Always a tinkerer, Robert Louis Cucin, M.D., was kicked out of middle school for making a radio-controlled stink bomb. The plastic, reconstructive and general surgeon and clinical instructor at Cornell Medical School, Manhattan, says his father, an electrical engineer, asked only one question when the principal summoned him for his son's mischief.

"My father asked the principal if I had used the AM band or the FM band. When he was told that I had used the FM band (which was pretty swift on my part) he wasn't as angry," the surgeon recalls with a chuckle.

Dr. Cucin has since graduated with a medical degree from Cornell Medical College; a law degree from Fordham Law School, Manhattan; and an MBA from Columbia University, New York City. A quarter century into his practice as a plastic surgeon, this 60-year-old Mensa member is betting that his latest venture, BioSculpture Technology, is the answer to liposuction.

LIPO ÉLAN "I wanted to come up with a way to make liposuction simply more elegant, with a lot less risk and effort for the surgeon," Dr. Cucin says.

The problem, he says, is that surgeons who perform liposuction have to shove cannulas back and forth underneath the skin thousands of times during each liposuction procedure.

"Every time the doctor pushes it forward, he is bruising the tissue and possibly injuring blood vessels and causing bruising and swelling," Dr. Cucin explains.

"Most surgeons find liposuction physically demanding. Sustained exertion and physical fatigue may result in compromised results, and liposuction's strenuous nature induces a tremor, which can affect your scheduling."

What's worse, he says, is that liposuction is traumatic for patients. Liposuction patients are swollen and sore for weeks, post-operatively. Aesthetic outcomes may be less than optimal — characterized by an uneven, wavy and lumpy appearance. Larger-volume liposuction procedures pose the risk of significant blood loss for patients, and revisions and touch ups are common.

"Taking this as a basic scenario, you want to make things better," he says.

THE LIGHT BULB Dr. Cucin says that single-tube reciprocation is not the whole answer. "The vibrating cannula moves through the tissue with a little less resistance, but you really have not saved the doctor the effort or the patient the trauma of those thousands of to-and-fro motions.

The only thing that really can change that is when you can move it back and forth two inches — similar to a normal surgeon's stroke. And the only way you can do that safely is to ensheath the tube [a tube within a tube] that is moving," he says.

Dr. Cucin explains that he believes he has solved the problem by creating exactly that: a twin-cannula design, which allows for faster, more effortless and less traumatic procedures with more precise fat removal.

"Every time it moves forward, it is not shoving into the patient; you are merely positioning the outer tube where you want to remove the fat," Dr. Cucin says.

Using his technology, surgeons save themselves and their patients thousands of these back and forth blows. "Here, you have a machine," he says. "You put it where you want it and are really just concentrating on sculpting as if you were using an electric sander, unleashing the artist in the surgeon."

TO MARKET, TO MARKET BioSculpture Technology, which started as a way to make his own liposuction practice easier and to improve results, has blossomed into a commercial venture.

Dr. Biesman

PROTECTIVE PROTOCOL To protect patients' eyes, physicians inserted specially designed plastic corneoscleral lenses (Oculo-Plastik; Montréal) before treatment, first applying two drops of topical ophthalmic anesthetic solution — the only anesthetic patients required, states Brian S. Biesman, M.D., assistant clinical professor of ophthalmology, dermatology and otolaryngology at Vanderbilt University Medical Center, Nashville, and the study's lead investigator.

Investigators typically began treatments at a setting of 32.5 (13 J), increasing or decreasing until patients reported discomfort of two to 2.5 on a four-point ascending scale. They also applied ThermaCool TC Coupling Fluid (Thermage) throughout treatment. Researchers — along with independent observers working from digital photos and patients themselves — then evaluated results at several intervals for six months post-treatment.

"The correlation between the treating physicians' evaluations, patients' reports and those of independent observers was very high," and no significant complications occurred, Dr. Biesman adds.

Dr. Carruthers

EYE SPY Furthermore, Dr. Biesman says that he left one very unexpected observation out of his report: in 40 to 50 percent of patients, "It appeared to the independent observers scoring the photographs as if some reduction in the fat prominence had occurred in the lower eyelids." He says that, while he's unsure whether this observation reflects true change in the orbital fat, he clearly has seen the same effect in at least one patient treated after the study.

