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Plastic Surgery

PROCEDURE: Face-Lift/SMAS Plication

OPERATION PERFORMED: Facelift procedure with SMAS plication, platysma plication and Giampapa suture.

DESCRIPTION OF OPERATION: With the patient supine on the office OR table under satisfactory IV sedation and analgesia, with constant pulse oximetry, EKG and regular BP monitoring, the skin of the face was prepped with PCMX and draped in sterile fashion. A solution of Marcaine and Xylocaine with epinephrine was utilized throughout the procedure. A submental incision was designed and infiltrated as well as the submental fat pad region. Standard preauricular posttragal facelift incisions were also marked and these areas infiltrated with local anesthesia as well as the skin anterior and inferior to the areas. A submental incision was then partially made and a 1.8-mm 3-holed suction cannula utilized to remove considerable quantities of submental fat from this region. The incision was then extended and the submental area opened. Further removal of fat was accomplished as well as undermining of the neck over the platysma medially. The medial borders of the platysma were then plicated with a running 4-0 Mersilene suture.

Attention was then directed to the right side of the face. The previously mentioned incision was made and undermining of the skin carried out anteriorly and inferiorly until a good portion of the underlying SMAS layer was exposed. After hemostasis had been achieved, the SMAS layer was then incised along the inferior border of the zygoma and undermined inferiorly. The SMAS was then placed on stretch and plicated utilizing interrupted 4-0 Mersilene suture. The area of subcutaneous undermining was continued anteriorly to the midline of the neck. An identical procedure was then carried out on the left side. A 3-0 nylon Giampapa suture was then passed bilaterally and sutured to the mastoid fascia resulting in excellent tightening and lift at the cervicomental angle. The submental incision was closed with interrupted 4-0 Monocryl followed by interrupted 5-0 Monocryl followed by a running 5-0 nylon. The facial skin flaps were then placed on stretch and excess skin marked and excised.

Wound closure was then carried out utilizing multiple interrupted 4-0 Monocryl followed by running 4-0 nylon for the scalp and postauricular suture with running 5-0 nylon for preauricular sutures. The patient tolerated the procedure well. Sterile dressing consisting of Xeroform gauze, Red Cross cotton, Kerlix and Kling bandages was then applied. She left the OR and the office after a period of recovery from the effects of sedation.

PROCEDURE: Bilateral Augmentation Mammoplasty

OPERATION PERFORMED: Bilateral augmentation mammoplasty utilizing saline-filled silicone elastomer implants.

INDICATIONS: Patient desires elective cosmetic breast augmentation for small breast size.

PROCEDURE: With the patient supine on the office operating room table under satisfactory intravenous sedation and analgesia with constant pulse oximetry, EKG and regular blood pressure monitoring, the skin of the chest was prepped with Betadine and draped in sterile fashion. Bilateral intercostal nerve blocks along the lateral chest wall were then performed as well as direct infiltration of the subglandular tissue plane as well as circumareolar skin. After time had been allowed for hemostatic and anesthetic effect, incision was made in the right breast. Dissection was carried down to the subglandular space and a pocket bluntly and sharply dissected at this location for placement of an implant. The pocket was then profusely irrigated with a bacitracin-containing solution. Hemostasis was then verified. After due consideration of the pocket present as well as the patient's preoperatively expressed wishes regarding size, 280 mL of normal saline was placed in 270 mL nominal-fill implants bilaterally.

Following placement of the implant and appropriate fill, the wound was closed in layers utilizing multiple 3-0 Vicryl sutures for the breast tissue followed by interrupted 4-0 Vicryl for the subcuticular layer. This was then followed by a running 5-0 nylon subcuticular pull-out suture for the skin. Sterile dressings consisting of Xeroform gauze, flat gauze and paper tape were then applied. The patient was placed in a brassiere. After a period of recovery she left the operating room in good condition.

PROCEDURE: Bilateral Blepharoplasty

OPERATION PERFORMED: Bilateral upper and lower lid blepharoplasty.

INDICATIONS: The patient seeks elective cosmetic surgery for improvement in the appearance of her upper and lower eyelids.

