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A General Remark
https://t.me/med1917
Thigh and Buttock Lift – New Methods
The technique for a thigh lift is similar to that for brachioplasty.
Deep, subcutaneous dissection of the fascia and step-by-step resection
of the skin, previously marked precisely, are performed.
An operation on the medial side of the thigh is one of the most unsatisfactory operations an aesthetic and plastic surgeon can perform.
The patient’s expectations of the procedure are usually too great and
he/she is then disappointed by the result. The patient should therefore
be given an extremely detailed explanation prior to the thigh and buttock lift. The indication should be considered carefully and if the
patient expects too much, they should preferabl y be turned away.
The extent of the resection should be defined carefully the day before
the operation. If the skin on the inner side of the thigh is loose, the buttock region is usually also loose, so these operations can be combined
well.
The incision line in the buttock area should not extend beyond the
lateral buttock fold, as otherwise there may be residual aesthetically
displeasing scars, which often disturb patients more than hanging skin.
With extremely slack skin in the area of the medial thigh, vertical tightening extending to the medial side of the knee can be performed in
addition to horizontal tightening in the groin and buttock region. This
allows extremely intense tightening of the entire medial thigh, but the
residual scar should be drawn to the patient’s attention and explained.
The video shows the most frequentl y requested operation for horizontal thigh and buttock lifting. In contrast to brachioplasty, it is important
that the thick cutaneous/fatty flap be secured at two points to achieve a
longer-lasting result and better scar formation, owing to gravity in the
thigh area. The points for fixation are the periosteum of the pubic bone
and the inguinal ligament. The extent of the resection is defined with
key sutures, and the area is resected in stages so that not too much and
not too little skin is removed. The operation is performed under general anesthesia on an inpatient basis. Thrombosis and infection prophylaxis is started. A special girdle must be worn for 3 weeks after the
operation, followed by care of the scar with a silicone plaster.
XLII
Because of the many requests, hair transplanta tion, Prof. Mang’s space-
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lift, and a few brief descriptions of adjuvant therapies have also been
included.
Adjuvant therapies are being continually developed and newly published, mainly within the field of dermatology. For this reason, only the
essential features of the adjuvant therapies are described very briefly in
this manual, with no claim to completeness.
The new edition retains the essential texts on biological implants (collagen), lipotransfer, botulinum toxin, dermabrasion, ultrapulse CO
laser,
2
erbium: YAG laser , coblation, and chemical peeling. In addition, we
have filmed short videos on biological implants (collagen, hyaluro nic
acid), botulinum toxin, dermabrasion, erbium: YAG laser, and chemical
peeling. For space reasons, these films have been kept very short and
should show that adjuvant therapies should also be included in the
repertoire of an experienced aesthetic surgeon.
Two of these treatments have been described in detail in the video and
the text.
Liposuction – Removal of Fat with the Tumescence Technique
(Mang’s Solution) – MicroAire® System
A General Remark
Liposuction is one of the most frequently performed operations in aesthetic and plastic surgery. In men, liposuction is primarily requested
for the abdominal/hip area; in women, it is for the lateral and medial
thigh, buttocks, and hips (“saddle area”).
Dry suction under general anesthesia does not merely put a strain on
the cardiovascular system with an increased risk of thrombosis and
embolism, but also causes blood loss, including a drop in hemoglobin
to under 8 g %, as well as destroying the infrastructural supporting tissue (IST).
This infrastructural supporting tissue is maintained when the tumescence technique is used, so that there is no “chewing gum effect”
followingliposuction,i.e.,theskindoesnothavedepressionsinitbut
instead is tightened.
The tumescence technique was first published at the beginning of the
1990s by Jeff Klein. Lidocaine was used as local anesthesia. In view of
the toxicity, we carried out a large study that showed that the aesthetic
and plastic surgical tumescence technique with lower doses of prilo-
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A General Remark
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caine solution (Mang’s solution) produces the same results with a lower
incidence of complications:
)
Mang’s solution = 0.9 % saline solution (NaCl) 3000 ml
)
1 % prilocaine 1500 mg (= 150 ml)
)
Epinephrine 3 mg
)
8.4 % NaHCO330 mEq
)
Triamcinolone acetonide 30 mg
As high doses of prilocaine may cause methemoglobinemia, no more
than 6000 ml of this tumescence solution should be injected per session
either manually or with a pump. The results are very good if the correct
indications are given. There is no blood loss, the risk of thrombosis and
embolism is significantly reduc ed, and there is protection from infection.
