Journal Publications Marina Plastic Surgery

One-Stage Augmentation Mastopexy A Review of 1192 Simultaneous Breast Augmentation and Mastopexy Procedures in 615 Consecutive Patients

Published in Aesthetic Surgery Journal, May 2014.

BACKGROUND: Despite the increasing popularity of the combined augmentation mastopexy procedure among patients, the safety and efficacy of this surgery have been questioned by many surgeons.

OBJECTIVE: The authors investigated the safety and efficacy of the combined augmentation mastopexy procedure.

METHODS: The authors retrospectively reviewed the medical records of 615 consecutive patients who underwent combined augmentation mastopexy procedures at a single outpatient surgery center from 1992 through 2011. Patient demographics, operative and implant details, and long-term outcomes were analyzed. Rates of complications and revisions were calculated.

RESULTS: The most common complications were poor scarring (5.7%), wound-healing problems (2.9%), and deflation of saline implants (2.4%). Of the 615 patients evaluated, 104 (16.9%) elected to undergo revision surgery: 54 revision procedures were secondary to implant-related complications, and 50 were secondary to tissue-related complications. Our data compare favorably with previously reported revision rates for breast augmentation alone and mastopexy alone.

CONCLUSIONS: With a skilled surgeon and proper patient selection, the combined augmentation mastopexy procedure can be safe and effective.

W. Grant Stevens, MD, FACS, Luis H. Macias, MD, Michelle Spring, MD, David A. Stoker, MD, FACS, Carlos O. Chacón, MD, MBA, Seth Eberlin, MD

Counterfeit Medical Devices: The Money You Save Up Front Will Cost You Big in the End

Published in Aesthetic Surgery Journal, April 2014.

Savvy Internet and e-mail marketers often tempt physicians with “best price” promotional offers to purchase medical devices that are “just like hot-selling models” of name-brand devices. Featured technologies run the gamut and include cold lipolysis, laser lipolysis, fractional radiofrequency microneedles, fractional C02 laser, intense pulsed light hair removal, cavitation, and microdermabrasion. Such devices are being sold at a fraction of the list price of the name-brand products, have no consumables, and can be purchase with the click of a mouse. If it sounds like there must be a catch, there is.

W. Grant Stevens, MD, FACS; Michelle A. Spring, MD, FACS; and Luis H. Macias, MD

A Prospective Study of 708 Form-Stable Silicone Gel Breast Implants

Published in Aesthetic Surgery Journal, July 2010.

BACKGROUND: Form-stable silicone gel breast implants represent the fifth generation of silicone gel augmentation devices. Additional crosslinking between the silicone molecules allows these implants to retain their shape, especially in the vertical position.

OBJECTIVE: The authors evaluate the efficacy of Silimed form-stable silicone gel breast implants.

METHODS: A total of 355 patients (708 implants) were enrolled prospectively over a 60-month period. Data were collected on patient demographics, implant factors, complications, and revisions. Chi-square analysis and Fisher's exact test were implemented to compare groups with respect to differences in complication and revision rates.

RESULTS: The overall tissue-related complication rate was 8.2% per patient, or 4.1% per breast. The overall implant-related cosmetic complication rate was 2.5% per patient, or 1.3% per implant. The overall implant-related complication rate, which was represented by the capsular contracture (CC) rate, was 1.4% per patient and 0.7% per implant. There were no complications in any of the reconstruction patients. There were no deep vein thromboses, pulmonary emboli, myocardial infarctions, or deaths among the patients in this study. In addition, there were no instances of flap necrosis, hematoma, or loss of implant integrity. The overall complication rate was 9.6% per patient, or 4.8% per implant. The overall tissue-related revision rate was 5.4% per patient, with the most common tissue-related reason for revision being unacceptable scarring. The overall implant-related cosmetic revision rate was 7.6% per patient, with the most common reason for revision in this category being size change. The overall implant-related revision rate was 1.1% per patient and was solely due to CC.

CONCLUSIONS: This study demonstrates that form-stable silicone gel breast implants are safe and have a complication profile similar to other models of silicone breast implants, with a lower CC rate and a decreased incidence of wrinkling compared to fourth-generation silicone gel implants (as well as other published studies of fifth-generation implants).