DESCRIPTION OF OPERATION: Prior to being brought to the operating room the patient was marked in a sitting position to identify the tarsal fold of the upper eyelid as well as the amount of redundant skin. The patient was then brought to the operating room. Under satisfactory intravenous sedation and analgesia with constant pulse oximetry, EKG and regular blood pressure monitoring, the skin of the face was prepped with appropriate antiseptic and draped in sterile fashion. An essentially identical procedure was then carried out bilaterally in sequential fashion as follows. The previously identified redundant upper eyelid skin was again marked with methylene blue. The skin was then infiltrated with a solution of Xylocaine and Marcaine with epinephrine.

An infraciliary incision continued laterally into a normal periorbital laugh wrinkle was also drawn. The skin of the lower eyelid was infiltrated with local anesthesia. After time had been allowed for hemostatic and anesthetic effect, the redundant upper eyelid skin was incised and sharply excised. Redundant medial and middle upper eyelid compartment fat pads were exposed through a small incision in the orbicularis oculi fibers. Redundant fat was then teased, clamped, excised and cauterized. The incision was then irrigated with BSS and hemostasis verified. Wound closure was carried out with a running 6-0 nylon subcuticular pullout suture.

Attention was then directed to the lower eyelid. The previously marked infraciliary incision was made and a skin flap elevated off the underlying orbicularis muscle. The middle, medial and lateral orbital fat pads were then exposed and redundant fat clamped, excised and cauterized. Where necessary, the orbicularis fibers were reapproximated utilizing interrupted 6-0 Vicryl suture. The redundant lower eyelid skin was then pulled in a superior and lateral direction. The patient was instructed to look upward and open her mouth. Excess skin was then marked and excised. Hemostasis was then verified. Wound closure was carried out utilizing multiple interrupted 6-0 silk sutures. An application of antibiotic ointment was then applied. The patient tolerated the procedure well and, following a period of recovery from effects of the sedation, left the operating room in good condition.

PROCEDURE: Correction of Ptosis/Levator Plication

OPERATION PERFORMED: Correction of ptosis, right upper lid, with levator plication.

INDICATIONS: This patient has an obvious ptosis of her right upper eyelid which she feels has been interfering with her vision. This has been documented by gross confrontational visual field testing.

DESCRIPTION OF OPERATION: With the patient supine on the office operating room table under satisfactory IV sedation and analgesia, with constant pulse oximetry, EKG and BP monitoring, the skin of the face was prepped with Betadine and draped in sterile fashion. The patient had been previously marked in an upright position to identify location of the pretarsal fold. In addition, the redundant skin of her upper lid was also noted and marked. This area was then infiltrated with a solution of local anesthesia. Redundant skin was excised, and the underlying levator muscle identified. Multiple sutures of 6-0 white Mersilene were then utilized to plicate and thereby shorten the effective length of the levator muscle. The patient was instructed to open and close her eyes and the degree of shortening deemed satisfactory to restore the upper lid to a more normal position. Incision was then closed with a running 6-0 nylon subcuticular pull-out suture. Ophthalmic ointment was applied. Patient tolerated the procedure well.

PROCEDURE: Facelift

OPERATION PERFORMED: Facelift.

DESCRIPTION OF OPERATION: With the patient supine under satisfactory intravenous sedation and analgesia with constant pulse oximetry, EKG and regular blood pressure monitoring, the skin of the face was prepped with Betadine and draped in sterile fashion. An essentially identical procedure was carried out bilaterally on the face as follows. Standard facelift incision extending from the temporal scalp to the preauricular region and posteriorly onto the postauricular skin was marked with methylene blue. This area, as well as the skin adjacent to it, was then infiltrated with a solution of Marcaine and Xylocaine with epinephrine.

After time had been allowed for hemostatic and anesthetic effect, the incision was made and the scalp and skin undermined, exposing the underlying SMAS layer. The SMAS layer was then incised over the zygoma and undermined inferiorly. SMAS was then placed on stretch and tightened with excision where required. The skin was then placed on stretch and, with the assistance of the d'Assumpacao marker, excess skin was excised.

Wound closure was then performed utilizing multiple interrupted 4-0 Vicryl followed by multiple 4-0 and 5-0 nylon sutures. Dressings consisting of Xeroform gauze, Red Cross cotton and a wrap-around Kerlix head wrap were then applied to the facelift portion of the procedure. The patient tolerated the procedure well and left the OR in good condition.