The patient is mobile on the first day after the operation.
The patient should be monitored for 24 h after the operation. He/she
may leave the hospital with a special girdle, which must be worn for
3 weeks. The injection sites may be treated with scar ointment for
3 weeks after the operation. Then the region treated by liposuction
should be exercised in a gym under supervision.
In the video, the manual tumescence liposuction technique with Mang’s
solution is presented as a basic technique. Auxiliary devices of whatever
type (MicroAire®, ultrasound, reciprocator, etc.) may be useful and
reduce the liposuction time, although the same results can be achieved
perfectly with the manual technique. This technique is simple, can be
performed without any large instruments, and there are no significant
risks if it is carried out by a specialist.
XLIV
Similarly, the tumescence injection can be given manually or mechanically with a pump . The manual technique, however, is very time-consuminganditisnecessaryforthesurgeontohavealotofstamina,so
at our clinic we apply the tumescence solution quickly (without too
much pressure and over at least 45 min) and homogeneously with a
six-cannula pump system. Following local tumescence anesthesia, you
should wait 30 min and then begin liposuction.
If performed by an experienced surgeon, manual liposuction may take
up to 90 min and up to 45 min with the MicroAire® system. The patient
must be prepared for the total liposuction procedure with tumescence
to last approximately 2.5 h.
Hair Transplanta tion
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Hair transplantation is a procedure frequently performed in men. We
have an experienced transplantation team, managed by Dr. Frank Neidel. Depending on the indication, we work with both slit and micropunch techniques, manually or with laser assistance. Precise surgical
planning, the correct technique, and the schedule of the hair transplantation team, which is made up of the surgeon and three assistants who
prepare the hair roots, are all important factors.
App r oximately 3000 hair roots are transplanted per session. The procedure is performed on an outpatient basis under local anesthesia. The
patient is then given antibiotic cover and hair hygiene is strict.
The hair should be washed on the fourth day after the operation with a
mild chamomile shampoo.
Spacelift
The name spacelift was chosen by Prof. Mang and protected by patent
(German Patent Office, Pat ent and Logogram No: 303 23891), as threedimensional fat droplets of 0.1–0.3 mm are injected via the purified
autologous fat cells into the space between the cutaneous and adipose
tissue of the face, virtually as if in a honeycomb. As these fat droplets
are not injected in a bolus dose but by using microinjections, they do
not die but retain a vascular association and are transformed into fibroblasts, or rather connective tissue cells, and thus stabilize the aging process. Fat cells are thus injected into the space between the cutaneous
and adipose tissue, particularly at those sites where the collagen and
elastinfibersbreakdownwithage,i.e.,inthenasolabial,mouth,forehead, lateral eye, and cheek regions.
A General Remark
The spacelift should be seen as a proph ylaxis against aging after the
35th year of life. If there is surplus skin in the area of the neck/cheeks
or eyelids, conventional tightening or lifting must be performed.
A spacelift cannot replace a facelift.
The procedure is carried out on an outpatient basis under local anesthesia. Cooling and lymph drainage are then necessary for 3 days, along
with antibiotic cover.
Adjuvant Therapies
Adjuvant forms of therapy administered during or after surgical procedures – or as a single form of therapy – play a very important role in
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A General Remark
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the area of aesthetic facial surgery. However, it is very important that
the correct form of therapy should be selected for each type of skin
aging. The manual presents a critical assessment of each individual
method along with practical instructions enabling the surgeon to perform them independently. In the chapter on laser therapy and adjuvant
therapies, a great deal of attention has been devoted to tricks, techniques, mistakes, and risks. As a result, even an inexperienced physician can quickly obtain an overview of the most important procedures
in aesthetic surgery currently performed on an outpatient basis.
This manual has been created to put aesthetic surgery on a serious professional foundation equal to that of the other surgical specialties and
to offer standard techniques.
Conscientious patient instruction, correct evaluation of the indication
for surgery, and quality-oriented and standardized surgical techniques,
together with good follow-up care, guarantee satisfied patients.
