Synopsis ■ Mastopexy ■ Breast ptosis presents in many forms and can be congenital in nature or acquired due to causes such as aging, weight changes, and pregnancy. ■ Patients with ptosis generally desire the same result – youthful and “perky” breasts. However, due to wide variations in breast volume and tissue quality, ultimate results vary with each patient, and as a result, preoperative management of…

Synopsis ■ Breast augmentation is one of the most commonly performed aesthetic procedures in the United States and abroad. ■ Preoperative assessment should determine the appropriate approach, including choice of implant, breast pocket (submuscular, subfascial, subglandular, subpectoral with dual plane), incision location (inframammary, periareolar, transaxillary, transumbilical), and the need to lower the inframammary fold (IMF). ■ Implant selection has expanded over the past few years to…

Synopsis ■ Defects due to failed laparotomy closures, tumor ablation, congenital anomalies, and trauma are the most common indications for abdominal wall reconstruction (AWR). ■ Ventral hernias can be the result of a genetic predisposition in impaired collagen formation or due to acquired structural collagen abnormalities from mechanical strain and predisposing risk factors, such as tobacco use, diabetes, and obesity. ■ Direct suture repair of ventral…

Synopsis ■ Reconstruction of the soft tissues of the back at first may seem to be a daunting task compounded by large wounds, unfamiliar and segmental anatomy, radiation, hardware, and difficulties with postoperative positioning. ■ Many of the conditions treated require significant coordination with surgical colleagues. ■ Many of the conditions are unfamiliar to the plastic surgeon and without parallel conditions elsewhere in the body, an…

Synopsis ▪ Rigid chest wall support may be achieved with mesh, acellular dermal matrix, or autogenous material such as tensor fascia lata (TFL). Of these, alloplastic mesh is most prone to infection. ▪ Soft tissue coverage can be achieved with local muscle flaps. ▪ Proper treatment of mediastinitis includes debridement, rigid sternal fixation when possible, and soft tissue coverage. ▪ Pectoralis muscle is the workhorse for…

Synopsis ■ The reconstructive surgery for the lower extremity has evolved from a staged approach to proving best solutions for functional and cosmetic outcome. ■ This chapter covers the classical approach with a gradual change of principle that advocates a one-stage elevator approach. ■ Special considerations should be given to overcome the complexity of lower extremity reconstruction, such as diabetes and chronic infection. ■ Finally, introduction…

Synopsis ▪ Normal speech is the primary goal of cleft palate repair; minimizing effects of maxillary growth is also important but ultimately secondary. ▪ Cleft palate repair prior to 1 year of age (ideally 9–10 months) results in better speech outcomes than later repairs. ▪ The levator veli palatini muscle is longitudinally oriented in the cleft palate patient. Realignment of the muscle to a transverse and…

Synopsis Unilateral lip repair Principles of unilateral cleft lip repair ▪ Presurgical nasoalveolar molding. ▪ Modification of surgical techniques. ▪ Mohler rotation incision. ▪ Mucosal flaps for nasal floor reconstruction, correction of mucosal deficiency in piriform area. ▪ Eliminate the perialar incision on advancement flap, limiting scars around the alar base and nostril floor. ▪ Mobilization of alar base. ▪ Nasal floor reconstruction with complete mucosal…

Synopsis ▪ Always consider the defect when planning a flap. ▪ Assess availability and laxity of local tissue. ▪ Rob Peter to pay Paul but only if Peter can afford it. ▪ Match the flap to the defect, not the defect to the flap. ▪ Keep your reconstruction as simple as possible. ▪ Good cosmesis is vital, but function trumps cosmesis. ▪ Do not burn bridges.…

Synopsis ▪ The teachings of John Converse, Nicholas Georgiade, and Reed Dingman provided the benchmark for an entire generation of surgeons in facial injury repair. ▪ The treatment concepts discussed in this chapter were developed at the University of Maryland Shock Trauma Unit and ultimately employed at the International Center for Facial Injury Reconstruction at Johns Hopkins. ▪ The proportion of severe injuries seen at these…

Synopsis ■ Incorporation of a diet and exercise program in conjunction with liposuction will allow patients to achieve their optimal shape and contour. Patients who do not adhere to diet and exercise are least happy with their results. ■ A thorough history and physical exam should be performed and a preoperative clearance obtained, especially for large-volume or long, combined cases. ■ Marking the patient in front…

Synopsis ■ The skin/fat envelope is tethered to the underlying musculoskeletal anatomy in zones of adherence. These include the spine, the sternum, the linea alba of the abdomen, the inguinal area, the suprapubic area, and the area between the hip and lateral thigh fat. ■ Massive weight loss (MWL) patients make up the majority of patients who undergo lower bodylift/belt lipectomy surgery. Second are females with…

Synopsis ▪ Assessment of the abdominal region includes a detailed medical and physical history, including pregnancies; prior surgeries, especially in the lower truncal area; and weight changes. Preoperative identification of any existing ventral hernia, including diastasis recti, is imperative. ▪ Essential abdominal exam findings include the existence and localization of vertical and horizontal tissue excess, the relationship between fatty excess and skin excess, and examination of…

Synopsis ▪ Analysis. Analyze the problem in thirds. ▪ Endpoint. Know what normal looks like, so you know your surgical endpoint. ▪ Do not be destructive. Do not do anything to the ear that cannot be reversed. ▪ Skin is precious but weak. Preserve skin in the sulcus, and do not rely on skin tension to maintain ear position. ▪ Lobule. Consider lobule setback in every…

Synopsis Open rhino ■ Accurate preoperative analysis and clinical diagnosis set the foundation for successful primary open rhinoplasty. ■ Open rhinoplasty allows anatomic exposure, identification, and correction of nasal deformities. ■ Component dorsal hump reduction allows accurate and incremental reduction of the nasal dorsum while preventing problems with internal valve collapse or dorsal irregularities. ■ Nasal tip suturing techniques allow control of definition without damaging the…

Synopsis ▪ Detailed knowledge of forehead anatomy is the basis for rejuvenation strategies of the forehead region. ▪ Eyebrow position is the net result of forces that depress the brow, forces that raise the brow, and the structures that tether the eyebrow in place. ▪ Brow depression is caused by glabellar frown muscles, the orbicularis, and gravity. Frontalis is the only effective brow elevator. ▪ Attractiveness…

Synopsis ▪ Age-related changes occur in all layers of the face, including skin, superficial fat, SMAS, deep fat, and bone. ▪ Patients presenting for facial rejuvenation surgery are usually middle-aged or older, thus increasing the chance of co-morbidities. Risk factors such as hypertension and smoking should be dealt with prior to facelift surgery. ▪ Careful preoperative assessment will provide the surgeon with an aesthetic diagnosis regarding…

Synopsis ▪ Blepharoplasty is a vital part of facial rejuvenation. The traditional removal of tissue may or may not be the preferred approach when assessed in relation to modern cosmetic goals. ▪ A thorough understanding of orbital and eyelid anatomy is necessary to understand aging in the periorbital region and to devise appropriate surgical strategies. ▪ Preoperative assessment includes a review of the patient's perceptions, assessment…