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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Ten Rules
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Ten Rules
During the past 20 years, the author has performed more than 30,000
surgical procedures with the aim of improving patients’ appearance.
During this time, he has developed a professional philosophy which can
be summed up in ten rules:
1. Your conduct toward your colleagues should be characterized by
fairness. Cooperation not confronta tion is the most important
thing.
2. Health takes precedence over beauty . Aesthetic surgeons, like all
other ph ysicians, are bound by the Hippocratic Oath.
3. Genuine beauty cannot be purchased.
4. Healthy nutrition, sports, and a positive lifestyle often do more for
a person’s look than aesthetic surgery.
5. A patient should never incur debts for aesthetic surgery .
6. Patients should be given comprehensive information about the
costs and risks of the operation. Cooperation with a trained cosmetician is a vital part of preo perative and postoperative treatment.
7. There are limits to what can be achieved by aesthetic surgery . Even
the best aesthetic surgeon has dissatisfied patients.
LII
8. Beware of poorly trained physicians, emotionally disturbed
patients, and cranks.
9. Neither the doctor nor the patient stands to profit from longdrawn-out litigation; the only “winners” are the lawy ers.
10. A patient should never make a rash decision to undergo aesthetic
surgery.Ifheorshehasanydoubtsatall,itisbesttoobtaina
second opinion from another surgeon before going ahead with the
surgery.
The decisive factors for the success of aesthetic surgery are the conscientious instruction of patients, state-of-the-art surgical methods, and
professional follow-up care. As a result of the large number of cases
treated there over the years, the Lake Constance Clinic has an impressive photographic archive.
The manual has been designed as an audiovisual medium and is
accompanied by a surgical atlas. The surgical techniques are explained
concisely, objectively, and vividly to a target audience, including physi-
cians from all medical specialties. The aim of the authors is to improve
https://t.me/med1917
surgical results and preven t complica tions. It is intended less for specialists in aesthetic surgery than for physicians who want to take up
aesthetic surgery. The manual is therefore also suitable for interested
students, interns, and residents. The surgical methods described hav e
been applied in a large number of cases (more than 1000 for each
technique); over the years, a sizable body of clinical and scientific
documentation has been amassed for each method. The methods have
proven themselves from the point of view of surgical outcome, risk
minimization, and long-term results.
Ten Rules
LIII
Contents
https://t.me/med1917
1 Photographic Documentation in Aesthetic and Plastic Surgery 1
2 Informed Consent in Aesthetic and Plastic Surgery 7
3 Rhinoplasty 13
4 Rhytidectomy 65
5 Eyelid Surgery – Blepharoplasty 165
6 Otoplasty 227
7 Breast Surgery 263
8 Brachioplasty 349
9 Abdominoplasty 379
10 Thigh and Buttock Lift 433
11 Liposuction 475
12 Hair Transplantation 519
13 Adjuvant Therapies, Including Laser Surgery 541
14 Aesthetic Surgery: Quo Vadis? 629
Contents
15 Bibliography 631
16 Subject Index 649
17 List of Suppliers 656
LV
1 Photographic Documentation in Aesthetic
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and Plastic Surgery
Standardized photo documentation is of fundamental importance in
aesthetic plastic surgery. Historically, photo documentation has its
th
roots in the 18
technique by George Eastman, founder of the Kodak-Eastmann company, did photography become accessible to a wider public and, as a
result, more popular. In this chapter, the most important aspects of
photo documentation will be explained and presented.
A fundamental aspect of high-quality standardized photography lies
in the preoperative planning of the procedure. In this regard, imaging
techniquesallowprocedurestobedepictedanddocumented,and
enable the patient to be given a detailed explanation of the surgical
procedure.
Furthermore, adequate documentation fulfils an important role in the
medico-legal context.
century . Only with the development of the dry-plate
It should be noted that the patient’s informed consent is required prior
to photographs being taken and published.
Digital photo documentation has become an integral part of medical
training and quality control. In particular, the increasing use of digital
photography has set new standards and enables the production of digital visual patient records.
For decades, photo documentation has had a firm place in academic
practice. Ho wever, only with the adven t of the digital technique did
photo documentation become a widely used instrument. A large numberofsurgeonscarryoutthispracticeofdocumentationtoagreat
extent independently. It is not rare that this results in non-standardized
and incorrect documentation, which in turn can have a negative effect
on the surgical result in the long-term. In addition, digital image processing techniques allow images to be manipulated and intentionally
falsely depicted.
Nevertheless, digital photography has some clear advantages. One very
important aspect is the significantly lower costs compared with analog
photography. The time aspect is also significant, given that developing
and digitalizing processes are dispensed with, thus guaranteeing immediate a vailability ofthis medium. In particular ,in an increasingly digitally networked society, audiovisual communication plays a central role.
1 Photographic Documentation in Aesthetic and Plastic Surgery
1
1 Photographic Documentation in Aesthetic and Plastic Surgery
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Scientifically sound photo documentation requires that the object to be
documented is photographed from various angles and perspectives.
In facial plastic surgery , for example, the so-called Frankfurt horizontal
plane plays a particularly important role. It depicts a standardized
procedure with frontal, lateral, and 45° images. Thus, an imaginary line
between the upper edge of the tragus and the infraorbital edge is
formed.
