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Background In this study, we seek to answer the question: Does blepharoplasty for dermatochalasis alter visual performance? Objectives We seek to determine the impact of blepharoplasty on visual performance (refraction, contrast sensitivity, and visual field) in patients with dermatochalasis. Methods A total of 146 eyelids of 74 patients, 48 (64.9%) females and 26 (35.1%) males ranging from 40 to 68 years old, with dermatochalasis were analyzed prospectively. Refraction, contrast sensitivity, visual acuity, higher-order aberrations (HOAs), and mean deviation index (MDI) in the Humphrey visual field were evaluated and recorded before and at 2, 4, and 6 months after upper eyelid blepharoplasty. Results At the latest follow-up, uncorrected and corrected distance visual acuity showed no significant differences (P > .05). Patients’ contrast sensitivity increased significantly at all spatial frequencies under both conditions (P < .05) except at 12 cycles per degree in the photopic condition (P = .947). Mean astigmatism significantly decreased from −1.17 ± 0.83 to −0.89 ± 0.66 postoperatively (P ≤ .001). Total HOAs decreased significantly from 0.59 ± 0.13 μm to 0.51 ± 0.09 μm (P < .01) after surgery. The root mean square of the spherical aberration (P < .01), vertical trefoil (P = .018), horizontal trefoil (P < .01), horizontal coma (P < .001), and vertical coma (P < .01) decreased significantly. The MDI of the Humphrey visual field increased significantly postoperatively at all times compared with preoperatively (P < .05). The Blepharoplasty Outcomes Evaluation questionnaire showed significant favorable satisfaction with visual quality indexes (P < .001). Conclusions Upper lid blepharoplasty, in addition to its aesthetic effect, is an effective intervention to promote visual function and quality of life. Level of Evidence: 3

BACKGROUND Nasal reconstruction after Mohs resection of skin cancer commonly uses local flaps, many of which present limitations concerning their movement and skin color/texture match. In this article, the use of a myocutaneous island pedicle flap based on the nasalis muscle with bilevel undermining for the management of defects at challenging locations on the nose is described as a versatile and cosmetically appropriate flap option. In addition, a novel mathematical sizing methodology for this flap is presented. METHODS Between March 2013 and May 2016, 57 patients having undergone Mohs resection of skin cancer underwent nasal reconstruction using a myocutaneous island pedicle flap based on the nasalis muscle with bilevel undermining at our clinic. During the postoperative follow-up, patients were monitored for complications and received proper wound care. RESULTS The mean age was 68.4 (range, 34-94) years. The mean follow-up was 10.1 (range, 3.0-34.9) months. The mean defect size was 1.99 (range, 0.70-5.25) cm2. No complete losses of flap occurred. Incidence of minor complications (pin cushion effect, minor delayed healing, etc) was minimal (4/57; 7.0%). Two of the cases in this series involved the utilization of cartilage grafts in combination with the myocutaneus island pedicle flap. CONCLUSIONS The myocutaneous island pedicle flap based on the nasalis muscle with bilevel undermining can be used as a versatile flap for the closure of defects of various sizes and locations on the nose because of its rich blood supply, ease and convenience of use, and highly acceptable cosmetic outcome.

Transconjunctival lower lid blepharoplasty is a safe and effective procedure with a low complication rate. Success with this procedure depends on proper patient analysis and selection. The lower lid periorbital fat can be resected, or preserved, and draped over the orbital rim or used as free fat grafts, depending on the clinical presentation. The lower lid skin can be resurfaced with a peel, with a laser, or by skin pinch depending on surgeon preference.

Capsular contracture remains a challenging complication of implant-based aesthetic breast surgery despite improvements in implant design. The lowering of capsular contracture rates noted with the past use of polyurethane foam-covered implants has increased awareness of the importance of the biologic response at the interface between the implant surface and breast tissue. Emerging evidence indicates that much like the polyurethane foam, acellular dermal matrices alter the biologic response at the surface interface, resulting in a more vascular and less constrictive pattern of collagen deposition. This study reports on the authors' clinical experience using Strattice Reconstructive Tissue Matrix (LifeCell Corporation, Branchburg, N.J.) for the treatment of capsular contracture in patients with established capsules and for prevention in patients undergoing primary augmentation or augmentation/mastopexy. Of 80 patients (154 breasts) in whom Strattice was used, clinically significant contracture (Baker grade III/IV) occurred in three breasts (3.75 percent), all of which were in the treatment of previous contracture group. In addition, the authors noted two seromas requiring implant removal (both patients developed capsules, as mentioned above) and two hematomas requiring revision, for an overall failure rate of 6.25 percent for Strattice-assisted surgery. The data confirm that the use of Strattice significantly lowers the incidence of capsular contracture in the first 3.5 years after implant placement.

