Aesthetic Surgery Journal

Aesthetic Surgery of the Face and Neck

Fritz E. Barton — 2009-11-01

Learning Objectives: The reader is presumed to have a basic understanding of facial anatomy and facial rejuvenation procedures. After reading this article, the reader should also be able to: Physicians may earn 1.0 AMA PRA Category 1 Credit™ by successfully completing the examination based on material covered in this article. This activity should take one hour to complete. The examination begins on page 464. As a measure of the success of the education we hope you will receive from this article, we encourage you to log on to the Aesthetic Society website and take the preexamination before reading this article. Once you have completed the article, you may then take the examination again for CME credit. The Aesthetic Society will be able to compare your answers and use these data for future reference as we attempt to continually improve the CME articles we offer. ASAPS members can complete this CME examination online by logging on to the ASAPS members–only website (http://www.surgery.org/members) and clicking on “Clinical Education” in the menu bar. Modern aesthetic surgery of the face began in the first part of the 20th century in the United States and Europe. Initial limited excisions gradually progressed to skin undermining and eventually to a variety of methods for contouring the subcutaneous facial tissue. This particular review focuses on the cheek and neck. While the lid–cheek junction, eyelids, and brow must also be considered to obtain a harmonious appearance, those elements are outside the scope of this article. Overall patient management, including patient selection, preoperative preparation, postoperative care, and potential complications are discussed.

Aesthetic Surgery of the Face and Neck

2009-11-01

The American Society for Aesthetic Plastic Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Perioral Wrinkles: Histologic Differences Between Men and Women

Emma C. Paes, Hans J.L.J.M. Teepen, Willemijn A. Koop, Moshe Kon — 2009-11-01

Background: Women tend to develop more and deeper wrinkles in the perioral region than men. Although much is known about the complex mechanisms involved in skin aging, previous studies have described histologic differences between men and women with respect to skin aging only incidentally and have not investigated the perioral region. Objective: The purpose of this study was to investigate gender-specific differences in the perioral skin. Methods: To determine wrinkle severity, skin surface replicas of the upper lip region in 10 male and 10 female fresh cadavers were analyzed by using the dermaTOP blue three-dimensional digitizing system (Breuckmann, Meersburg, Germany). In 30 fresh male and female cadavers, three full-thickness lip resections were investigated in a blinded fashion for specific histologic features. All results were statistically analyzed in a linear regression model with SPSS software (version 15.0; SPSS, Chicago, IL). Results: The female replicas showed more and deeper wrinkles than the male replicas (P < .01). Histologic analysis revealed that the perioral skin of men displayed a significantly higher number of sebaceous glands (P = .000; 95% confidence interval [CI] 23.6–53.2), sweat glands (P = .002; 95% CI 2.1–8.1), and a higher ratio between vessel area and connective tissue area in the dermis (P = .009; 95% CI 0.003–0.021). The amount of hair follicles did not significantly differ between men and women, although the average number of sebaceous glands per hair follicle was greater in men (P = .002; 95% CI 0.33–1.28). Conclusions: Women exhibit more and deeper wrinkles in the perioral region and their skin contains a significantly smaller number of appendages than men, which could be a feasible explanation for why women are more susceptible to development of perioral wrinkles.

Masseter Muscle Reattachment After Mandibular Angle Surgery

Mathew A. Thomas, Michael J. Yaremchuk — 2009-11-01

Background: Altering the dimensions of the mandibular angle by alloplastic augmentation or skeletal reduction requires elevation of the insertion of the masseter muscle, including the pterygomasseteric sling. Disruption of the pterygomasseteric sling during exposure of the inferior border of the mandible can cause the masseter muscle to retract superiorly, resulting in a loss of soft tissue volume over the angle of the mandible and a skeletonized appearance. Subsequent contraction of the masseter elevates the disinserted edge of the muscle and not only increases the skeletonized area, but also exaggerates the deficiency by causing a soft tissue bulge above it. Objective: The authors describe the disinsertion of the masseter and the resulting deformity as a potential complication of mandibular angle surgery and review the technique for repair. Methods: The records of 60 patients (44 primary, 16 secondary) who presented for alloplastic mandible augmentation between 2003 and 2008 were reviewed. Results: Nine patients presented with clinical signs of disruption of the pterygomasseteric sling after mandibular angle surgery. Five patients had clinical signs consistent with complete disruption. Two of these patients requested reconstruction. The other four had signs consistent with partial disruption. Through a Risdon approach, the masseter was successfully reinserted using drill holes placed at the inferior border of the mandible. Conclusions: Masseter disinsertion is a previously unreported sequelae after aesthetic surgery for the angle of the mandible. The resultant static and dynamic contour deformity can be corrected by reattaching the muscle to the inferior border of the mandible.