— W.G. Stevens, E.M. Hirsch, M.J. Tenenbaum, M. Acevedo

Safe and Consistent Outcomes of Successfully Combining Breast Surgery and Abdominoplasty: An Update.

Published in Aesthetic Surgery Journal, March 2009.

BACKGROUND: Combined cosmetic procedures have become increasingly popular. One of the most common combinations of cosmetic procedures includes abdominoplasty and cosmetic breast surgery. The shortened recovery and financial savings associated with combined surgery contribute to the increased demand for these combined surgeries.

OBJECTIVE: The goal of this study was to evaluate the safety and efficacy of combined abdominoplasty and breast surgery at a single plastic surgery practice that performs a large volume of these cases. This is an update to a study published in 2006.

METHODS: A retrospective review was performed for patients who underwent combined abdominoplasty and cosmetic breast surgery during the last 10 years at a single outpatient surgery center. Abdominoplasty inclusion criteria were defined as lower, mini, full, reverse, or circumferential abdominoplasty. Cosmetic breast surgery inclusion criteria were defined as augmentation, mastopexy, augmentation-mastopexy, reduction, or removal and replacement of implants. Pertinent preoperative and intraoperative data were recorded along with complications and revisions.

RESULTS: There were 268 patients during the 10-year period between 1997 and 2007. There were no cases of death, pulmonary embolism, deep venous thrombosis, or other life-threatening complications. The overall complication rate was 34%. Abdominoplasty seroma and scars requiring revision comprised 68% (n = 74) of the complications. The total revision rate was 13%.

CONCLUSIONS: Combined abdominoplasty and cosmetic breast surgery was safe and effective in this large series of cases performed at a single plastic surgery practice. The complication and revision rates of the combined surgery were similar to those reported for individually staged procedures. ( Aesthetic Surg J 2009;29:129-134.)

— W.G. Stevens, R. Repta, S.J. Pacella, M.J. Tenenbaum, R. Cohen, S.D. Vath, D.A. Stoker

Clinical Experience With a Fourth-Generation Textured Silicone Gel Breast Implant: A Review of 1012 Mentor MemoryGel Breast Implants

Published in Aesthetic Surgery Journal, November-December 2008

BACKGROUND: Since the introduction of fourth- and fifth-generation silicone gel implants, manufacturers have conducted several prospective, multicenter trials to examine their safety and efficacy. However, these studies were not standardized with regard to surgeon skill, pocket placement, operative technique, adjunct therapies, or postoperative management.

OBJECTIVE: The purpose of this study was to examine the surgical outcomes of a single surgeon (WGS) in a consecutive series of breast augmentation cases using a fourth-generation cohesive silicone MemoryGel breast implant (Mentor, Santa Barbara, CA).

METHODS: A retrospective chart review was conducted to identify all patients who underwent silicone breast augmentation within the Mentor Adjunct Silicone MemoryGel breast implant by a single surgeon (WGS) within a single free-standing outpatient surgical center over a 13-year period (1992 to 2006). For each patient, demographic information, comorbidities, and surgical information (implant size and concomitant surgery) were recorded. In addition, outcomes were analyzed to identify complications and the need for surgical revision.

RESULTS: A total of 1012 fourth-generation, textured, cohesive silicone gel implants were placed in 511 patients during the 13-year study period. The overall complication rate per implant was 5.5% (n = 56 implants in 43 patients). The most common complication was capsular contracture (n = 26; 2.6%) followed by abnormal scarring (n = 11; 1.1%). The overall revision rates per patient and per implant were 8.0% (n = 41 patients) and 6.8% (n = 69 implants), respectively. The average time interval between initial implantation and revision was 18.5 months (range, 2 weeks to 26 months). The most common indication for surgical revision was patient desire for implant size change (n = 15 patients) followed by Baker class III or IV capsular contracture (n = 13 patients). The presence of previous surgery for capsular contracture was not statistically correlated to the need for revision (P = .326). Age (P = .568), previous history of breast surgery (P = .704), and history of smoking (P = .138) were also not statistically correlated to revision. Placement of the implant in the subglandular position (n = 30 implants), however, was statistically correlated with need for revision (P < .01).

CONCLUSIONS: Mentor fourth-generation cohesive silicone gel implants possess a complication and revision profile that is superior to earlier-generation silicone gel implants. Implantation with MemoryGel implants, when standardized with regard to surgeon and operative technique, can have significantly reduced complication and revision rates compared to the Mentor Core Data.