"We seemed to see a toning of the skin, which appeared to pull the fat back in a bit. I don't believe there was a direct effect on the fat. It was more like a girdle" tightening the skin over the fat, explains Jean D. Carruthers, M.D., clinical professor of ophthalmology at the University of British Columbia, Vancouver, and a study co-author.

"There seemed to be a dose-response curve" among patients her office treated, she adds. While most patients received five passes, Dr. Carruthers notes, "The one patient we did eight passes on had a bigger lift."

SKIN SUBTLETIES Conversely, Dr. Biesman says, "The biggest drawback to this technique is the variability of response. More patients got a modest response than a dramatic one, which is true of skin tightening in general."

Dr. Toriumi

INJECTION ISSUES There is a rapidly growing selection of injectable filler materials available in the U.S. Restylane and Juvéderm are hyaluronic acid derivatives and provide temporary contour changes, lasting approximately six months before resorbing. Many surgeons feel that this material is safe because, in other areas of the face, it is not permanent and has not been correlated with long-term problems. Unfortunately, in the nose, this does not appear to be the case. I have seen several patients who underwent Restylane injections and subsequently developed infections that permanently damaged the nasal skin envelope. These problems are more likely to occur in patients who underwent previous rhinoplasty, have a thin, compromised skin envelope, or have an alloplastic implant, such as MedPor or silicone, in their noses.

If a patient with healthy skin has a minor irregularity, Restylane and Juvéderm are reasonably safe options, as they will eventually resorb if injected correctly. However, the patient must understand that this correction is temporary, and the person who performs the injection must be careful to inject deeply against the bone or cartilage and avoid placing the filler in the dermis, as this can permanently damage the nasal skin. If the patient chooses to undergo secondary rhinoplasty before the material resorbs, the reconstruction will be more complicated and post-operative irregularities are more likely.

Unlike their hyaluronic acid counterparts, Radiesse and ArteFill are much longer-lasting filler materials. Radiesse is composed of hydroxyapatite particles suspended in gel and can last two years or more. ArteFill is polymethylmethacrylate beads in a collagen suspension and is permanent. Many surgeons who use these materials state that if injected deeply below the skin, there is little risk to the patient. The problem with both of these materials is that they last for a long period of time and, if injected too superficially, can result in permanent changes to the skin. Surgical removal of these materials is very difficult and puts the patient at high risk for permanent skin damage. One option is to leave the filler in the nose to avoid the risk of skin necrosis and proceed with the rhinoplasty. If the filler used is semi-permanent and surgery is undertaken before resorption is complete, this may ultimately leave the patient with a depression that had nothing to do with the reconstruction. Injectable fillers in the nose create so many variables that getting a good surgical outcome is much more difficult. These patients must accept multiple irregularities if they choose to undergo surgical correction.

Dr. Barton

44-year-old female with negative vector orbit and "tear trough triad."  Patient shown (left) before and (right) six months after septal reset blepharoplasty. (Photo credit: Fritz E. Barton Jr., M.D., F.A.C.S.)

NO FEAR The study showed the surgical technique to be effective in correcting the deformity: 95 percent of patients demonstrated at least one grade of improvement post-operatively. "Our group of patients was the most resistant to conventional methods of blepharoplasty, but, interestingly, they were also the patients at the greatest risk for extensive procedures traversing the middle lamella," Dr. Barton says. One of the most important results of the study was the absence of significant middle lamella shortening or contracture, which, according to Dr. Barton, is one of the most feared complications following this procedure and may be the reason the procedure never received recognition as a viable surgical technique for the correction of the tear trough triad.

Dr. Peters

UNILATERAL PRESENTATION Because the autoinflation that has occurred has been predominantly unilateral, clinicians have considered alternate diagnoses, according to Dr. Peters. "There is an asymmetry that occurs with unilateral breast enlargement," he explains. "A late infection would be a different differential diagnosis for unilateral enlargement." Other possible causes for a unilateral breast enlargement after insertion of saline-filled implants include late capsular hematoma and breast lymphoma, and clinicians should consider these rare conditions before concluding autoinflation has occurred, Dr. Peters advises. Small changes in implant size can occur with saline implants once they have been inserted because of variations in concentrations in sodium chloride injection, the solution that is generally recommended for saline-filled implants. The response of the surgeon to this rare adverse event has been removal and replacement if a patient wishes to continue to augment with implants, notes Dr. Peters. "There is really nothing a surgeon can do [pre-operatively or intra-operatively]," he says. "You have to take out the implants and replace them."