This study evaluated patients who underwent primary breast surgery within a single group practice from 1994 to 2009. Reoperations were divided by reoperation reason into total reoperations and implant-specific reoperations. The authors hypothesized that the implant-specific reoperation rate will provide the most accurate measurement of complications caused by the breast implant device.A total of 812 patients received the same brand of breast implant for primary breast augmentation or augmentation/mastopexy. Safety and efficacy data were recorded and complication rates were calculated. Statistics were applied using Kaplan-Meier estimated cumulative incidence calculations.This study included 482 patients with saline and 330 patients with silicone implants. The most common complications included capsular contracture, rippling, rupture, infection, and hematoma. A total of 8.2 percent of patients developed Baker grade III/IV capsular contracture by 6 years. The raw incidence of rippling was 7.1 percent, and the rate was significantly increased in underweight patients with subglandular saline implants (p = 0.045). The rate of total reoperation at 1 year was 14.2 percent. While a significantly increased rate of total reoperation was seen for silicone compared with saline implants (p0.01), no difference was seen in the rate of implant-specific reoperation for saline compared to silicone implants (p = 0.582).The use of total reoperation rates as an indication of complications of breast implants can lead to both an overestimation of implant-related complications and the inaccurate conclusion that silicone implants result in higher complication rates than saline implants. The implant-specific reoperation rate may provide a more accurate incidence of implant complications than the total reoperation rate, which includes reoperations for factors unrelated to the implant.

Transconjunctival blepharoplasty remains a popular and safe technique to treat periorbital aging. In the lower lid, it can be used successfully for orbital fat excision, redistribution, or septal tightening. In the upper lid, transconjunctival blepharoplasty has a role in removal of the nasal fat pad via an isolated, direct approach.The authors review anatomy, indications, and surgical approaches for upper and lower lid transconjunctival blepharoplasty.Potential complications, patient results, and the senior author's personal series are discussed.In the lower lid, this technique can be advocated in an effort to avoid lower lid complications such as sclera show or lid malposition. In the upper lid, it can be effective in treating isolated fat pads with minimal skin excess.

The contour of the neck is a very important determinant of facial aesthetics. Precise knowledge of neck anatomy is essential for adequate planning and execution of this procedure. There are three anatomic and surgical planes involved in the management of the aging neck; the superficial plane (subcutaneous fat), the intermediate plane (platysma muscles and the fat between the two muscles), and the deep plane (subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands). These planes need to be thoroughly evaluated in the preoperative assessment and dealt with according to each patient's needs. Even though this article focuses on isolated management of the aging neck, careful evaluation of the neck and its relationship to the lower third of the face is fundamental. If there is significant jowling and descent of the neck-face interface, an isolated neck-lift procedure will not address that problem and will lead to a suboptimal result. In these patients, a face and neck lift is a more appropriate operation.

Background: Spacer grafts in the eyelid are used in both reconstructive and aesthetic procedures. The authors report their experience using a new acellular porcine dermal graft (Enduragen) in 129 eyelids. Methods: A retrospective chart review was performed that included every case in which Enduragen was used by the two primary authors in the upper or lower eyelid. Patient demographics, type of procedure performed, and complications were reviewed. Results: Sixty-nine patients and a total of 129 eyelids were included in the study. Eight procedures were spacers in the upper lid, 104 were for spacers in the lower lid, and 17 were for lateral canthal reinforcement. Twenty-two procedures were in primary cases and 47 were in eyelids for secondary reconstructions, for a total of 69 patients. There were 13 eyelid complications, for a complication rate of 10 percent. Nine cases required surgical revision, and there were four cases of infection, all of which were successfully treated with oral and topical antibiotics. Conclusions: Enduragen has proved to be a very satisfactory substitute for ear cartilage and fascia in eyelid surgery in both reconstructive and primary eyelid cases. It seems to be far superior to other commercially available tissue substitutes because of its predictability of structure and robust behavior. All problems that were encountered in this series seemed to be related more to technical errors than to any deficiency in or reaction to the Enduragen. The increased strength, rigidity, and durability give support to the lids comparable to that obtained with autogenous ear cartilage and fascia.