— W.G. Stevens, S.J. Pacella, A.J.L. Gear, M.E. Freeman, C. McWhorter, M.J. Tenenbaum, D.A. Stoker

Outpatient Reduction Mammaplasty: An Eleven-Year Experience

Published in Aesthetic Surgery Journal, March-April 2008

BACKGROUND: In the last 15 years, reduction mammaplasty has been increasingly performed on an outpatient basis. Despite this evolution, few outcome studies have been published regarding outpatient breast reduction surgery.

OBJECTIVE: The authors documented clinical outcomes of reduction mammaplasty performed in an outpatient setting over an 11-year period and compared these results with published normative values in the plastic surgery literature.

METHODS: A retrospective review was undertaken of 884 reduction mammaplasties in 444 patients at a single outpatient surgical center performed by the senior author (W.G.S.) from 1995 through 2006. In all cases, a laser-assisted, inferior pedicle, Wise pattern, reduction mammaplasty was performed. In addition to demographic and surgical data, complication frequency and type were recorded. Complication data were further stratified into minor and major categories. Potential minor complications included seroma, hematoma, soft tissue infection, dog-ears requiring revision, and small incisional breakdowns or delayed healing of less than 2 cm. Potential major complications included large incisional breakdowns or delayed healing of greater than 2 cm, nipple/areolar necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death.

RESULTS: The mean patient age was 38 years (range, 16 to 73 years). Mean body-mass index was 27 (range 17 to 47). The reported preoperative brassiere cup sizes ranged from a 34 C to a 38 K, with a DD being the most common size. The mean preoperative sternal notch-to-nipple distance was 29 cm (range 22 to 54 cm). Forty patients smoked (9%). Mean clinical follow-up was 13 months. Mean total resection weight of breast tissue was 1228 g (range 100 to 5295 g). Mean operative time for reduction mammaplasty was 115 minutes (range 50 to 195 minutes). Nineteen percent of patients underwent multiple procedures, including abdominoplasty, lipoplasty, and facial procedures, with a mean operative time of 132 minutes (range 75 to 345 minutes). The overall complication rate was 14%, with 70 minor complications occurring in 62 patients. Specific minor complications included one seroma, four hematomas, eight soft tissue infections, two of which required a short course of intravenous antibiotics, one patient with dog-ears requiring surgical revision, and 56 small incisional wound breakdowns (<2 cm). The small incisional breakdowns, which represented the largest group of complications, were further subdivided into 44 minor T-zone wounds, 3 nipple-areolar complex wounds, and 9 wounds of the vertical and horizontal incisions. Three major complications (0.67%) were recorded. Two patients had development of partial nipple/areolar necrosis. A third patient required anticoagulation for a pulmonary embolus diagnosed 10 days after surgery. Statistical analysis of the complication data revealed one significant relationship. Patients with a body mass index above the mean had a 21% complication rate as compared with a 12% rate for those below the mean. Of note, there was no increase in complication rate in the context of multiple procedures.

CONCLUSIONS: This retrospective series is the largest to date involving outpatient reduction mammaplasty. Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility.

— W.G. Stevens, A.J.L. Gear, D.A. Stoker, E.M. Hirsch, R. Cohen, M. Spring, S.D. Vath, S.A. Schantz, R.T. Heck

One-Stage Mastopexy with Breast Augmentation: A Review of 321 Patients

Published in Plastic and Reconstructive Surgery Journal, November 2007

BACKGROUND: One-stage mastopexy with breast augmentation is an increasingly popular procedure among patients. In the past 9 years, there has been a 506 percent increase in mastopexy procedures alone. Although some recommend a staged mastopexy and breast augmentation, there are currently no large studies evaluating the safety and efficacy of a one-stage procedure.

METHODS: A retrospective chart review was conducted of 321 consecutive patients who underwent one-stage mastopexy and breast augmentation. Data collected included the following: patient characteristics, implant information, operative technique, and postoperative results. Complication and revision rates were calculated to evaluate the safety and efficacy of the one-stage procedure.