STUDY CASES In a paper published in the Canadian Journal of Plastic Surgery, Dr. Peters describes his own experiences with three cases of autoinflation of saline-filled inflatable breast implants. The unilateral inflation in all instances occurred with smooth, single-lumen, round, saline-filled implants anywhere from four to 23 years after implantation. The implants were of two types: the Simaplast implant and the Mentor style 1800 leaflet valve implant, which is no longer manufactured. The probable cause of the auto-inflation with the Simaplast implant was an injection of a hypertonic filling solution, which is twice as concentrated as normal saline. Such a potent injection would create an osmotic gradient, which would have been conducive to autoinflation via diffusion. In one patient, there was a volume gain of 45 percent over a 23-year period and the appearance of the fluid was transparent and watery. The patient underwent explantation and had 275-mL Mentor style 1600 inflatable implants inserted. With the leaflet valve implants, autoinflation likely resulted due to mechanical alterations of the valve mechanism, according to Dr. Peters. In those two instances, the volume rose 88 percent and 49 percent, respectively. In the case where volume nearly doubled, the gain occurred in the left implant, measuring 620 mL compared to 305 mL in the right breast ten years following surgery. The patient had her implants removed, but not replaced.

"The effect has been attributed to the quality of the product," Dr. Peters says. "It's thought that the effect is related to the valves, but we can't pinpoint exactly what it is. The valves are somehow faulty." Newer saline implant models are not resulting in such incidents, Dr. Peters adds. "I have not seen a case for close to a decade."

Reference

Peters W. Autoinflation of saline-filled inflatable breast implants. Can J Plastic Surg. 2006;14:219-226.

For more information
Walter Peters, M.D., Ph.D.
walter.peters@utoronto.ca

Dr. Matarasso

"There is a steadily growing trend for surgeons to feed patients immediately following a full abdominoplasty surgery without any increase in danger to the patient or any increase in post-operative nausea and vomiting when compared to the traditional approach of initially withholding oral intake of food until bowel activity is heard," says Alan Matarasso, M.D., F.A.C.S., at the Department of Plastic Surgery at the Manhattan Eye, Ear & Throat Hospital in New York. Dr. Matarasso and colleagues conducted a prospective study in 22 patients who underwent a full abdominoplasty. In the study, 10 patients received nil per os (NPO) until bowel sounds were heard and 12 received oral intake of food immediately following the surgery.

OUT WITH THE OLD "What my colleagues Drs. Sameer Jejurikar and Michael Orseck did was try to look at a conventional teaching in plastic surgery and abdominoplasties, which was that patients were kept NPO until they had active bowel sounds. In this study, we challenged that dogma to see if the withholding of food was really necessary," Dr. Matarasso tells Cosmetic Surgery Times . "We found that there was no real difference between the two study groups in respect to post-op nausea and vomiting, which is arguably one of the most disagreeable experiences for a patient following a surgery, and can lead to other problems." The post-op effects of the general anesthesia, as well as dehydration, can all contribute to post-op nausea and vomiting. Also, if patients are not moving their bowels adequately, this could also be a contributing factor.

THOUGHT SHIFT? The traditional approach and a rule of thumb in surgery dictate that patients who undergo abdominal surgery should not be sent home until they pass gas and only then should they be fed and/or discharged. The rationale behind the practice of NPO following abdominoplasty is to diminish the effects of nausea and vomiting caused by paralytic ileus. According to Dr. Matarasso, however, it has not been demonstrated that abdominoplasty slows gastrointestinal motility. "I think like many things in medicine, we see incremental changes in behavior in surgery — and very often it is not a paradigm shift — that, taken together, can advance the science of surgery." In fact, he says that this early post-op feeding movement could make shorter hospitalizations and out-patient surgery a reality. "I believe that many surgeons may even be using this approach already," he adds.

According to Dr. Matarasso, who was the senior author on the paper, "the group that we compared where we did not feed them [the patients] has made me a believer." He now uses this approach with his patients and believes that surgeons should consider possibly adopting it as a new dogma in post-op care. "In the end," he states, "it is advantageous and safe."