Wer ne r L . M ang
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Acknowledgements
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As aesthetic surgeons, we are often unable to define beauty, and we
shouldnotbeswayedbyfashion.Whatissaidtobebeautifulinthe
media today may be different again in a few years’ time. The aesthetic
surgeon must therefore impart timeless beauty through his creative
work. The patient must feel good. Less is often more and overly aggressive aesthetic surgery is not my style.
During the 1980s and 1990s, I spent a lot of time at conferences in the
USAandBrazil,butinthelastfewyearsIhavebeenmoreactivein
Russia and China. I often receive invitations from these countries
because of my Manual of Aesthetic Surgery as aesthetic surgery is only
just being developed there, and an y knowledge in this field is extremely
welcome. I have become acquainted with many competent plastic
surgeons who are very interested in the field of aesthetics, particularly
in Russia. The demand is also increasing in these countries.
I have a close relationship with the Univ ersity of St. Petersburg through
Prof. Malakhov, whose human qualities I admire just as much as his
surgical skills.
Within Europe, our task is also to share our knowledge in aesthetic
surgery . In doing this, doctors will make a substantial contribution to
international understanding. The same applies to China where there is
a great demand for knowledge in aesthetic surgery . Young doctors from
this coun try have demonstrated their technical skill in my clinic.
Acknowledgements
I hav e already mentioned all of my medical colleagues with whom I
have been working since 1975 and have had the privilege to learn from,
as well as everyone who has helped me on the way. In addition to these,
I would also like to mention my long friendship with Prof. Ivo Pitanguy.
I first visited Prof. Pitanguy at his clinic in Rio de Janeiro in 1972. Since
then, Prof. Ivo Pitanguy has often taken part in conferences in Lindau
andisalwaysaverywelcomeguestinourhome.Hisprofessionalcompetence, his charm, his gentlemanly nature, his warm-heartedness and
his ability to get things done, as well as his pioneering spirit and his
love for aesthetic and plastic surgery have perhaps encouraged me to
continue resolutely in this specialty and to pass on my knowledge to
young colleagues. This young team of enthusiastic aesthetic and plastic
surgeons at my clinic has also helped me to complete the manual. For
this, I would like to give particular thanks to my plastic surgery consultants,Dr.med.ABeckerandDr.med.MarianStefanMackowskifor
their assistance, Dr. med. Frank Neidel for compiling the hair trans-
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Acknowledgements
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plantation chapter, Dr. J.T. Schantz for the photographic documentation
and his marvelous care of patients on the ward. Particular thanks also
go to Dr. med. Ulrike Then-Schlagau (plastic and general surgeon) for
her tireless and enthusiastic work on this book and whose excellent
qualifications have been a positive asset to this second edition. My
sincere thanks fo rthis. I would also lik eto thank Ms Annemarie Anzenbacher and Ms Karina Engelhardt for the clerical work and organization
and my entire surgical and inpatient team who likewise gave up much
time to compile the films and photographs.
My particular thanks naturally go to Springer-Verlag and, in particular,
Ms Gabriele Schröder, who has alway s been very patient with me and
has not pressed me too much, despite my delays. I would like to thank
Martha Berg and Joachim W. Schmidt for the wonderful production of
the manual and, last but not least, Mr Klaus Peter Prieur, who recorded
the films in the operating room and edited and set them in the studio
with much patience, skill, and originality.
The Manual of Aesthetic Surgery is brought to life by the excellent
illustrations. Mr Hans Jörg Schütze created these in an ingenious way.
He was present at the operations and drew every important stage.
I offer him my warmest thanks for this.
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Wer ne r L . M ang
History – Vita
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Whereas aesthetic surgery has enjoyed widespread acceptance in the
USA and Brazil since the 1970s, it is only during the last 20 years that
this field has become established in Germany and Europe.
At the age of 14 – way back in 1964 – I already knew that I wanted to
become a facial surgeon. I was absolutely fascinated by plastic surgery,
and spent my free time making models of faces and noses. From the
start, my father, Dr. Karl Mang, supported my wish to study medicine
and to specialize in plastic surgery . During my first year of medical
school, I traveled to Brazil to meet Prof. Ivo Pitanguy, my most important role model at that time.
