(1) Lip enhancement and shortening
Montreal, Quebec
Vermilion incision, dermis and GoreTex grafts, fat grafts, collagen… we have tried them all on many occasions with mixed results, the worst being the vermilion incision. In the last three years, we have started the VY technique published by Dr Reza Samiian and so far we are more than pleased with the results. Complications are few. Added fullness can be achieved by secondary revision. Lip sensation has been maintained in all cases.
(2) Avoiding the pitfalls of breast augmentation with smooth-walled and textured inflatable implants
PG Whidden
Calgary, Alberta
The author reviews his experience with smooth-walled and textured inflatable implants clarifying the indications for and the pitfalls of the use of each device in the management of congenital and acquired deformities of the female breast.
(3) Hair problems following facelift surgery
Montreal, Quebec
Problems with hair position or hair loss are often brushed away by the attending surgeon as the inevitable drawback to achieve adequate correction. Unhappy patients will eventually seek advice from another surgeon who may inform them either that their problem could have been prevented by choosing alternative procedures or be more discreet and offer some corrections. This presentation will offer some preventive alternatives along with ways to correct postoperative alopecia and visible hairline scars by using a combination of surgical revisions for repositioning, folicular grafting and pigmentation.
(4) Correcting the plunging tip/witch’s smile deformity
DC Birdsell
Calgary, Alberta
Some people who present for reduction rhinoplasty perceive that when they smile they `look like a witch’. Analysis of the anatomic features in these situations reveals, as well as a large nose, some combination of:
- a labial columellar angle that is too acute and decreases on smiling
- a prominent caudal margin of the septal cartilage
- a short, thin upper lip
- a relatively deficient anterior maxilla
- and “active” smile muscles that stretch the upper lip and elevate the alae.
The author describes a technique whereby the muscles are liberated from the anterior maxilla and nose, the nose is reduced, and the tissue obtained from the nose is used to alleviate the deformity.
(5) The Obagi Skin Program
HJ Shimizu
Edmonton, Alberta
The Obagi Skin Program continues to be a valuable adjunct to our cosmetic practice. Our experience has been that skin health can be achieved with the use of Obagi skin creams and Retin-A. The Obagi Skin Program combines the best effects of Retin-A, Alpha Hydroxy Acids, Hydroquinone and the Mikuda Complex 272. Because of the success of the cream program, the Obagi TCA peel has been changed for treatment of limited areas of `peel’ for acne treatment. We will demonstrate the use of our skin program with a presentation of several patients who have been treated using the above program.
(6) Advances in secondary rhinoplasty
RJ Rohrich
Dallas, Texas
Secondary rhinoplasty over the last decade has included a refinement of anatomy, analysis, approach and use of autogenous material. The anatomic refinements include an increased understanding of the blood supply of the nasal tip and enhanced understanding and critical analysis of the patients to establish preoperative goals. The use of the external approach has allowed for increased visualization and correction of secondary nasal deformities using nondestructive techniques to reconstruct malaligned or distorted anatomy. Finally, the use of autogenous cartilage is a critical element in secondary rhinoplasty. These principle advances in secondary rhinoplasty will be demonstrated and established by case analysis
(7) Painless hair transplantation
DJ Seager
Scarborough, Ontario
How to achieve perfect pain control during hair transplantation will be discussed in detail. Suitable preoperative sedation, intravenous sedation with fentanyl and/or midazolam, different varieties of needleless injectors and effective application of topical local anaesthetic such as EMLA will be discussed in detail. An overview of the use of local anaesthesia during hair transplantation will be discussed. This will include details of techniques for administering large amounts of local anaesthesia in a painless manner without toxicity, the optimal placement of local anaesthetic solution, the preparation and the contents of the local anaesthetic solution itself. Recognition of early symptoms and signs of toxicity of local anaesthetic, and its treatment, the use of local anaesthetic with adrenaline in cardiac patients and patients on beta-blockers will be discussed. Beta-blocker adrenaline interaction and its treatment will be reviewed. Finally, postoperative pain management including reduction of incidence and treatment of postoperative neuralgia will be discussed.
(8) Breast augmentation — infra-areolar approach
K Rai
New Westminster, British Columbia
Experience with infra-areolar augmentation mammaplasty and its sequelae is presented. Although scars look good and indiscernible, the consequences must be emphasized. Sensory paresthesia and residual numbness in the incision is a lot higher than one thinks. During augmentation mammaplasty procedure, splitting of the breast to reach the pre-pectoral or retro-pectoral plane does create some concern and the likelihood of `future hernia’ is a possibility, so fascial planes must be closed anatomically. Herniation of implant in the infra-areolar complex is difficult to treat, and is managed by repositioning implants in subpectoral plane with capsular repair of breast tissue to prevent future hernia and maybe a small prosthesis replacement done. Herniation of implant on the inframedial side of the breast could also possibly occur, and can be treated by capsular repair if conservative management fails. Distortion of the breast during pectoralis major contractures can be minimized by detachment of medial fibres of pectoralis major. Infra-areolar augmentation mammaplasty should be recommended with caution and its limitations mentioned to patients seeking augmentation mammaplasty.