HYDRATION IS KEY According to Dr. Matarasso, this new approach is safe, assuming the patients are getting adequate hydration — an important point. He says that some people choose not to eat, despite the fact that they are allowed to eat. "This is probably because these patients may be uncomfortable, might not want to eat, may be fearful of eating post-op or may be tired. Here, it is important to continue their I.V. But in those patients who want to eat and can maintain adequate hydration, it allows them to," he says.

Reference

Jejurikar SS, Orseck MJ, Matarasso A. Reevaluating resumption of oral intake after abdominoplasty. Aesthetic Surg J. 2007;27:233-238.

For more information
Alan Matarasso, M.D., F.A.C.S.
matarasso@aol.com

Allen Putterman, M.D.

FEAR FIXATION Many of us downplay all the possible problems that can occur from our proposed procedures because we fear that we'll talk the patient out of having surgery. Another problem stems from the malpractice atmosphere we live in, which results in patients perceiving problems from surgery as mistakes and wanting restitution. And lastly, we deal with a certain segment of the population who are "crazy" and have expectations that never can be met. Many also obsess over problems from their surgery — even those that are very minor — and are unable to let go of this fixation.

TAKING ACTION So what do we do? First, give patients a true analysis of their cosmetic issues and an over-explanation of probable complications so that their expectations are greatly reduced. Second, let the patient know that no matter how skillfully we perform their surgery, problems can occur and they might need secondary touch-up surgery. We must be aware of the "crazy" patient who has had multiple previous procedures that he or she finds unacceptable and who fixates on cosmetic issues that they perceive as a "ten" when we see them as a "one" or "two." Lastly, it is important that we own up to our complications and stand by our unhappy patients by seeing them more frequently and empathizing with their distress, rather than running away from them for our comfort. Cosmetic oculofacial plastic surgery is "a battle against complications and unhappy patients." Many of my colleagues are falling victim to this battle by retiring or threatening to quit. It is our challenge to be victorious, peaceful warriors.

For more information
Allen Putterman, M.D.
puttermanmd@hotmail.com

Dr. DiBiase

"Most of our patients have lost their eyebrow hair due to overzealous tweezing, where the eyebrow hair stops growing because of follicle loss," Dr. DiBiase tells Cosmetic Surgery Times . "Then there are people who either — on a congenital or familial basis — have a very weak-looking eyebrow."

GRAFT FOR GROWTH Surgeons have performed eyebrow transplantation for approximately three decades, Dr. DiBiase says.

Dr. DiBiase uses a 21-gauge hypodermic needle to create tiny openings into which the follicles are implanted. He also points out that patients don't undergo any special preparation for the in-office procedure. "It is a simple procedure done under local anesthesia, with a little sedation. It takes about two to three hours," he says.

Dr. DiBiase notes that most of his patients have a good idea of what look they want to achieve, so he begins by drawing the patient's eyebrows according to their desires and what he thinks is aesthetically pleasing. After he and the patient discuss the possibilities with drawings in hand, they arrive at the patient's ideal brow.

"Some people just want to reshape their brows or add a little here and there, while others want very large Brooke Shields-type restorations," he says.

One critical aspect of the pre-procedure consult, according to Dr. DiBiase, is counseling patients that the hair transplanted to the eyebrows is "programmed" to grow to the length of the donor hair on the scalp, so they will need to regularly trim and groom it to maintain shape and appearance.

50-year-old female patient shown before and approximately 5 months after eyebrow transplantation. (Photo credit: Anthony P. DiBiase, M.D.)

Patients who dye the hair on their heads, can also dye their brows. The belief is that African Americans can use hair relaxing agents to straighten unruly transplanted brow hair — although Dr. DiBiase notes that this is anecdotal.

Patients' recoveries tend to be relatively comfortable, according to Dr. DiBiase. Some patients experience ecchymosis over the eye, but not as severe as it would be from eye trauma. They also generally get some itching, which he treats with a topical petroleum-based ointment.

CANDIDATES ABOUND Ideal candidates for the procedures have a mature outlook and a realistic goal, realizing that eyebrow transplantation is not going to result in a God-given eyebrow, but will improve the look of the brow. Potential patients also need a good amount of donor hair and must be able to tolerate sitting under local anesthesia for a few hours. Dr. DiBiase says the discomfort is similar to that experienced during a long dental appointment.