Starting in 1972, I made regular visits to Professor Pitanguy’s clinic
during the summer and semester breaks. Over the years our mentorstudent relationship grew into a deep friendship, and we now see each
other regularly at congresses all over the world.
Without the generosity with which Professor Pitanguy shared his
knowledge and experience, and the intellectual and professional fascination he exerted on me, I would perhaps not have had the strength to
raise the field of aesthetic surgery to its present level in Germany. In
1987, I founded the German Society of Aesthetic Surgery, of which I
was President for 12 years and I am now President of the International
Society for Aesthetic Medicine (IGÄM e.V.). False modesty aside, I feel
that it is fair to say that I have had a decisive influence on the development of aesthetic surgery in Germany.
History – Vita
At congresses in Germany , surgeons with international reputations are
often invited as guest speakers . When I accept such invitations, my
objectiveisalwaystopromotequalityassuranceandadvancesin
aesthetic and plastic operations.
After studying medicine, I underwent postgraduat e training in surgery,
with guest residencies in Australia, England, and the USA. I realized
early on that training in otolaryngology (ENT medicine) is indispensable to a surgeon planning to work in the area of facial plastic surgery .
During this part of my postgraduate training (1975–1980), I received
enormous clinical and scientific support from Professor Volker Jahnke.
After gaining this additional qualification as an ENT specialist and
performinganumberofplasticoperations,Iworkedonthestaffofthe
Klinikum rechts der Isar in Munich run by Professor Werner Schwab.
Professor Schwab deserves a large amount of the credit for encouraging
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History – Vita
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my scientific work and allowing me to pursue an independent course as
an aesthetic surgeon. Without his tolerant support, I would perhaps
never have founded the German Society of Aesthetic Surgery or completed the work required to achieve professorial status.
Ihavealwaysviewedaestheticsurgeryasaninterdisciplinaryfieldof
study. It is evident from the forewords in this manual, written by prominent representatives of several medical specialties, that the various
medical specialties have a lot to learn from each other . Dermatology is
one of the fields related to aesthetic surgery. Professor Roland Kaufmann is a dermatologist who has accom panied us along much of our
journey.
In the field of oromaxillofacial surgery, I would like to express my special gratitude to Professor Rainer Schmelzle, whose motto is “cooperation instead of confrontation.” Professor Schmelzle shares my view that
medical specialties have a lot to learn from each other and that quality
assurance and continued education are of central importance in the
field of aesthetic surgery.
During the 1990s, I was very involv ed in collaborating with aesthetic
surgeons in the USA and in setting up international training programs. I have had a good relationship – a friendship in fact – with
Dr . George Brennan for many years. I visited Dr. Brennan for the first
time in 1983 and was immediately fascinated by his facelift technique.
In 1998, I asked him if he would like to become vice president of the
World Society of Aesthetic Surgery (WASS). The WASS would like to
set up an annual exchange program in aesthetic surgery between
Europe and the USA. We have already held highly successful winter
meetings in St. Moritz and Aspen and summer meetings in Lindau
and Newport Beach.
L
I would like to take this opportunity, moreover, to thank Dr . Mario
Ceravolo, who participated actively in the development of aesthetic surgery. This colleague has always encouraged and supported me in the
view that physicians attending professional conferences should not concentrate exclusively on scientific topics but should seize the opportunity
to make inval uable personal contacts offered by conferences, meetings,
publications, and professional societies. Another person deserving of
special mention is Dr. Bruce Connell, an outstanding aesthetic surgeon
whohastaughtmealot.DuringmyvisitstotheUSA–andhisvisitsto
Germany – we have spent many memorable times together. I have the
highest respect for his work and am very pleased that he is taking such
an active role in the WASS – and now in the International Society of
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Aesthetic Medicine (ISAM e.V.).
These acknowledgements would not be complete without a mention of
Dr. Hamid Massiha from New Orleans, whose excellent blepharoplasty
techniques and outstanding human qualities inspire my deep respect.
Finally , I would like to thank all of the colleagues who agreed to write a
foreword to the Manual of Aesthetic Surgery. These people are not just
good plastic and aesthetic surgeons but I also count them as friends.
Wer ne r L . M ang
History – Vita
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