The American Journal of Cosmetic Surgery

Maintaining and improving the quality of advanced education in nationally recognized cosmetic surgery fellowships is a primary aim of the American Academy of Cosmetic Surgery (Academy). The Academy is an accredited council of professionals devoted to postgraduate medical education in the field of cosmetic surgery. It is the nation's largest multi-disciplinary medical organization that exclusively devotes its educational efforts to cosmetic surgery.

To define a subgroup of postblepharoplasty patients with persistent lower eyelid retraction despite attempted lower eyelid reconstruction and midface-lifting, and to propose a revisional midface-lifting procedure to address complex cicatricial patterns in these patients.

This is a retrospective observational case series of consecutive patients with bilateral persistent cicatricial lagophthalmos from lower blepharoplasty despite prior lower eyelid reconstruction and midface-lifting. An approach for midface-lifting and lower eyelid reconstruction was designed that consisted of transconjunctival, sublabial, and temporal approaches to the subperiosteal space with manual distraction cicatricial scar matrix lysis. Routine postoperative evaluation of clinical outcome, safety, patient satisfaction, and photographic analysis was performed.

A total of 8 patients who underwent revisional midface-lift surgery (15 ipsilateral surgeries) were identified. In all 15 cases, a 3-dimensional cicatricial matrix was identified that involved the lower eyelid and midface and limited visual exposure of the subperiosteal space and mobility of the midface despite complete subperiosteal release to the sublabial incision. Manual anterior distraction of the midface via the sublabial incision provided a mechanism for lysis of the cicatricial matrix. Improved midface mobility allowed successful vertical fixation with maximal anterior lamellar recruitment and lower eyelid support. No complications were encountered. All patients reported improvement in cosmesis and ocular comfort. Average improvements in lower margin to reflex distance (MRD2) was 0.9 mm, scleral show was 0.8 mm, palpebral fissure height at the medial limbus was 1.2 mm, and palpebral fissure height at the lateral limbus was 1.2 mm.

Patients who presented with postblepharoplasty cicatricial lagophthalmos after unsuccessful lower eyelid reconstruction, including midface-lifting, may have a complex 3-dimensional cicatricial matrix involving the lower eyelid and midface. A combined transconjunctival, sublabial, and temporal subperiosteal approach with manual scar matrix release for midface elevation and lower eyelid support is a safe and effective management paradigm.

Traditionally, liposuction techniques have been used to address excess abdominal fat, and abdominoplasty procedures have been used to address excess abdominal skin and abdominal muscular laxity. The Avelar lipoabdominoplasty is a procedure that combines abdominal liposuction with abdominoplasty and can address all of these issues with a single operative procedure. In this series, we report on our initial operative results using this operative technique.

A total of 67 patients underwent Avelar lipoabdominoplasty during the period from November 2004 to June 2006 and were included in this series. Intraoperative and postoperative complications were recorded. Overall patient satisfaction with the procedure was recorded as well.

Patient satisfaction surveys were recorded for all 67 patients who underwent Avelar lipoabdominoplasty in this series. In all, 55 patients (82%) stated that they were very satisfied with the procedure, 9 patients (13%) stated that they were satisfied with the procedure, 2 patients (3%) stated that they were somewhat satisfied with the procedure, and 1 patient (2%) expressed dissatisfaction with the procedure. No intraoperative complications were encountered for patients undergoing the Avelar lipoabdominoplasty in this series. Postoperative complications during this series were recorded and included 4 seromas (6%), 5 minor wound infections (7%), and 2 minor skin necroses (3%).

The Avelar lipoabdominoplasty is a safe and effective operative technique that can address excess abdominal fat, abdominal muscular laxity, and excess abdominal skin with a single operative procedure. The technique is associated with a high level of patient satisfaction and is more rapid than traditional abdominoplasty techniques.

Many investigators have evaluated the utility of local anesthetic use before, during, and after augmentation mammoplasty. Routes used include subcutaneous injections, intercostal nerve blocks, pump infusions, drain infusions, and “splashing” into the submuscular pocket. Although many of these techniques yield statistically significant results, they can add time to the operation and can cause additional complications. In particular, local anesthetic pump infusions add significant cost and require a foreign body to be in contact with the skin in a pocket with a sterile implant. We sought to find an affordable solution that would decrease postoperative recovery time, reduce narcotic requirements, and decrease pain in the early postoperative period without adding significant cost or risk to the procedure.

To determine whether Marcaine placement into the breast pocket during breast augmentation actually improves patient pain in the early postoperative period, and to determine whether this therapy has any detrimental effects.

