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Knowing the details of nasal anatomy is absolutely necessary when undertaking the responsibility of rhinoplasty surgery. It is the essential first step. Careful study of these details makes for a more confident, prepared practitioner.

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To prospectively evaluate the efficacy of ultrasonography in the diagnosis of ruptured silicone gel breast implants, 98 patients (192 implants) underwent preoperative breast ultrasonography prior to silicone gel breast implant removal. The prevalence of implant rupture confirmed at surgery in this group of patients was 62 of the 192 implants (32 percent). Of the 60 implants diagnosed as ruptured by ultrasonography, 46 were confirmed as having visible defects at surgery (true positive) for a positive predictive value of 77 percent. Of the 132 implants diagnosed as intact by ultrasonography, 116 were confirmed as intact at surgery (true negative) for a negative predictive value of 88 percent. Overall, the sensitivity of ultrasonography for implant rupture was 74 percent, and the specificity was 89 percent. These findings demonstrate that ultrasonography is an effective imaging modality for the diagnosis of silicone gel breast implant rupture. Compared with mammography, ultrasonography appears to offer superior sensitivity and specificity without radiation exposure or discomfort. Although magnetic resonance imaging has shown considerable promise in the diagnosis of implant rupture, ultrasonography provides comparable sensitivity at a fraction of MRI's cost.

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The subperiosteal browlift and midface lift combination is a total mobilization of the composite full-thickness soft tissues from the bony skeleton with superior suspension. The object is to correct midfacial ptosis and the "tired" look of the lateral eyelids. It is done in conjunction with a browlift so that a composite correction of the upper and midface is achieved. When indicated, a modified lower cheeklift and the usual procedures for correcting neck deformities are utilized in combination. We believe the procedure is safe and the results reported are natural and long-lasting. This review of 130 cases also stresses technical aspects and the safety of the procedure.

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OBJECTIVE: The purpose of this study was to describe and illustrate the sonographic appearances of 19 ruptured silicone gel breast implants. MATERIALS AND METHODS: We retrospectively reviewed the sonograms of 16 patients with 19 ruptured silicone gel implants from two institutions. The ruptured implant was confirmed at surgery in 17 cases and by mammographic and clinical findings of a ruptured implant combined with biopsy findings of a silicone granuloma in two cases. Breast sonograms were available for review in all patients. The clinical presentation of each patient was recorded. The sonograms and mammograms were reviewed, and the findings were correlated with the surgical findings. In 16 of the 19 ruptured implants, mammographic findings suggested rupture, including lobulation of the contour of the implant and/or silicone extrusion into the breast parenchyma or axilla. In two ruptured implants, mammographic findings were normal, and in one case, no mammogram was available. In those three patients, palpable masses and clinical findings were suggestive of rupture. RESULTS: Sonography showed a unique echogenic appearance called echo-dense noise, in 17 of the 19 ruptured implants; in 10 of the 17, sonograms showed hypoechoic masses of extruded silicone also. In two ruptured implants, sonograms showed only the hypoechoic masses of extruded silicone gel. CONCLUSION: Our experience suggests that echogenic noise is a unique sonographic sign of ruptured silicone gel breast implants and may be caused by phase aberration related to the speed of sound being slower in silicone than in soft tissue.

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Multiple techniques for breast reduction have been proposed. For carefully selected women with macromastia, the technique of choice may be amputation mammoplasty with free nipple-areolar grafting. These select groups include the following: the poor-risk elderly, women with systemic disease that could affect the vascularity of the skin flaps or impair wound healing, women with previous operative procedures in the breast affecting skin flap or pedicle vascularity, and women with indications for removal of tissue in the region of the inferior pedicle. Our experience demonstrates that in these high-risk women, amputation mammoplasty with certain technical refinements provides an aesthetic safe result without significant perioperative surgical or medical complications. A clinical series is presented with an average follow-up of 2.75 years.

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The long-term fate of 6-alpha-methyl-methylprednisolone hemisuccinate (MPHS) placed into breast prostheses prior to implantation in humans was determined. MPHS hydrolyzes to the active form 6-alpha-methylprednisolone (MP) in water, which then diffuses out of the implant. Twenty prostheses were recovered 5.3 to 34.7 months after placement, and the solution inside was analyzed for MPHS and MP. Half-lives were calculated for the hydrolysis of MPHS to MP (3.4 +/- 0.58 months [mean +/- SEM]) and for the diffusion of MP out of the prostheses (20.63 +/- 6.10 months). The large half-lives found imply that MPHS slowly hydrolyzes to MP, and that active steroid is released for a longer time than was previously thought. This long release could be the cause of the long-term effects seen with steroids used in this manner.

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A study of 11 strips of curved cartilage harvested from 11 pigs' ears was undertaken to compare quantitatively the forces required to bend the strips before and after modification. The results show no statistical difference between the intact curvature and curvature produced when skin and perichondrium were resutured over 4 full-thickness, cartilaginous crosscuts. These in vitro findings suggest that, when one attempts to modify the shape of curved cartilage, lasting results may be obtained by shortening the convex surface length using a wedge excision method. The perichondrium is incised on the concave surface or the surface that will become longer with cartilage scoring, such as in otoplasty. If the cartilage surface will require elongation for ultimate straightening, the perichondrium as well as the cartilage must be incised.

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This case report illustrates the use of a Radovan tissue expander in a patient undergoing reconstruction of the upper two-thirds of the external ear. The expansion facilitated draping of the superior retro-auricular skin over the autogenous costal cartilage framework that was used for the skeletal reconstruction of the ear.

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Long-term follow-up of 12 patients who have undergone augmentation mammaplasty with breast prostheses containing 62.5 mg of methylprednisolone hemisuccinate is presented. Significant complications, including prosthesis ptosis, atrophy and thinning of overlying breast tissue, impending extrusion, and capsular contracture are discussed. Excellent results can be followed by significant complications many years later. Many of these changes are reversible when steroid-containing prostheses are exchanged for new nonsteroid prostheses. Long-term follow-up of patients who have undergone augmentation mammaplasty with prostheses containing steroids is recommended.

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