complications of lipoplasty – Management and preventive strategies
Received 23 June 2008; accepted 30 June 2009. published online 06 August 2009.



Lipoplasty and its associated complications are well researched and documented. In most articles, the focus has been on the major life-threatening complications of liposuction. Most of these major complications are related to conditions other than surgical trauma per se, namely anaesthesia, hypothermia, long duration of surgery and fluid overload. With the exception of pneumothorax and abdominal perforation, surgical trauma does not cause major complications.Although most surgical complications are classified as minor, they present as major events for patients and the treating physician. All efforts to prevent even minor complications to enhance patient satisfaction are needed.This article presents a review of only the surgical-trauma-related complications of lipoplasty and discusses their management and preventive strategy.


A review of 200 consecutive cases of lipoplasty, performed between July 2006 and December 2007, including large-volume liposuctions (LVLs) and combined liposuction abdominoplasties, was undertaken. Complications relating only to the surgical trauma of liposuction were analysed.


Complications such as hyperpigmentation of access points, postoperative fluid collection, asymmetry, irregularity, external genital swelling and haematoma were noted.Postoperative fluid collection and haematoma required active intervention. Drainage of fluid collection using a liposuction cannula was effective and prevented recurrence and the need for repeated aspirations. Major surgical complications such as pneumothorax and abdominal wall perforations could be avoided by following simple rules.


Major complications related to surgery can be avoided by following well-known safety guidelines.To enhance patient satisfaction, minor complications related to surgical trauma need to be addressed aggressively. This article discusses methods to lower the incidence of most surgical complications.Keywords: Liposuction, Complications, Prevention, Safety, Lipoplasty, Seroma

Note: It is rare to have complications from liposuction, I have used cannulas to evacuate seromas and hematomas without significant problems. On a rae occasion indentation warent treatment with release and fat injections.


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