This double-blind, randomized study was undertaken to compare the effects of placing 10 mL 0.25% Marcaine with epinephrine into 1 or both breast pockets of each patient undergoing bilateral breast augmentation. We sought to evaluate whether this therapy improved postoperative pain and to assess the safety of using Marcaine for this purpose.

A total of 26 patients voluntarily enrolled in and completed our study. Of these, 25 received Marcaine in 1 or both breast pockets. In all, 24 patients reported less pain on the Marcaine-infused side, and 1 believed that her pain was equal in the 2 breasts. Among 4 patients who received Marcaine in both pockets, no narcotics were required in the recovery suite. No negative reactions to Marcaine were reported in any patient, nor were any infections or hematomas noted.

Placing 10 mL of 0.25% Marcaine with epinephrine into each breast pocket during breast augmentation is a safe and effective form of early postoperative analgesia.

This study evaluates postoperative nausea and vomiting (PONV) after bilateral submuscular saline breast augmentation surgery. The efficacy of a particular protocol of medications and anesthetics, used during the preoperative, intraoperative, and postoperative phases of care, is evaluated.

Preoperatively, all but 2 patients (who were allergic to sulfa) received 200 mg of Celebrex capsule, a cyclooxygenase (COX)-2 inhibitor, along with Alka Seltzer Gold or Bicitra, and had the option of taking 5 mg of Valium. Six patients with a prior history of nausea and vomiting were given Emend 40 mg PO within 3 hours of surgery, and Benadryl was withheld from these 6 patients to evaluate the effects of Emend. All patients received intravenous propofol, Versed, and fentanyl for induction. Intraoperatively, they were given intravenous Zofran 4 mg, Benadryl 25 mg, and Decadron 8 mg. Sevofluorane gas was used, and no nitrous gas was used. Postoperatively, patients were advised to take Celebrex. They were given supplemental prescriptions for Zofran ODT 4 mg and Valium 5 mg. Patients were advised that they could use antacids like Rolaids or Turns for postoperative nausea if needed. The questionnaire evaluated PONV on the day of surgery and on the following 2 days; patient satisfaction with the overall surgical experience was evaluated, and results of their operation were reported on a scale from 0 to 10.

In all, 72.6% of the 241 patients reported no nausea and vomiting on the day of surgery. The numbers of patients who reported no nausea and vomiting on the first and second days after surgery were similar, at 73% and 75.5%, respectively. On average, the remaining 27.4% had some PONV (“3” on the 0 to 10 scale) on all 3 days. A total of 94% of patients reported a “10” to rate their overall experience, and 90% gave a “10” rating for the results of their operation.

My approach, which evolved over 10 years with 3000 patients, has improved my results from several days of extreme postoperative nausea and vomiting to almost zero. I attribute much of this success to the use of Decadron, Zofran, Benadryl, and Emend, all of which may affect multiple pathways and nausea receptor sites. During surgery, I use a laryngeal mask airway (LMA) and eliminate nitrous; I believe this may help decrease postoperative nausea and vomiting. I also use Celebrex, which may possibly lower the amount of narcotic needed during and after surgery. Finally, I believe that the outstanding level of patient satisfaction reported in the study is directly related to the fact that patients had minimal or no nausea and vomiting after surgery.

Body dysmorphia disorder (BDD) is defined as a preoccupation with an imagined or a very slight defect in physical appearance that causes significant distress to the individual. Patients with body dysmorphia may approach cosmetic surgeons or dermatologists seeking surgery or medical treatments, and this places the doctor at risk of having a patient who is continually dissatisfied with whatever is done.

With BDD there is preoccupation with the supposed appearance problem. The patient takes actions to “hide” the defect or avoid certain situations because they feel ugly and do not want to be seen by others. Many patients with BDD also suffer from depression and from obsessive compulsive disorders, such as eating disorders, anxiety disorders, trichotillomania (hair pulling), and abuse of drugs or alcohol. There is a high rate of suicidal ideation.

Serotonin-reuptake inhibitors (SRIs) are a group of medications that appear to be useful and effective in patients with BDD. Cognitive behavioral therapy appears to be an effective treatment for BDD. The behavioral component consists of exposure and response prevention, where the patient exposes his or her defect in situations that they would usually avoid and response prevention involves helping the patient stop the compulsive behavior related to the defect.

Treatment for patients with BDD is medication, usually SRIs, or psychiatric care with cognitive behavioral therapy. Surgeons need to identify patients with BDD before surgery, tell them that surgery is not the treatment for their problem, and refer them to a psychiatrist for treatment.