PROCEDURE: Facelift/Lipectomy/Blepharoplasty

OPERATION PERFORMED: Facelift with submental suction-assisted lipectomy; bilateral upper and lower lid blepharoplasty.

INDICATIONS: The patient desires elective cosmetic sugery for facial aging.

PROCEDURE: With the patient supine on the office operating room table under satisfactory intravenous sedation and analgesia with constant pulse oximetry, EKG and regular blood pressure monitoring, the skin of the face was prepped with Betadine and draped in sterile fashion. Prior to being brought to the operating room, the patient was marked in a sitting position to identify the amount of redundant upper eyelid skin. The face lift was performed first in similar fashion in a sequential fashion bilaterally as follows.

Incision extending from the temporal scalp inferiorly to the preauricular region and posteriorly around the earlobe onto the posterior auricular skin was marked with methylene blue and then infiltrated with a combination of Marcaine and Xylocaine with epinephrine. In addition, the fat of the submental region was also infiltrated with local anesthesia. A small stab incision was made at the submental crease and excess fat from the submental region removed by means of suction. Incision was then made and the scalp facial and neck skin incised and undermined. The SMAS layer was identified over the zygoma. This was incised and undermined. The SMAS was then pulled snugly, excess excised and the remainder sutured into position with a running 4-0 Mersilene. The redundant facial skin was then placed tightly on stretch and pulled in an upward and posterior direction. Redundant skin was then marked and excised. Wound closure was carried out utilizing interrupted 4-0 Vicryl subcuticular sutures as well as running 5-0 and 6-0 nylon sutures for the scalp, postauricular and preauricular areas respectively.

With the facelift achieved, attention was directed to the blepharoplasty. This was performed in sequential fashion as follows. The redundant upper eyelid skin was infiltrated with local anesthesia as was the skin of the lower eyelids. After time had been allowed for hemostatic and anesthetic effect, the redundant upper eyelid skin was excised. Attention was directed to the medial fat pads which were exposed through a small stab incision in the orbicularis muscle. The redundant fat was clamped, excised and cauterized. Hemostasis was then achieved. The wound was closed with a running 6-0 nylon subcuticular pullout suture. An infraciliary incision was then made on the lower eyelid, and a skin flap dissected. Redundant lower lid fat was then exposed and excised. The patient was then instructed to open her mouth and look upward, and redundant lower lid skin was marked and excised. After hemostasis was achieved, wound closure was performed utilizing multiple interrupted 6-0 silk sutures.

Following completion of the bilateral lower lid blepharoplasty, ophthalmic antibiotic ointment was applied to all 4 eyelid incisions. A dressing consisting of Xeroform gauze, Red Cross cotton, Kerlix and Kling bandages were then applied and secured with paper tape to provide gentle compression to the neck, submental and lateral face regions. The patient tolerated the procedure well and left the office in good condition after a period of recovery from the effects of the sedation.

PROCEDURE: Removal of Breast Implants

OPERATION PERFORMED: Removal of breast implants.

INDICATIONS: The patient has determined that she is not happy with the rippled appearance nor the feel of her breast implants and desires elective explantation at this time.

DESCRIPTION OF OPERATION: With the patient supine on the office OR table under satisfactory IV sedation and analgesia with constant pulse oximetry, EKG and regular blood pressure monitoring, the skin of the chest was prepped and draped in sterile fashion. An essentially identical procedure was then carried out in bilateral fashion as follows. A solution of local anesthetic was instilled into the patient's previous circumareolar incision scar. After time had been allowed for hemostatic and anesthetic effect, incision was made down to the underlying periprosthetic capsule which was then incised. The implant was then removed. Wound closure was performed after irrigation of the pocket with bacitracin. Multiple interrupted 3-0 Vicryl and 4-0 Vicryl were utilized. The patient tolerated the procedure well and left the OR in good condition.

PROCEDURE: Scar Revision Right Deltoid

OPERATION PERFORMED: Revision of scars of right deltoid.