RESULTS: No severe complications were recorded over an average of 40 months’ follow-up. The most common complication was deflation of a saline
implant (3.7 percent), followed by poor scarring (2.5 percent), recurrent ptosis (2.2 percent), and areola asymmetry (2.2 percent). Forty-seven patients (14.6 percent) underwent some form of revision surgery following the one-stage procedure. Thirty-five (10.9 percent) of these were for an implantrelated issue, whereas 12 patients (3.7 percent) underwent a tissue-related revision. This 10.9 percent implant-related revision rate is less than a previously documented 13.2 percent 3-year reoperation rate for breast augmentation alone. The authors’ 3.7 percent tissue-related revision rate also compares favorably to an 8.6 percent revision surgery rate in patients who underwent mastopexy alone.

CONCLUSIONS: Although it has been stated that the risks of a one-stage procedure are more than additive, the results of our review suggest otherwise. Although a revision rate of 14.6 percent is significant, it is far from the 100 percent reoperation rate required for a staged procedure.

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

A Review of 100 Consecutive Secondary Augmentation/Mastopexies

Published in Aesthetic Surgery Journal, September-October 2007

BACKGROUND: Simultaneous breast augmentation and mastopexy has historically been a controversial topic, and it has been considered by some to be a difficult and unpredictable procedure. Secondary breast augmentation and mastopexy after previous breast surgery is rarely discussed in the literature, and little is known about the outcomes of these secondary procedures.

OBJECTIVES: The authors present the indications, surgical techniques, and outcomes in a series of 100 consecutive secondary simultaneous breast augmentation and mastopexy cases.

METHODS: One hundred consecutive patients who underwent secondary combined augmentation mammaplasty and mastopexy from 1992 to 2005 were retrospectively reviewed. The complications and revision rates in this group of patients were analyzed and compared with primary mastopexy alone, as well as with primary combined augmentation and mastopexy. Independent variables such as patient age, history of smoking, body mass index, type and size of implant, and type of mastopexy incision were analyzed for correlation with complication and revision rates.

RESULTS: No major complications were noted in an average of 3.5 years follow-up (range 13 months to 13 years). Minor complications occurred in 13 patients, of whom 8 required revision surgery. The most common tissue-related complications were poor scarring (3%) and recurrent ptosis (3%). The most common implant-related complications were infection (3%) and capsular contracture (2%). In addition, 6 patients underwent reoperation for implant size exchange, and 1 patient underwent revision surgery to receive silicone implants. Patient age, history of smoking, body mass index, type and size of implant, type of mastopexy incision, type and number of previous breast surgeries, surgical time, concurrent non-breast operations, and preoperative ptosis grade were not statistically significant risks when correlated to the complication and revision rate.

CONCLUSIONS: Simultaneous breast augmentation and mastopexy after previous breast surgery is a commonly performed procedure that is not adequately reported in the literature. Our study indicates that the procedure is safe and has complication and revision rates comparable to primary augmentation/mastopexy.

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

Ten Years of Outpatient Abdominoplasties: Safe and Effective

Published in Aesthetic Surgery Journal, May-June 2007

BACKGROUND: Abdominoplasty has traditionally been described in the literature as an operation that is performed in a hospital setting, although more recently it is likely that most procedures are performed on an outpatient basis. To date, there have been very few large series illustrating the safety and efficacy of abdominoplasty performed in outpatient surgery centers.

OBJECTIVES: This study reports the complications and revisions of outpatient abdominoplasties in a large patient population.

METHODS: The charts of 519 consecutive abdominoplasty procedures performed at a single outpatient surgical center over the past 10 years (1996-2006) were reviewed. Follow-up was 6 months to 10 years, with an average of 4.3 years. Mean age at the time of operation was 43 years; range 19 to 74 years. Gender, smoking history, American Society of Anesthesiologists risk score, body mass index, type of abdominoplasty, and concurrent procedures were recorded. Each patient's chart was reviewed to assess complication and revision rates, including deaths, venous thromboembolism events, wound dehiscence, infection, seroma, hematoma, and scarring unacceptable to the patient or surgeon.

RESULTS: The most common complication was seroma (10.6%), followed by unacceptable scarring of the abdominal or umbilical incisions (7.9%). The most common reason for revision was abdominal scar revision (6.4%). Most patients had concurrent additional procedures at the time of abdominoplasty, most commonly lipoplasty (91%). There was no statistically significant difference in complications or revisions when comparing groups based on age, body mass index, operating room time, smoking status, full abdominoplasty versus a less complex procedure such as a “mini” or floating umbilical abdominoplasty or simultaneous procedures. Men were significantly less likely to have a complication when compared with women.