Soft Tissue Fillers in the Nose

Clinton D. Humphrey, John P. Arkins, Steven H. Dayan — 2009-11-01

Using soft tissue fillers to correct postrhinoplasty deformities in the nose is appealing. Fillers are minimally invasive and can potentially help patients who are concerned with the financial expense, anesthetic risk, or downtime generally associated with a surgical intervention. A variety of filler materials are currently available and have been used for facial soft tissue augmentation. Of these, hyaluronic acid (HA) derivatives, calcium hydroxylapatite gel (CaHA), and silicone have most frequently been used for treating nasal deformities. While effective, silicone is known to cause severe granulomatous reactions in some patients and should be avoided. HA and CaHA are likely safer, but still may occasionally lead to complications such as infection, thinning of the skin envelope, and necrosis. Nasal injection technique must include sub-SMAS placement to eliminate visible or palpable nodularity. Restricting the use of fillers to the nasal dorsum and sidewalls minimizes complications because more adverse events occur after injections to the nasal tip and alae. We believe that HA and CaHA are acceptable for the treatment of postrhinoplasty deformities in carefully selected patients; however, patients who are treated must be followed closely for complications. The use of any soft tissue filler in the nose should always be approached with great caution and with a thorough consideration of a patient's individual circumstances.

Use of the Acellular Dermal Matrix in Revisionary Aesthetic Breast Surgery

G. Patrick Maxwell, Allen Gabriel — 2009-11-01

Background: Revisionary augmentation and revision of augmentation mastopexy are of considerable interest to plastic surgeons who perform breast surgery because of the procedures' complexity. In these cases, surgeons are faced with either thinned breast tissues resulting from large breast implants with tissue stretch or encapsulation caused by excessive scarring. To our knowledge, there are currently no large-series studies describing the use of acellular dermal matrices (ADM) in cosmetic breast surgery. Objective: The authors describe the use of the ADM in revisionary breast surgery to establish the aesthetic breast form. Methods: A retrospective chart review was conducted of 78 consecutive patients who underwent revisionary breast augmentation and augmentation mastopexies with ADM during a period of just over two years (October 2005 to January 2008). Data collected included patient characteristics, complications, outcomes, and reoperation rates. Results: Seventy-eight procedures were performed with ADM during the two-year period, with a minimum of 12 months of follow-up. There were two complications requiring reoperations for a hematoma and implant malposition, respectively. There were no Baker III or IV capsular contractures at one year postprocedure. Conclusions: Revisionary augmentation and revision of augmentation mastopexy are commonly performed procedures and they have a significantly higher complication rate than primary procedures. This series shows that the ADM can be used both safely and effectively in revisionary cases, resulting in decreased rates of capsular contracture and implant cushioning/stabilization.

Clinical and Radiographic Poland Syndrome Classification: A Proposal

2009-11-01

Background: Many chest wall deformities have a characteristic radiologic appearance that can be the basis for a definitive diagnosis. Consequently, imaging techniques have fundamental roles in the detection, location, and characterization of these disorders. Objective: The authors propose a clinical and radiographic Poland syndrome (CRPS) classification system and possible treatment algorithm for the thoracic manifestations of Poland syndrome (PS) in women, based on both clinical examinations and imaging studies. Methods: A retrospective study was conducted of 28 female patients evaluated over 17 years in the 28th Infirmary, Plastic and Reconstructive Surgery Division of the Hospital Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil. After clinical examination, all patients underwent radiographic examination with chest radiographs, conventional computed tomography scans, magnetic resonance imaging and, in some cases, additional imaging studies. All clinical and radiologic variables were compiled in a database and used in the classification system, which included three levels of disease severity. Results: Based on the CRPS classification of the 28 female patients, 10 patients had first-degree PS, 14 patients had second-degree PS, and four patients had third-degree PS. Eighteen patients underwent surgical correction; a total of 39 surgical procedures were performed using the CRPS algorithm. Conclusions: Identification of the severity of PS using the proposed classification system provided an accurate study of each patient and enabled better planning for the surgical correction of functional and aesthetic deformities.