DESCRIPTION OF OPERATION: With the patient supine on the office OR table, the skin of the right deltoid region was prepped with Betadine and draped in sterile fashion. Two-and-a-half power loupe magnification was utilized throughout the procedure. An elliptical excision was designed on the patient's anterior scar with a skin marking pencil and then infiltrated with a solution of 1% Xylocaine with epinephrine. A much smaller ellipse of the area of depressed skin over the posterior scar was similarly marked, and the skin and surrounding subcutaneous tissues infiltrated with local. Attention was then directed back to the anterior scar which was sharply excised. Hemostasis was achieved utilizing the Ellman. Meticulous closure of the wound was then carried out utilizing multiple interrupted 4-0 PDS suture followed by running 5-0 Monocryl PDS. Sterile dressing consisting of multiple Steri-Strips, Xeroform gauze, flat gauze and paper tape was applied. Attention was then directed to the scar of the posterior deltoid region. A small ellipse of skin was excised. Considerable undermining was then performed. The subcutaneous tissues on either side were advanced as much as possible into the midportion of the wound to therefore increase the depth of the underlying tissue. Approximation was done with interrupted 4-0 PDS suture. The skin was then closed with running 5-0 Monocryl intracuticular suture. Sterile dressing was placed. The patient tolerated the procedure well and left the OR in good condition. Return in 1 week for dressing change.

PROCEDURE: Suction-Assisted Removal of Lipomas

OPERATION PERFORMED: Suction-assisted removal of lipomas of back.

INDICATIONS: This 37-year-old white male had noted 2 slowly enlarging masses of his back which, in his job as a truck driver, have been causing increasing discomfort. Patient presents at this time for removal. It was agreed that an attempt will be made at removal of these masses by suction technique with resort to open standard excision if necessary.

DESCRIPTION OF OPERATION: With the patient in a prone position on the office OR table, the skin of the back was prepped with Betadine and draped in sterile fashion. The 2 large lipomas (each measuring approximately 4 x 6 cm in size and present over the upper right midscapular and left lower midlumbar region) were extensively infiltrated with a solution of dilute Xylocaine with epinephrine. After time had been allowed for hemostatic and anesthetic effect, a small stab incision was made at the lateral periphery of each lesion. Through these incisions it was possible to totally aspirate the lipomatous tissue utilizing a 3.7-mm single-holed suction cannula. Following complete removal of the lipomas, the incisions were closed with interrupted 4-0 Vicryl subcuticular sutures. Sterile compression dressings were placed over each area. Patient will return in 1 week for suture removal.

PROCEDURE: Suction-Assisted Lipoplasty of Hips, Thighs and Abdomen; Augmentation Mammoplasty

OPERATION PERFORMED: Suction-assisted lipoplasty of hips, thighs and abdomen; augmentation mammoplasty, bilateral, utilizing saline-filled implants.

DESCRIPTION OF OPERATION: With patient in a prone position under satisfactory epidural anesthesia, the skin of the hips, thighs and buttocks was prepped with Betadine and draped in sterile fashion. Tumescent technique was utilized. Unwanted fat of the hips, lateral and medial thighs was then suctioned from those locations through small stab incisions at the infragluteal crease and at the lower midback utilizing a combination of Grams and Tulip cannulas. The patient was then placed in a supine position and reprepped and draped, and unwanted fat of the lower abdomen medial thighs and anterolateral thighs removed through small stab incisions. Incisions were closed with interrupted 5-0 Vicryl subcuticular sutures. Sterile dressings were placed. The patient was then placed in a compression garment.

Attention was then directed to the breasts which were prepped with Betadine and draped in sterile fashion. An essentially identical procedure was then carried out bilaterally as follows. Direct infiltration of a solution of Marcaine and Xylocaine with epinephrine was carried out for local anesthesia. At this point in time the patient was carried under intravenous sedation with constant EKG, pulse oximetry and regular blood pressure monitoring. An essentially identical procedure was carried out bilaterally. A circumareolar incision was made and a subglandular pocket dissected for placement of the implant. After the pocket had been dissected, it was profusely irrigated with a bacitracin-containing solution. Hemostasis was then achieved. A McGhan style 468 anatomic-textured implant was then placed in the pocket and 285 mL of normal saline were added to the 270 mL nominal-fill implant.

Wound closure was then carried out utilizing multiple interrupted 3-0 Vicryl and 4-0 Monocryl followed by running 4-0 nylon subcuticular pull-out suture. Sterile dressing consisting of Steri-Strips, Xeroform gauze, flat gauze and paper tape were then applied. The patient tolerated the procedure well and left the OR after a period of recovery in good condition.