CONCLUSIONS: This large retrospective study of 519 consecutive abdominoplasty procedures performed on an outpatient basis demonstrates that abdominoplasties may be performed safely and effectively at an accredited outpatient surgery facility.

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

Mastopexy Revisited: A Review of 150 Consecutive Cases for Complication and Revision Rates

Published in Aesthetic Surgery Journal, March-April 2007

BACKGROUND: Although there is an abundance of data in the literature regarding the safety of breast reduction and augmentation, nearly all of the literature concerning mastopexy describes techniques. There are few studies regarding revision and complication rates for mastopexy procedures.

METHODS: A retrospective review was performed on a series of 150 consecutive patients who underwent a mastopexy procedure. Operations were performed by one of two surgeons (W.G.S. or D.A.S.) in an outpatient surgery center over a 6-year period (1999-2005), with an average follow-up of 36 months. Patients were identified as being either primary (no previous breast surgery) or secondary (history of at least one previous breast surgery). The type of mastopexy design was recorded (inverted-T or vertical), and trends were examined. Complication and revision rates were observed, and their rates were calculated.

RESULTS: One hundred forty-eight women underwent bilateral and two underwent unilateral mastopexy for a total of 150 women and 298 breasts. There were 119 primary and 31 secondary patients. Mastopexy incision designs were as follows: 86% inverted-T and 14% vertical. There were no major complications. The most common complications were poor scarring (6%) and seroma formation (2.7%). The revision rate was 8.6%; 75% of revisions were for poor scarring. Some of these were performed with the patients under local anesthesia or at the time of a subsequent unrelated surgery.

CONCLUSIONS: Our series of 150 consecutive patients, with no major complications and a revision rate of 8.6% over an average of 36 months, indicates that mastopexy may be considered a safe and effective procedure. (Aesthetic Surg J 2007;27:150-154.)

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

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.

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.

In vitro deflation of prefilled saline breast implants.

Published in Plastic and Reconstructive Surgery Journal, 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.

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

Published in Plastic and Reconstructive Surgery Journal, 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) wound breakdowns. Major complications evaluated included large (>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.

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 Plastic and Reconstructive Surgery Journal, 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 < 0.001), year 3 (chi-square, 37.91; p < 0.001), and year 4 (chi-square, 32.69; p < 0.001), the difference was statistically significant.

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.

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.

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.

“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.

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.

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.

Osseous anatomy of unilateral coronal synostosis.

Published in The Cleft Palate Journal, April 1986

SUMMARY: High resolution, thin slice computerized tomography (CT) scans with paraxial and three-dimensional surface reconstructions were utilized to document the endocranial, exocranial, and orbital anatomy of non-syndromal unicoronal synostosis (UCS). Eighteen patients with UCS were evaluated qualitatively and quantitatively. Of these, 10 were studied both preoperatively and 1 year postoperatively. The endocranial base in UCS is characterized by a 9 degree angulation toward the synostosis of the anterior cranial base with respect to the posterior cranial base. The exocranial base has a 7 degree angulation toward the synostosis between the midpalatal suture and the posterior cranial base. The locus of angulation appears to be posterior to the anterior clinoids endocranially, and between the maxillopalatopterygoid articulations and the mandibular condyle exocranially. The orbital rim height is greater ipsilateral to the synostosis than contralaterally. The analysis documents the normalizing effect of one of two different surgical procedures upon orbital height. Application of computer assisted medical imaging to the study of UCS has allowed in vivo quantitation of cranial base and orbital dysmorphology for both preoperative assessment and postoperative evaluation.

— Marsh, J.L., M. Gado, M.W. Vannier and W.G. Stevens

Computerized imaging for soft tissue and osseous reconstruction in the head and neck.