New Technologies for the Assessment of Breast Surgical Outcomes

2009-11-01

Background: Although interest in objective and quantitative breast surgical outcome assessment is rapidly increasing, published reports have yet to make a real impact on everyday clinical practice. Objective: The authors offer a preliminary report on an innovative methodology customized for breast shape evaluation that, in our opinion, could overcome most of the technical and conceptual limitations of previous studies. Methods: Three-dimensional/four-dimensional breast scanning was performed using a breast-dedicated prototype laser scanner made up of a handheld device, including a charge-coupled device (CCD) camera coupled to a spot laser source. Two additional motion analyzer cameras were used for handheld device tracking and the acquisition of patient motion. Results: Seven female volunteers, including both subjects who had undergone cosmetic or reconstructive breast surgery and those with no such history, underwent a dynamic breast shape survey. Curvature mapping on three-dimensional mesh warranted precise measurements of local geometric properties of the breast surface. Elaboration and representation of breast dynamic behavior during common motor tasks (eg, walking, running, sitting, and lying) was also possible. Conclusions: The scanning methodology reported here reliably describes the breast surface not only in a static position, but also at specific postures or during motion of the body. It also opens the door for quantitative static and dynamic assessment of surgical outcomes, the intraoperative assessment of breast shape, and other applications. Limitations include the relatively long amount of time required for each scan and the need for technical and clinical validation, particularly with respect to four-dimensional assessment.

Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices

Lina Triana, Carlos Triana, Carlos Barbato, Marco Zambrano — 2009-11-01

Background: The development of liposuction provided plastic surgeons with a safe and effective way to sculpt the human figure. The techniques and instrumentation used in the performance of liposuction have evolved significantly since its introduction. Objective: The authors review their experience with different liposuction techniques over the past 25 years. Methods: Data from patients who had undergone liposuction were collected from the personal databases of four different surgeons and from the database at the Corpus and Rostrum Plastic Surgery Clinic in Cali, Colombia. A retrospective review was conducted and the results from different liposuction techniques were compared. Results: A total of 26,259 patient charts were reviewed. The results showed that 5% of patients experienced a postsurgical seroma. Postsurgical fibrosis developed to some degree in 2.3% of patients. Anemia was present in 18% of all patients and in 60% of those patients who underwent dry liposuction. Ninety percent of patients reported postoperative pain. The incidence of deep vein thrombosis was 0.03%, as was the incidence of pulmonary embolism. Mortality was 0.01% and was mainly caused by pulmonary embolism. Patient satisfaction was similar for all of the described techniques. Conclusions: The incidence of anemia was reduced significantly in patients undergoing tumescent liposuction versus dry liposuction. However, the occurrence of seroma increased with the introduction of tumescent liposuction. The incidence of postoperative pain and fibrosis was similar for all liposuction techniques reviewed. The aesthetic results obtained using ultrasound- or laser-assisted liposuction were similar to those obtaining using other techniques.

Does Thighplasty for Upper Thigh Laxity After Massive Weight Loss Require a Vertical Incision?

Michele A. Shermak, Jessie Mallalieu, David Chang — 2009-11-01

Background: After massive weight loss (MWL), many patients present with concerns about skin excess and laxity. The thigh is one of the more complex regions to address in MWL patients because of the differing degree, location, and quality of skin excess and fatty tissue, as well as surgical risk factors. Objective: The authors describe a technique called the anterior proximal extended (APEX) thighlift to effectively treat upper thigh skin excess with a hidden scar while also enhancing adjacent body regions. Methods: A review was performed of 97 MWL patients who underwent thighlift surgery between March 1998 and October 2007. Eighty-six women and 11 men, with average weight loss of 146 lb and average body mass index (BMI) at contouring of 29.8, were included in the study. The risk factors that were assessed included age, gender, medical conditions, tobacco use, BMI, weight of skin excised, and surgery performed. The outcomes that were assessed included wound healing and lymphedema. Extended vertical thighlift was performed in 11 patients and anterior superior thighlift in 86 patients. Results: Complications of thighlift included wound healing problems (n = 18; 18.6%); lymphedema (n = 8; 8.3%); cellulitis (n = 7; 7.2%); seroma (n = 3; 3.1%); and bleeding (n = 1; 1%). On multivariate statistical analysis, age and BMI were found to impair healing in the entire thighlift group. For patients with a BMI greater than or equal to 35, the odds ratio (OR) for a wound healing complication was 13.7 (P = .03). Hypothyroidism was strongly associated with lymphedema, with an OR of 23 (P = .06). Extended thighlift trended toward lymphedema (OR = 16.7; P = .08). Conclusions: Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aesthetic improvement in terms of skin excess and laxity. The APEX thighlift is a new technique that expands upon those previously described in the literature to effectively treat upper thigh laxity with a hidden scar after MWL.