The amount of donor hair, he says, is usually not a problem. "I use about 250 follicles per eyebrow, so it would have to be an extreme case of low density in the donor zone [to be problematic]." Another consideration and potential preclusion might include a patient who "might need that donor hair for scalp restoration, which could take cosmetic priority in their mind in the future," he adds.

High patient satisfaction is what keeps Dr. DiBiase recommending the procedure. Patients who have been burn victims or have lost the symmetry of their brows or an entire brow from surgery, in particular, find great satisfaction after brow transplantation, he says.

For more information
Anthony P. DiBiase, M.D.
anthony.p.dibiase@verizon.net

Dr. Apfelberg

SURGEON SATISFACTION Coapt Systems conducted a multicenter, multispecialty study involving eight surgeons who implanted the Endotine Ribbon device in the neck, jowl, upper face, midface or in combination, in a total of 41 patients, fixating the soft tissue in this facelift procedure. Follow-up was conducted at 30, 60 and 90 days, post-procedure. Thirty-two patients completed the study at 90 days and 10 patients were lost to follow-up. Immediately following the procedure, surgeons were asked to rate their experience using the device and rate the satisfaction of the results and of the device. During the follow-up visits, physicians were required to record the ongoing performance of the device by rating the visibility, palpability and elevation of tissue, as well as the patient's skin sensitivity and satisfaction with their appearance.

34-year-old female patient shown before (left) and approximately 10 weeks after (right) minimally invasive placement of Ribbon device in cheeks/jowl and neck. (Photo credit: Jason Diamond, M.D.)

Dr. Apfelberg expects the Ribbon's results to be considerably more permanent than those of Contour Threads and other thread lifts.

Dr. Binder

Whether due to an innate predisposition, the orbital and periorbital anatomy of the patient, or a LASIK or blepharoplasty procedure, keratoconjunctivitis sicca is bothersome for those who develop this condition. Moreover, patients who have previously undergone these procedures are even more prone to developing dry eye symptoms. Blepharoplasty patients can develop dry eye symptoms as a result of post-operative lagophthalmus, eyelid retraction, weakening of the orbicularis oculi, as well as due to diminished blink speed and strength.

Patients who suffer from dry eye symptoms either do not have a sufficient production of tears or the correct composition of tears on the surface of the cornea to lubricate the eyes. Common complaints can include a persistent ocular irritation, itchiness, dryness, foreign-body sensation, fatigue and visual disturbances. Patients with more severe dry eye symptoms are at risk of developing corneal infection, scarring or ulceration, which can culminate in permanent loss of vision. Hence, an active and aggressive prevention of dry eye symptoms is paramount.

"People who have very large eyes where you can see much of their globe are undoubtedly more prone to develop dry eye symptoms following a blepharoplasty procedure," Dr. LaTrenta tells Cosmetic Surgery Times , referring to the orbital and periorbital morphology of a patient's eyes. "The more white of the eye you see pre-operatively, the more of the cornea is exposed," Dr. LaTrenta explains. Therefore, a blepharoplasty, which could enlarge the aperture of the eye, could potentially place a patient already prone to dry eye symptoms into a state of even dryer eyes.

According to Dr. LaTrenta, the eyes of patients who have a lot of cornea exposed are termed morphologically prone eyes, a positive vector eye, or a proptotic eye — and can be a warning sign for dry eye symptoms. He says that eye surgeons must be aware of this and act accordingly.

PRE-SCREEN POINTERS "All patients that may seem to be prone to dry eye should have an evaluation from an ophthalmologist pre-operatively," Dr. LaTrenta emphasizes. "This is one important step in the prevention of dry eye symptoms."

In his opinion, a Schirmer's test is the best test to ascertain the potential for dry eye and should be performed to help identify patients with diminished tear production before the blepharoplasty. "This simple test can be pivotal in the decision to operate or not," Dr. LaTrenta asserts. However, he adds that although a Schirmer's test is a critical pre-operative exam that should be performed on all prospective blepharoplasty patients, the test should not be relied on as the sole method of screening potential patients.

According to Dr. LaTrenta, the most important step to take prior to a blepharoplasty procedure is to coordinate the surgical intervention with an ophthalmologist. It is paramount that the ophthalmologist evaluates the patient both pre- and post-operatively, as he believes that ophthalmologists' supplemental knowledge can help to ensure that the blepharoplasty runs as smoothly as possible.