Published in Clinics in Plastic Surgery, April 1985

SUMMARY: Recent developments in computer-aided medical imaging coupled with the related emergence of computer-aided design and manufacturing technology have had a significant effect on our management of patients with congenital and acquired head and neck deformities. In our institution, plain film skull radiography, cephalometry, and pluridirectional tomography have been largely replaced by high-resolution CT scanning augmented by planar reformations and three-dimensional surface reconstructions. A sophisticated computer-assisted radiologic imaging unit has been established to assist the surgeon and researcher. This marriage of advanced radiographic techniques, industrial computer-aided design technology, and clinical surgery have allowed us to better define aberrant anatomy, design new operative solutions for familiar as well as unusual problems, and quantitate changes of surgery and growth over time.

— Marsh, J.L., M.W. Vannier, W.G. Stevens, J.O. Warren, D. Gayou and D.M. Dye

Musculoskeletal applications of three-dimensional surface reconstructions

Published in Orthopedic Clinics of North America, July 1985.

SUMMARY: We have applied computer programs originally developed for craniofacial surgical planning and evaluation to complex musculoskeletal problems. These computer programs reformat ordinary CT scans into black and white images of the three-dimensional osseous surfaces found in the scanned volume. These reformatted three-dimensional CT scan images increase the utility of CT scan examinations of complex osseous structures, such as the wrist, spine, hip, knee, and shoulder. The software, which operates on an unmodified commercially available CT scanner, can produce high-quality surface reconstructions from CT scan slices without operator intervention. No special knowledge of the principles used in the reconstruction methods is needed to successfully use the programs.

— Vannier, M.W., W.G. Totty, W.G. Stevens, P.M. Weeks, D.M. Dye, W.J. Daum, L.A. Gilula, W.A. Murphy and R.A. Knapp

Three-dimensional imaging of the wrist.

Published in J. Hand Surgery, January 1985

SUMMARY: The objective of this study was to determine the diagnostic quality of three-dimensional images of the carpal bones that could be constructed from raw data obtained from a computerized tomography scan. The quality of raw data collected was determined by collimation, slice interval, the number of projections, and x-ray tube operating specifications. The quality of two-dimensional images that were constructed from the raw data was determined by user-specified parameters including zoom or magnification factor, convolution kernels, and centering. The two-dimensional images were modified by erasure, the level of reconstruction, and animation, which permitted isolation of individual carpal bones, the construction of three-dimensional images viewing the external and internal surfaces of the bones, and the rotation of the images to provide multiple views. Representative images are presented.

— Weeks, P.M., M.W. Vannier and W.G. Stevens

When Should Nerve Gaps Be Grafted, An Experimental Study in Rats

Published in Plastic and Reconstructive Surgery, May 1985.

SUMMARY: In conclusion, animal experiments have shown the following: (1) extensive elevation (mobilization) of a nerve from its bed does not interfere with its capacity to regenerate as long as the longitudinal epineural vessels are preserved, (2) suturing nerve ends under tension has a deleterious effect on the final results, (3) when a segment of nerve has been resected, the remaining nerve and the site of repair can lengthen to accommodate joint extension (within limitations), (4) if there is a segmental loss of nerve and if the nerve ends can be approximated with 10-0 epineural sutures, even if the joints must be fully flexed, the result is better than using a nerve graft, and (5) when a graft is required, it is important to avoid reversing the nerve graft. We believe direct nerve repair is preferred when flexion of the joints and mobilization of the nerve ends permits approximation with 10-0 epineural suture.

— Stevens, W.G., J.D. Hall, P.M. Weeks and L.V. Young

Reinsertability After Breast Prosthesis Pocket Infection

Published in Plastic Reconstructive Surgery, February 1982.

SUMMARY: We report the development of an animal model for the study of S. aureus infection in silicone gel-filled prosthesis pockets. The purpose of this study was to determine (1) whether successful reinsertion of a prosthesis into a contaminated pocket requires a finite recovery period between implant removal and reinsertion, and (2) whether parenteral antibiotic treatment affects the success of reinsertion. All infected pockets were lavaged with saline and none were drained, either after wound closure or after implant reinsertion. The results indicate that a delay of 2 or more hours between lavage and reinsertion protects against implant exposure. Therapeutic parenteral antibiotic treatment neither prevented implant exposure nor altered the effect of temporal delay on reinsertion. These studies coupled with recent clinical reports suggest that women who develop breast pocket infection need not wait months for restoration of breast symmetry.

— Marsh, J.L., W.G. Stevens, G.L. Smith and D.J. Krogstad