Commentary

Al Aly — 2009-11-01

Shermak et al describe their anterior proximal extended (APEX) thighlift technique, a variant of the Lockwood horizontal thighlift, which in its excision spans anteriorly from the abdominoplasty scar to the infrabuttocks crease posteriorly. They conclude that APEX thighlift is the most appropriate thighlift for massive weight loss (MWL) patients with redundancy extending no further than the midportion of the medial thigh. While I am in agreement with the authors that the infrabuttocks area should be addressed more frequently in the MWL patient, I disagree that APEX should be the preferred methodology for patients with proximal thigh excess.

Botulinum Toxin for the Correction of Asymmetric Crying Facies

Tonguc Isken, Ayla Gunlemez, Bulent Kara, Hakki Izmirli, Huseyin Gercek — 2009-11-01

The clinical hallmark of asymmetric crying facies (ACF) is a symmetric appearance of the oral aperture and lips at rest, but significant depression of one side of the lower lip with animation (crying or smiling). ACF can resolve spontaneously in the first year of life, but surgical intervention may be required at some point to ensure a good cosmetic outcome. The authors report on the successful use of botulinum toxin type A to achieve temporary facial symmetry in two children with ACF with results lasting up to six months and suggest that such treatments may be helpful in providing more time to consider and/or plan surgical intervention.

Tip Refinement Grafts: The Designer Tip

Rollin K. Daniel — 2009-11-01

In cosmetic rhinoplasty, the patient's satisfaction is most often determined by the quality of the tip surgery, but perfecting a technique for consistently attractive tips can be challenging. As a result, rhinoplasty surgery is now entering a new era of “designer tip” operations, wherein surgeons can employ a combination of open suture tip techniques and tip refinement grafts to achieve consistent results. The grafts are made from excised lateral crural cartilage and, depending upon the specific aesthetic goals, the shape can include the following: domal, shield, diamond, folded, or combination. It is possible to alter dome-defining points, tip point, projection, definition, volume, and size and shape. A study of 100 consecutive female rhinoplasties indicated that tip sutures alone were used in 36% of cases, while a tip refinement graft was added to a sutured tip in 59% of cases.

Improving Practice Performance in Aesthetic Surgery

R. Barrett Noone — 2009-11-01

Every aesthetic surgeon has the goal of improving practice performance. It is a fact, however, that one cannot substantiate improvement—or sometimes even determine the need for improvement in specific areas—without some form of measurement. That is why the Maintenance of Certification in Plastic Surgery (MOC-PS) program includes a format for practice-based learning that allows surgeons to actually measure their practice performance relative to their own outcomes data and chart review and comparative data from other practitioners. This program is a vitally important opportunity for plastic surgeons to evaluate and substantially improve their performance.

Erratum

2009-11-01

In the July/August issue, 2009;29(4), an inadvertent data error was made on page 297, Figure 3. The caption was incorrect in stating that “58% [of surgeons] reported performing revisions in 58% of their cases.” It should have read: “58% [of surgeons] reported performing revisions in 0% to 5% of their cases.”

Erratum

2009-11-01

In the Editorial from Dr. Foad Nahai which appeared in the September/October issue of ASJ (2009;29(5), page 443), Dr. Nahai's “Safety Diamond” description was incorrectly attributed to The American Society for Aesthetic Plastic Surgery in the references. The original description of the “Safety Diamond” actually appeared in reference 6, Clinical Risk (in press).

2009-11-01

Aesthetic Surgery Journal

Aesthetic Surgery of the Face and Neck

Aesthetic Surgery of the Face and Neck

Perioral Wrinkles: Histologic Differences Between Men and Women

Masseter Muscle Reattachment After Mandibular Angle Surgery

Soft Tissue Fillers in the Nose

Use of the Acellular Dermal Matrix in Revisionary Aesthetic Breast Surgery

Clinical and Radiographic Poland Syndrome Classification: A Proposal

New Technologies for the Assessment of Breast Surgical Outcomes

Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices

Does Thighplasty for Upper Thigh Laxity After Massive Weight Loss Require a Vertical Incision?

Commentary

Botulinum Toxin for the Correction of Asymmetric Crying Facies

Tip Refinement Grafts: The Designer Tip

Improving Practice Performance in Aesthetic Surgery

Erratum

Erratum

Table of Contents

Table of Contents