A Comprehensive Three-Dimensional Rejuvenation Center

What I learned from the 50th American Society of Aesthetic Plastic Surgery Meeting in San Diego April 27- May 2 2017

First off I have to congratulate all the contributions of past and present board members and officers who forged a society which was originally viewed as a rogue society within the frame work of organized plastic surgery, shunned by all chairman of academic programs and has progressed to be the preeminent society for education of aesthetic surgery and safety concerns to provide the highest quality of care for all patients.

There were more classes and presentations than I could attend so I was strategic in my mission to glean information pertinent to my aesthetic solo private practice in Knoxville, Tn.

Facial Rejuvenation

Many advances in non-invasive techniques to slow the aging process have occurred but in the poignant words of Dr. Dan Baker, “surgery still remains the gold standard and stop apologizing for being a surgeon”. No question that the absolute best and in many ways a far more economical approach to face and neck aging problems is surgery. Many techniques can be employed to achieve natural and balanced results but the absolute most important factor is a surgeon with a good aesthetic eye and prudent judgement in the execution of a procedure. In my opinion adjuvant use of fat grafting to the main areas of facial fat wasting demonstrated by Dr. Rohrich is imperative to achieve outstanding results when atrophy is noted. Additionally Dr. Little showed some nice results of secondary procedures around the upper eyes and brows from over-resection of too much tissue with high riding eyelid crease and hollowed eyes with fat grafting. A provocative panel on sub-platysma tissue resection in neck lifts demonstrating that the subcutaneous layers of the neck actually thin with age and the deep plain below the platysma increases in size with fat deposition and salivary gland enlargement contributing to a fuller neck appearance. Some interesting results were seen with submandibular gland resection and even parotid gland resection to achieve a more sculpted look of the neck. However some of the results did appear overdone and not as natural compared to corset platysmaplasties. They report few complications but my concern for hematoma and salivary gland fistulas certainly would be higher than pre-platysma procedures.

Refinements in hyaluronic acid filler agents continue to occur both in terms of product as well as techniques and the science behind them. New findings are being seen with the interaction of the mimetic muscles and hyaluronic acid. Muscles adjacent to filler agents tend to reduce muscle activity. For example direct injection into the nasolabial fold can reduce muscle activity of the levator, and orbicularis muscle thus reducing the retraction activity thus softening the fold. Higher G’ fillers injected into the vermillion cutaneous border can weaken the pursing action of the orbicularis muscle softening the vertical lines. More studies to follow but this was a new concept for me.

A class in secondary rhinoplasties discussed the early experience of Dr. Rohrich’s use of tissue bank fresh frozen rib cartilage for visible grafts for noses. The cost is very reasonable avoids donor site morbidity and handles like native tissue. I see a number of revision surgeries from elsewhere and I plan to use this material in the future.

Breast

Many interesting topics but in general I find the Southeastern Society Atlanta Breast Meeting to be a more intense study of this field of aesthetic surgery. Certainly a poignant topic was ALCL related to breast implants sparked by the FDA recent public notification of this topic. The Aesthetic society has been at the forefront of this issue since it became a known entity over ten years ago. More in-depth studies are needed. Of particular interest is the etiology of this inflammatory derived lymphoma. It appears that individuals who have a certain genetic predisposition that become exposed to certain biofilms adjacent to implants containing certain bacteria that have antigens which trigger antigen presenting lymphoid cells to produce certain interleukins which overtime create clonal expansion of T cells resulting in lymphoma. Textured implants have been identified as a risk factor for developing this disease but based on the above mentioned model it is suspected that the texturing only increases the surface area of the implant surface compared to a smooth devise creating a larger area of biofilm contact with the opposing tissue around the implant. Fortunately successful treatment occurs with early detection and diagnosis and complete capsule removal and implant exchange. Late stages can result in distant disease and death. Fortunately compared to the denominator of all implants placed this is a very rare disease with low risk of death. It is interesting there are geographic clusters of this disease with Australia and New Zealand with higher rates than Europe which utilizes more textured implants than the United States which has a very low incidence.

Body Contouring

One interesting aspect of this meeting demonstrated the increase in male aesthetic surgery demands by having the first ever male only body contouring panel. I found Dr. Wall’s presentation for gynecomastia intriguing in his technique of not just contouring the male chest with liposculpturing and direct sub-areolar tissue removal as a subtraction technique. He actually employs axillary and serratus anterior and epigastric overlying fat removal and utilizing it for lipo-filling the anterior free border of the pectoralis major muscle as well as the lower insertion points on the chest wall to enhance a muscular appearance avoiding a flat amorphous look to the chest. Other presenters are trying to give a more masculine appearance by enhancing the appearance of the underlying muscle anatomy with fat enhancement. My question is:  what is the long term appearance after aging (i.e. sagging skin and weight gain)?

Of course the biggest discussions involved the ever increasing demand of buttock reshaping and enhancement with fat grafting. Based on pulling data from all countries including the United States this procedure has the greatest risk of dying compared to any other aesthetic procedure. The number one cause is the misplacement of a fat grafting cannula and injecting the piriformis muscle with fat which just below houses very large bore veins that can transmit the fat to the heart as an embolic event. It is imperative to use large bore cannulas over 4mm and stay always in the subcutaneous plain and keep the instrument moving. I agree with embracing the techniques of Drs. Wall and Del Vecchio with SST (simultaneous separation and tumescence) as a single step to enhance vasoconstriction and reduce time while separating the fat from stroma. Then the paradigm shift away from Coleman concepts of fat graft with EVL (expanded volume lipofilling) for buttock enhancement as well as breast. My couple of month experience with this technique mostly in the breast has been favorable.

Labia Majora and Labia Minora rejuvenation

This is another segment of aesthetic surgery which has flourished in the last several years based on changes in grooming habits and the athleisure trends of yoga pants that make women seek out these procedures. I also have seen more demand with my post-bariatric patients as well. The two most common techniques for labioplasty is the direct trim and the wedge technique respecting the posterior blood supply to the region. Excessive clitoral hooding must be addressed at the same time. I suspect the demand will continue for some time.

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