After reading this article, the participant should be able to: 1. Understand and describe the anatomy of the breast as it relates to reduction mammaplasty. 2. Appropriately evaluate a patient considering reduction mammaplasty. 3. Be familiar with the different procedures available for reduction mammaplasty. 4. Describe the common early and late complications following reduction mammaplasty and their management.The goal of this continuing medical education module is to present the preoperative assessment, formation of a surgical treatment plan and its execution, postoperative patient management, and identification and treatment of early and late postoperative complications in breast reduction surgery.

Prior studies indicated that horizontal mattress sutures can control the curvature of a convex lateral crus. This study undertook to ascertain the ideal spacing for mattress sutures, determine what effect they have on the subsequent strength of the cartilage, and compare that to the resultant strength after scoring procedures used to control curvature. Curved fresh cadaver septa of various thicknesses (0.5, 1, and 1.5 mm) were used. The ideal spacing (gap between suture purchases) for the mattress suture was sought in 15 specimens. The consequent change in stiffness (modulus) of the cartilage was measured in nine other specimens before and after suture placement and after scoring. If the spacing was too large, instability resulted. If it was too small, curvature correction could not be obtained. An ideal mattress spacing (6 to 8 mm for 0.5-mm specimens and 8 to 10 mm for 1.5-mm specimens) removed most curvature and provided stability. The mattress suture increased the stiffness (modulus) above normal and far above that when the curvature was removed by scoring. The mean composite modulus before suturing was 4.6 MPa. After ideally spaced sutures, it was 6.2 MPa, a 35 percent increase in stiffness. After scoring to improve curvature, it was 2.4 MPa, a 48 percent reduction in stiffness (p = 0.02, Wilcoxon signed rank test). The horizontal mattress suture technique corrects cartilage curvature if the appropriate spacing is used. The corrected cartilage is stiffer/stronger than normal cartilage and much stiffer/stronger than if scored.

Despite the efficacy of opioid analgesics for postsurgical pain, they are associated with side effects that may complicate recovery. Liposome bupivacaine is a prolonged-release formulation of bupivacaine approved for intraoperative administration at the surgical site for postsurgical analgesia.To evaluate the effect of a single intraoperative administration of liposome bupivacaine on postsurgical pain, opioid use and opioid-related side effects in subjects undergoing breast surgery and/or abdominoplasty.In the present phase IV, multicentre, prospective observational study, subjects received a single intraoperative administration (266 mg) of liposome bupivacaine. Rescue analgesia was available to all subjects as needed. Outcome measures, assessed through postoperative day 3, included postsurgical pain intensity (11-point numerical rating scale), opioid consumption and overall benefit of analgesic score. Results were evaluated comparing investigators' previous experience with similar surgeries.Forty-nine subjects entered the study: 34 underwent breast surgery only and 15 underwent abdominoplasty with or without breast surgery (six underwent breast surgery in addition to abdominoplasty). Mean numerical rating scale pain scores remained ≤4.3 from discharge through postoperative day 3. Median daily oral opioid consumption was approximately 1.0 tablet postoperatively on the day of surgery and was approximately 2.0 tablets by postoperative day 3. Mean overall benefit of analgesic score ranged between 2.8 and 4.9 throughout the study.In this particular subject population, liposome bupivacaine was associated with low pain intensity scores and reduced opioid consumption compared with the investigators' previous experiences. Subjects' satisfaction with postsurgical analgesia was high, with a low burden of opioid-related side effects.Malgré l’efficacité des opioïdes pour soulager la douleur postchirurgicale, des effets secondaires peuvent compliquer le rétablissement. La bupivacaïne liposomique est une formulation à libération prolongée approuvée pour l’administration peropératoire d’une analgésie postchirurgicale au site opératoire.Évaluer l’effet de l’administration peropératoire d’une seule dose de bupivacaïne liposomique sur la douleur postchirurgicale, ainsi que sur l’utilisation d’opioïdes et leurs effets secondaires chez des sujets subissant une chirurgie mammaire, une abdominoplastie ou les deux interventions.Dans le cadre de la présente étude d’observation prospective et multicentrique de phase IV, les sujets se sont fait administrer une seule dose peropératoire de bupivacaïne liposomique (266 mg). Tous les sujets pouvaient recevoir une analgésie de secours, au besoin. Les mesures des résultats, évaluées jusqu’au troisième jour postopératoire, incluaient l’intensité de la douleur postchirurgicale (sur une échelle numérique de onze points), la consommation d’opioïdes et les bienfaits globaux du score analgésique. