Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases.

Published in Aesthetic Surgery Journal, November-December 2006.

BACKGROUND: Although some authors have reported that 1-stage breast augmentation with mastopexy does not increase the risks of surgery, recent literature has raised the question of whether better results might be achieved by staging the procedures.

OBJECTIVE: The authors evaluated the safety and efficacy of 1-stage breast augmentation with mastopexy in their own patients by analyzing long-term complication and revision rates.

METHODS: A retrospective chart review was performed of 186 consecutive patients who underwent primary 1-stage breast augmentation with mastopexy at a single outpatient facility. Patient data recorded included age, body mass index, smoking status, degree of breast ptosis, and any preoperative asymmetry. Operation-related data recorded included type of mastopexy performed, operating surgeon, length of surgery, American Society of Anesthesiologists level, and concomitant procedures. Data on implant type, volume, and position were also collected. Complication and revision rates were recorded and calculated.

RESULTS: Ninety-six patients (44%) received saline implants; 104 (56%) received silicone implants. In most cases, textured implants were placed in submuscular pockets. The mean implant volume was 320 cc. Inverted T mastopexy was performed in 60% of cases, circumareolar in 24% of cases, and vertical or crescent accounted for most of the remainder. No severe complications occurred, although 1 patient developed a late infection that required removal of the breast implant. The most common complication was saline implant deflation (5.9%), although saline implants were used in less than half of cases. Thirty-one patients (16.7%) underwent some form of revision surgery within the average 42-month follow-up period.

CONCLUSIONS: Our review of 1-stage breast augmentation with mastopexy procedures revealed no severe complications. Although the overall revision rate of 16.7% is significant, it is comparable to rates for breast augmentation alone and is significantly lower than the 100% reoperation rate required for a staged procedure. In our experience, it is a safe and effective procedure, although one that is not easy to perform. Patients should be advised of the possibility that a second procedure may be necessary.

— W.G. Stevens, D.A. Stoker, M.E. Freeman, S.M. Quardt, E.M. Hirsch, R. Cohen.

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Laser-assisted breast reduction: A safe and effective alternative. A study of 367 patients.

Published in Aesthetic Surgery Journal, July-August 2006.

BACKGROUND: Although several studies have been published documenting the safety of laser-assisted breast reduction, they have involved only small numbers of patients.

OBJECTIVE: The authors conducted a retrospective chart review of a series of 367 consecutive patients who underwent inferior pedicle laser-assisted breast reduction surgery at a single outpatient facility from 1995 through 2004.

METHODS: All patients received appropriate preoperative intravenous antibiotics and had sequential compression devices placed on their lower extremities before induction of anesthesia. Pedicle deepithelialization was performed using a carbon dioxide laser in continuous mode. Following deepithelialization, an inferior pedicle Wise-pattern breast reduction was performed in standard fashion. In approximately 20% of cases, breast reduction was combined with lipoplasty, facial aesthetic surgery, or abdominoplasty. Minor complications assessed included seroma, hematoma, infection, dog-ear, and incisional wound breakdown. Major complications were defined as >25% nipple/areola necrosis, blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, or death.

RESULTS: No major complications were noted in our series. Two patients with infections required short-term hospitalization for administration of intravenous antibiotics. A total of 47 minor complications occurred in 42 patients (11%), including 36 incisional wound breakdowns, 6 infections, 3 hematomas, 1 seroma, and 1 dog-ear revison. The incisional breakdowns included 25 minor T-zone wounds, 2 nipple-areolar complex wounds, and 9 wounds of the vertical and transverse incisions. No inclusion cysts were noted in any patients.

CONCLUSIONS: Complication rates for our series of patients who underwent laser-assisted breast reduction surgery were consistent with those reported for non–laser-assisted procedures. These results, combined with the benefits and efficient operating time afforded by laser deepithelialization, indicate that laser-assisted breast reduction surgery can provide an alternative to standard methods of deepithelialization for those surgeons with access to a carbon dioxide laser.

— W.G. Stevens, R. Cohen, S.A. Schantz, D.A. Stoker, S.D. Vath, E.M. Hirsch, R. Heck, M.E. Freeman.

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In vitro deflation of prefilled saline breast implants.

Published in Plast Reconstr Surg, August 2006

BACKGROUND: The purpose of this study was to determine whether or not prefilled breast implants retain their volume in packaging.

METHODS: This study examined 32 Poly Implant Prosthesis prefilled textured saline breast implants. All of these implants were within the manufacturer’s expiration date at the time of weighing. No holes were visible on any of the implants. All were weighed on an electronic scale. The measured weight was compared with the expected weight (based on the implant size as specified by the manufacturer) and the percentage deflation was calculated. The manufacturer declined to provide specific information about the manufacture dates of the implants; thus, relative age (rather than absolute age) was examined with respect to percentage deflation.

RESULTS: Of the 32 implants examined, all showed some degree of deflation (range, 8.84 to 57.14 percent; 95 percent confidence interval of the mean, 22.01 +/- 4.17 percent). There was a moderate correlation (r = 0.41) between relative age of the implant and percentage deflation.

CONCLUSIONS: From these results, it is clear that this type of prefilled saline breast implant does not maintain its volume in vitro. If these implants are used, the underfilling could contribute to a higher deflation rate and cosmetic deformity. This risk should be taken into account by plastic surgeons who use this type of implant in breast augmentation procedures.

— W.G. Stevens, E.M. Hirsch, D.A. Stoker, R. Cohen.

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Is it safe to combine abdominoplasty with elective breast surgery? A review of 151 consecutive cases.

Published in Plast Reconstr Surg, July 2006

BACKGROUND: This study was designed to evaluate and compare the complication rates of patients having abdominoplasty without breast surgery with the rates of those having abdominoplasty with various types of elective breast surgery, including breast augmentation, breast reduction, mastopexy, and mastopexy combined with simultaneous augmentation.

METHODS: The data collected represent a retrospective chart review of consecutive abdominoplasty procedures performed at a single outpatient facility by the senior surgeon (W.G.S.) over a 15-year period (1989 to 2004). Two groups were compared: patients who underwent abdominoplasty without breast surgery and those who had abdominoplasty with breast surgery. The second group was subdivided by the various types of breast procedures noted above. The minor complications assessed included seromas, hematomas, infections, and small (5 cm) flap necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. Additional data compiled included age, sex, tobacco use, body mass index, past medical history, American Society of Anesthesiologists physical status level, and operative times.

RESULTS: Of the 415 abdominoplasty procedures, 264 (group 1) did not include simultaneous breast surgery. One hundred fifty-one procedures (group 2) involved simultaneous breast surgery, representing 36 percent of the total. Group 2 was further subdivided into those who had breast augmentation surgery (group 2A, n = 50), those who had breast reduction surgery (group 2B, n = 31), those who had mastopexy surgery (group 2C, n = 28), and those who had simultaneous mastopexy and breast augmentation surgery (group 2D, n = 42). Removal and replacement of implants and capsulectomy/capsulotomy procedures were included in the augmentation group (group 2A). There were no major complications, including flap necrosis (open wound >5 cm), blood transfusions, deep vein thrombosis, pulmonary embolus, myocardial infarction, or death. No patients required hospitalization. No statistically significant associations with complications were noted between groups 1 and 2 (chi-square, 0.0045; p > 0.95, not significant). Furthermore, when subdivided by type of breast surgery, no statistically significant associations were noted among subgroups: group 1 versus 2A (chi-square, 0.96; p > 0.05, not significant), group 1 versus 2B (chi-square, 0.032; p > 0.9, not significant), group 1 versus 2C (chi-square, 0.003; p > 0.975, not significant), and group 1 versus 2D (chi-square, 0.83; p > 0.5, not significant).

CONCLUSION: The results of this retrospective review indicate that combining elective breast surgery with abdominoplasty does not appear to significantly increase the number of major or minor complications.

— W.G. Stevens, R. Cohen, S.D. Vath, D.A. Stoker, E.M. Hirsch.

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A comparison of 500 prefilled textured saline breast implants versus 500 standard textured saline breast implants: is there a difference in deflation rates?

Published in Plast Reconstr Surg, June 2006.

BACKGROUND: This study provides the first large-volume (1000 implant) comparison of the deflation rates of Poly Implant Prosthesis prefilled textured saline breast implants versus a control group of Mentor Siltex textured saline implants.

METHODS: A consecutive series of 500 Poly Implant Prosthesis prefilled textured saline breast implants was compared with a consecutive series of 500 Mentor Siltex breast implants. Each breast implant was evaluated for a 4-year period, and the annual deflation rate (number of deflations during a given year divided by the total number of implants) and cumulative deflation rate (cumulative total of deflations through a given year divided by the total number of implants) were recorded. Statistical significance was calculated using the Fisher’s exact test at year 1 and the chi-square analysis at years 2 through 4.

RESULTS: The cumulative deflation rates of the Poly Implant Prosthesis implants was as follows: year 1, 1.2 percent; year 2, 5.6 percent; year 3, 11.4 percent; and year 4, 15.4 percent. The cumulative deflation rates of the Mentor implants was: year 1, 0.2 percent; year 2, 0.6 percent; year 3, 1.6 percent; and year 4, 4.4 percent. At year 1, the difference between deflation rates was not statistically significant (Fisher’s exact test, p > 0.05). However, at year 2 (chi-square, 13.29; p

CONCLUSIONS: There was a statistically significant difference between the overall deflation rates of Poly Implant Prosthesis prefilled textured saline breast implants and Mentor Siltex breast implants at year 2, year 3, and year 4. After 4 years, the 15.56 percent cumulative deflation rate of Poly Implant Prosthesis implants was over 3.5 times higher than the 4.31 percent deflation rate of the Mentor Siltex implants. There may be several factors contributing to the higher deflation rate seen in Poly Implant Prosthesis implants, including possible in vitro deflation before implantation and silicone shell curing technique. Nevertheless, this statistically significant deflation difference must be taken into account when balancing the risks and benefits of Poly Implant Prosthesis breast implants.

— W.G. Stevens, E.M. Hirsch, D.A. Stoker, R. Cohen.

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Does lipoplasty really add morbidity to abdominoplasty? Revisiting the controversy with a series of 406 cases.

Published in Aesthetic Surgery Journal, July-August 2005.

BACKGROUND: The popularity of plastic surgery “makeover” television programs has increased interest among the public and the medical community in both the positive and negative aspects of combined surgery procedures. In particular, the safety of combining abdominoplasty with lipoplasty became a matter of concern following multiple deaths in Florida and the consequent moratorium on simultaneous abdominoplasty and lipoplasty enacted by the Florida Board of Medicine.

OBJECTIVE: The goal of this study was to evaluate the morbidity of abdominoplasty combined with suction-assisted lipoplasty (SAL) compared to the morbidity of abdominoplasty alone.

METHODS: A retrospective review of 406 consecutive abdominoplasty procedures performed by the senior author (W.G.S.) at a single outpatient surgery center was conducted. Cases were sorted into 2 groups: those that had abdominoplasty only and those that had abdominoplasty with SAL. The SAL group was further subdivided into 4 groups based on the volumes of aspirate removed. The primary groups and subgroups were compared with regard to morbidity. In addition, the location of SAL, age, body mass index (BMI) and surgery time of each patient were evaluated as contributing factors to morbidity.

RESULTS: No statistically significant differences in complication rates were found when comparing abdominoplasty with SAL to abdominoplasty alone. Additionally, the amount and location of lipoplasty, age, BMI and surgery times did not significantly affect patient morbidity. The prevalence of morbidity in all groups compared favorably to parameters established in previous studies of abdominoplasty and SAL.

CONCLUSIONS: This extensive retrospective study provides further evidence that combining abdominoplasty with SAL does not increase patient morbidity compared to abdominoplasty alone.

— W.G. Stevens, R. Cohen, S.D. Vath, D.A. Stoker, E.M. Hirsch.

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Acceleration of textured saline breast implant deflation rate: Results and analysis of 645 implants.

Published in Aesthetic Surgery Journal, January-February 2005.

BACKGROUND: Although inflatable saline implants have been in use since 1965, few studies have examined their deflation rates over time.

OBJECTIVE: We conducted a retrospective study to analyze the deflation rate for Mentor inflatable Siltex saline implants (Mentor Corp., Santa Barbara, CA) for a period of 5 years following implantation.

METHODS: The study group included 645 Siltex inflatable implants placed in 324 patients for primary breast augmentation between 1992 and 1997. The implants were placed by a single surgeon using the same surgical technique. Implant data were obtained from the operative log and patient charts for a 6-year period from 1992 to 1997. All patients were followed for 5 years.

RESULTS: The deflation rate of the implants was 0.3% within the first year of implantation, 2.2% within the first 3 years, and 5.3% over 5 years. The rate of spontaneous deflation per implant year was 0.3% at 1 year, 0.7% at 3 years, and 1.0% at 5 years. The deflation rate was lower than the expected deflation rate reported in the manufacturer’s product insert data sheet.

CONCLUSIONS: The rate of spontaneous implant deflation per year was demonstrated to increase with time. Further studies are needed to ascertain the long-term deflation rates for each type of breast implant.

— W.G. Stevens, D.R. Fellows, S.D. Vath, D.A. Stoker.

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“Extreme” cosmetic surgery: a retrospective study of morbidity in patients undergoing combined procedures.

Published in Aesthetic Surgery Journal, July-August 2004.

BACKGROUND: It is increasingly common for patients to request that multiple cosmetic procedures be performed during a single operation. The advantages of combined procedures include a single recovery period, reduced surgery costs, and faster patient gratification. Traditional surgical thinking, however, has favored the performance of some procedures individually in an effort to decrease complications associated with prolonged anesthesia.

OBJECTIVE: The goal of this study was to determine whether performance of combined cosmetic surgery procedures results in increased morbidity.

METHODS: Two hundred forty-eight abdominoplasties performed by the same surgeon over a 10-year period were reviewed retrospectively. Four groups of procedures were compared: abdominoplasty alone, abdominoplasty combined with breast surgery, abdominoplasty combined with facial surgery, and abdominoplasty combined with both breast and facial surgery.

RESULTS: No statistically significant differences in complication rates were found among the four groups. The prevalence of morbidity in all groups compared favorably to the parameters established in previous reviews.

CONCLUSIONS: The results of this retrospective review do not indicate that the combination of cosmetic surgical procedures increases morbidity. The potential benefits of combined procedures may be considered with the expectation of comparably low complication rates.

— W.G. Stevens, S.D. Vath, D.A. Stoker.

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An integrated approach to the repair of inverted nipples.

Published in Aesthetic Surgery Journal, May-June 2004.

BACKGROUND: Many methods for the correction of the inverted nipple have been described, but no consensus has been reached as to which is the best approach.

OBJECTIVE: We describe an integrated approach to the correction of nipple inversion that minimizes ductal disruption.

METHODS: We performed initial nipple eversion using gentle traction with a skin hook. The nipple base was approached with the use of an inferior periareolar incision through the subcutaneous tissue. Blunt dissection parallel to the ducts restored varying degrees of projection. Selective ductal division was performed as necessary to obtain complete eversion with normal projection. To maintain the nipple in an overcorrected position, we placed a nylon traction suture through the center of the nipple and affixed to a stent consisting of a medicine cup and gauze padding.

RESULTS: In a series of 21 patients, nipple eversion was maintained after at least 1 year’s follow-up.

CONCLUSIONS: The technique for correction of nipple inversion reported here is focused on blunt dissection through vertical spreading parallel to the lactiferous ducts, with selective division of only those ducts that restrict nipple projection. The use of traction stenting helps ensure eversion and protects the repair. The technique produces excellent results without recurrence of nipple inversion.

— W.G. Stevens, D.R. Fellows, S.D. Vath, D.A. Stoker.

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The endotine: A new biodegradable fixation device for endoscopic forehead lifts.

Published in Aesthetic Surgery Journal, March 2003.

BACKGROUND: No single technique for fixation of the scalp after endoscopic forehead lift is universally accepted, and complications such as alopecia and regression of elevation have been reported with all techniques.

OBJECTIVE: This report describes the preliminary results of a study of the Endotine 3.5 forehead device (Coapt Systems, Inc, Palo Alto, CA), a new biodegradable fixation device.

METHODS: The Endotine 3.5 device consists of a post on the deep side for anchoring it in the skull and five tines on the superior side for engaging the deep scalp tissues. It was tested in 9 patients, with postoperative follow-up ranging from 6 to 8 months. The surgeon evaluated the device for difficulty/ease of use, palpability, postsurgical pain, and wound healing.

RESULTS: The Endotine 3.5 device produced a secure fixation without problems or complications, although it was often palpable with moderate degrees of sensitivity. It could be applied in less than 2 minutes per side.

CONCLUSIONS: Our preliminary findings indicate that the Endotine 3.5 forehead device provides rapid, secure fixation without the complications associated with other fixation techniques. After patients reported that it was still palpable up to 24 weeks after implantation, a second-generation polymer that dissolves more rapidly was fabricated. Further studies are under way to evaluate long-term efficacy.

— W.G. Stevens, D.B. Apfelberg, D.A. Stoker, S.A. Schantz.

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Complications of injectable synthetic polymers in facial augmentation.

Published in Dermatol Surg, October 1997.

BACKGROUND: Injectable synthetic materials have been used for augmentation of soft tissue defects, correction of wrinkles, and augmentation of facial features such as the nasal dorsum. Success has been limited by inflammatory reactions, material migration, and the difficulty of removal should complications occur.

OBJECTIVE: To evaluate complications resulting from soft tissue augmentation with injectable alloplastic materials.

METHODS: Retrospective review of seven cases. Clinical history, treatment, histopathologic findings, and outcomes are assessed.

RESULTS: Inflammatory reaction and tissue damage were refractory to antibiotics and steroids, and surgery was required to remove the foreign material. Histologic examination revealed giant cell foreign body reaction in all cases.

CONCLUSION: Injectable synthetic polymers can produce significant complications including deformity and inflammatory tissue destruction, the control of which is complicated by the difficulty of removing the materials. Removable tissue fillers, such as e-PTFE, or natural materials such as collagen, autologous, fat, or Alloderm, should be considered instead.

— C.S. Maas, I.D. Papel, D. Greene, D.A. Stoker.