(9) Implications of retained silicone-gel breast implant capsules
WJ Peters, D Smith, S Lugowski, C Baines
Toronto, Ontario
Because breast implant capsules have been thought to resolve uneventfully, and because capsulectomy adds to morbidity and expense, and can increase deformity, surgeons have often elected to leave capsules in place when gel implants are removed. Recent evidence, however, suggests that failure to remove capsules may result in several potential problems. Retained capsules may function as a reservoir for high levels of silicone and other foreign materials. We have analyzed the silicon levels in over 100 capsules from gel implants. The median silicon levels in these capsules were approximately 10,000 � g/g, compared to 0.093 � g/g for control breast tissue. There were no significant differences associated with implant status (intact, leaking or ruptured), duration in situ, or year of implantation. In addition, analysis of capsules from 20 `low-bleed’ implants demonstrated that they retained `low-bleed’ properties for only two to three years. Then they behaved as `high-bleed’ implants. Cases are also presented of retained implant capsules that resulted in: a spiculated mass — suspicious for carcinoma, dense calcifications that obscured imaging of adjacent breast tissue, and persistent serous effusions. To avoid these complications of retained breast capsules, total capsulectomy should be considered when silicone-gel capsules are removed.
(10) The `no touch’ submuscular saline breast augmentation technique
RA Mladick
Virginia Beach, Virginia
The `no-touch’ technique using saline implants has been used in approximately 1700 patients. The refinements of this technique over the past 20 years have virtually eliminated capsule formation and have produced soft, natural-looking breasts. The technique’s heightened sterility attempts to eliminate any contamination with bacteria from the skin or breast. In addition to eliminating capsules, a benefit of the technique is that there have been no infections of the entire series. Details of the technique, including a precise muscle release that minimizes muscle distortion, folds and sagging, is emphasized.
(11) Circumferential `intermediate’ lipoplasty of the legs
RA Mladick
Virginia Beach, Virginia
Circumferential intermediate lipoplasty of the thighs and lower legs is an expansion of the traditional lipoplasty technique. Rather than limiting the correction to defined bulges, the goal is to thin the thigh and/or the calves and ankles circumferentially. This procedure is indicated for selected patients with extremely heavy thighs, with large medial, lateral and anterior thigh bulges. In the calves and ankles, circumferential lipoplasty reduces the entire lower leg, giving a more attractive result rather than just reducing the medial and lateral ankle bulges. The concept of intermediate lipoplasty is introduced. This technique has advantages over the superficial technique and the traditional deep lipoplasty. No special equipment, incisions, drains or change in technique is needed. Using circumferential intermediate lipoplasty to contour the entire lower leg results in a slimmer looking leg. There has been no increase in complications. The author reviews his experience with this technique.
(12) Applying the techniques of limited abdominoplasty to full abdominal repair
TS Wilkinson
San Antonio, Texas
The evolution of abdominoplasty involves shortening of incisions, more rapid plication and extended application of liposuction. The primary principle is to avoid tension in the flap closure. This is accomplished by `floating’ the umbilicus, smaller skin resections, separating the umbilicus and closing the umbilicus site in the midline to maintain length and upward fixation of the mons. To conform to current clothing, the `French line’ advancement procedures are indicated and may be extended to advanced undamaged flank skin onto this abdominal wall to allow resection of unsightly abdominal skin. The short, upturned incision of limited abdominoplasty rarely requires extension for complete abdominal repair.
(13) Lip enhancement, reduction, lengthening and rejuvenation
TS Wilkinson
San Antonio, Texas
Changes in the appearance of the lip are an essential factor in aesthetic surgery. Procedures are developed with minimal visible scarring, minimal complications, and the most rapid return to normal activity. For the normal or atrophic lip, enhancement involves multilevel tunnelling with insertion of autologous tissue. Foreign bodies, such as GoreTex, are contraindicated. Concentrated fat placed by the withdrawal technique is affected in all but the underdeveloped lip. In these individuals, the double V-Y or `lip roll’ procedure provides new vermillion by advancing wet vermillion from beneath the lip. `Permanent edema’ completes the procedure. Lip lengthening is accomplished from within the nostril by separating the orbicularis forcing it downward by degloving the upper maxillary and anchoring it into position. Lip rejuvenation involves filling the furrows that may be apparent only with speaking, filling the superficial furrows and dermaplaning the ridges on either side of the wrinkles, filling the depressions with autologous tissue (fat grafting) and applying a controlled burn to the surface. In contrast to laser and dermabrasion burns, the intermittent light “35% TCA” program with frequent line touch-ups almost completely eliminates the risks of hypo- and hyperpigmentation and, yet, restores the lost elements.
(14) Recent trends in hair restoration surgery
DR Brown
Chicago, Illinois
State of the art techniques of male and female pattern hair loss and subsequent restoration will be discussed. The importance of patient selection and some of the critical factors in achieving a completely invisible restoration are discussed. Included are selection of hair, site of hairline, alignment of hair follicles, and number of grafts per session. Female pattern loss is presented with the variables necessary to achieve patient satisfaction. Male pattern reduction will be discussed with its indications and limitations.
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