In addition, camera equipment, film material, light sources, as well as
background and picture detail should be standardized. Clothing or
jewelry should not be worn. Of the innumerable reports in the specialist literature on medical photo documentation, there are only a few
studies which have specifically investigated the influence of incorrect
photo documentation on aesthetic results. Sommer and Mendelsohn
investigated how varied positioning of the object can lead to an altered
appearance and, therefore, to differing evaluations of findings. They
concluded that the slightest variation in positioning, such as flexion
and extension of the head, can cause pronounced changes in the image
asawhole.
To create internationally comparable standards, there is a consensus
that nasal images, for example, should be taken frontally, laterally at a
90° angle on both sides, and at a 45° angle. Light quality, background,
andcamerasettingsshouldbeconsistent.Aningenioussystemofnasal
documentation was described by Kuhnl and Wolf, whereby all planes
were documented and standardized by means of one single image with
the help of mirrors in the form of a semi-circle.
In addition to the aforementioned aspects of photographic technique
and instrumenta tion, an appropriate software program for data acquisition should be available. A good database enables images to be
searched for and sorted by name, procedure, surgeon, as well as diagnosis. All image data should be stored on a server in duplicate in order
to minimize loss of data. In addition, all access should be passwordprotected in order to avoid distribution of confidential data to nonauthorized third parties.
Themostrecentdevelopmentintheareaofnon-invasiveimagingtechnology in plastic surgery is 3D laser scanning. Using this method,
structures can be captured in three dimensions and depicted by means
of a laser scanner. This opens up numerous possibilities in preoperative
planning and the assessment of complex structures such as the female
breast or the face, for example. Moreover, morphometric analyses and
2
volume definition can be carried out. Software programs make it possi-
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ble for images to be overlaid, thus enabling accurate preoperative and
postoperative comparisons to be made. In combination with rapid
prototyping procedures, such as the one demonstrated below, precise
implants and models can be developed.
Surface scanner
Laser emitting
window
1 Photographic Documentation in Aesthetic and Plastic Surgery
Creation of curved surface to
represent underlying chest wall
Overlaying of breast onto
chest wall image
Calculation of breast volume with Rapidform software
I. Volume Symmetry: Calulation of breast volume with Rapidform software (Fig. 1.1)
Distance
(mm)
● 120
● 90
● 60
● 30
● 0
Matched pair
II. Contour Symmetry (Fig. 1.2)
3
1 Photographic Documentation in Aesthetic and Plastic Surgery
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Examples in Photo Documentation
1. Breast Procedures
Overview: Entire thorax
Borders: Cranial: shoulder (upper part)
Caudal: small breasts: lower part of rib cage
large breasts: umbilical region
4
Fig. 1.3
a Frontal view
b 45° Lateral
c 90° Lateral
d Lateral
2. Facial Procedures
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Face and Neck
Borders: Cranial: vertex
Caudal: jugulum
Bilateral: helix rim
Position: horizontal
1 Photographic Documentation in Aesthetic and Plastic Surgery
Fig. 1.4
a Frontal view
b From distal direc-
tion: maximum
elevation of the
head
c 3/4 Lateral: lateral
border: lateral
canthus
d 90° Lateral: tip of
the nose
5
1 Photographic Documentation in Aesthetic and Plastic Surgery
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3. Body Contouring Procedures: Abdomen
Overview: Entire abdomen
⬃
Borders: Cranial:
4 cm cranial to the xiphisternum
Caudal: 15 cm caudal to the inguinal ligament
Medial, lateral: lateral body contour
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Fig. 1.5
a Frontal view
b Posterior view
c 45° Lateral
d 90° Lateral
If necessary, functional views are indicated.
2 Informed Consent in Aesthetic and Plastic Surgery
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Informed consent forms the legal and ethical framework of all medical
practice.
The roots of modern medical informed consent go back to 1914 when a
NewYorkjudgestated:“Everyhumanbeingofadultyearsandsound
mind has a right to determine what shall be done with his body, and a
surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.”
Widespread access to medical information via television and, in particular, the internet has led to an increase in public awareness of aesthetic
plastic surgery.
Patients consider themselves not simply as cons um er s, but as partners
and decision-makers during the course of treatment. Therefore, communication and availab ili ty of information regarding treatment, prognosis, and aftercare are significant aspects that need to be discussed
and presented in the informed consent discussion. This is a prerequisite
of all elective surgical procedures. Patients have a right to receive comprehensive information. Hence the following guiding principle: Only
the patient who is fully informed can make an informed decision. Both
the treatment and the informed consent should be sufficiently and
understandably documented.
2 Informed Consent in Aesthetic and Plastic Surgery
Medical liability litigation relating to aesthetic plastic surgery procedures is increasing. Approximately 16% of all medical malpractice cases
are indirectly or directly associated with the informed consent itself. It
is assumed that this percentage is significantly higher for plastic surgery; howev er, there are no statistics available with regard to this.
Therefore, the fewer reasons there are for a procedure to be carried out
on purely medical grounds, the ‘more significant’ the aspect of
informed consent and documentation becomes. The format and extent
are country- and medical system-specific, and depend on the jurisdiction under which they fall. For this reason, regulation s are constantly
being amended.
In Great Britain, O’Brien and his colleagues questioned 63 patients,
who were undergoing elective plastic surgery procedures, in an open
survey with regard to informed consent and what they would like to
know prior to an operation. They found that patients particularly
wanted information on the type and extent of the procedur e and its
potential benefits.
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