Issue #12 summary - GO BACK TO ARCHIVE

Decade of CO2 blepharoplasty
The advantage of the CO2 laser for blepharoplasty over standard scalpel, scissors and electrocautery has been demonstrated in a comparative study by David LM, Sanders, G: “CO2 Laser blepharoplasty: a comparison to cold steel and eletrocauter,”. J Dermatol. Surg. Oncoll 13:2 Feb 1987. The accurate patient evaluation, correct preoperative diagnosis, knowledge of the anatomy of the eyelid (Dailey RA; Wobig JL: “Eyelid anatomy,” J Dermatol Surg, Dec 1992, 18(12) p1023-7; Siegel RJ: “Essential anatomy for contemporary upper lid blepharoplasty,” Clin Plast Surg, Apr 1993, 20(2) p209-12; de Castilho HT; Andrews J de M; Zani R: “Eyelid pouches: anatomical study of the orbital fat applied to surgery,” Rev Paul Med, Sep–Oct 1991, 109(5) p217-20) plus a meticulous surgical technique (Holt JE; Holt GR: “Blepharoplasty. indications and preoperative assessment,” Arch Otolaryngol, June 1985, 111(6) p394-7) are all fundamental in performing a successful blepharoplasty (Meyer DR; Linberg JV; Wobig JL; McCormick SA: “Anatomy of the orbital septum and associated eyelid connective tissues. Implications for ptosis surgery,” [see comments]: Ophthal Plast Reconstr Surg, 1991, 7(2) p104-13. Comment in: Ophthal Plast Reconstr Surg 1993 Jun; 9(2):150-1; Siegel R: “Surgical anatomy of the upper eyelid fascia. Ann Plast Surg Oct 1984, 13(4) p263-73.
   We have found that, in blepharoplasties, the main advantages of the CO2 laser are the possibility of resecting skin, fat and muscle with no bleeding, and of cauterising the blood and lymphatic vessels without damaging the surrounding tissue. We have noticed that, once the initial difficulties with the new instrument have been mastered, the CO2 laser procedure shows reduced intra-operative time, largely because no bleeding allows for a far superior intra-operative visibility.

Effective augmentation
Since the 1960s it has been possible to perform soft tissue augmentation with a diversity of products. Initially solid materials and soft tissue were imported from other areas by pedicled or free tissue transfer. The problem was, although excellent for use in contending with trauma or congenital problems, soft tissue augmentation had little place in aesthetic procedures. Injectable materials that could be accurately positioned, did not migrate and could be performed in the ambulatory day-care facility under local anaesthesia were required.
   The first of the injectable implants, developed in the 1970s, was reconstituted bovine collagen—Zyderm. Its main problem was that it was of bovine origin and therefore was, to some extent, rejected by the body. Three per cent of patients had hypersensitivity reactions, and in the others it had only a short duration of three to six months’ effect. It also had to be kept refrigerated. However, it was user-friendly and it did provide augmentation to all wrinkles around the face and enhance the lips. Throughout the USA and Britain, collagen therapists developed—nurses highly trained in the use of collagen—and the product was widely used.
   There was a need, at that time, for a more permanent product and the injection of minute quantities of liquid silicone was successful, but it was much abused and vast amounts were injected into various patients which subsequently migrated to different parts of the body and caused problems. It was, therefore, withdrawn.

Saving the nipple areola
When the surgeon decides to leave the nipple areola (NA) in place for a prophylactic or oncologic procedure, no mammary tissue should be left underneath. But as it is the original breast gland, a modified cutaneous adnexa, it gives a fundamental basic support to the NA vascular supply. Usually the surrounding vascular dermal network is not strong enough to support sudden NA viability, specifically during and after subcutaneous mastectomy with a large skin incision, unless a preliminary autonomisation is performed.
   A two-step surgical procedure can work well. First, on an outpatient basis under local tumescent anaesthesia, the autonomisation of the vascular supply to the nipple-areola complex is addressed by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. This ambulatory session is done by a preliminary biopsy of the gland stalk and with minimum invasive laparoscopic instrumentation.
   The second step, under general anaesthesia but again requiring the tumescent technique, removes the breast within its capsule, allowing a careful check of any remnant but further biopsies and imprint smears of the deep dermic-subdermal NA plane and offers an adequate approach to the axilla.
   A subpectoralis prosthesis completes the procedure. In the supine position, each side of the areola-periareolar subcutaneous tissue is infiltrated, using a 21-gauge long needle with anaesthetic solution (1% carbocaine+adrenaline). Peak-orange skin results over an approximate 20cm diameter.

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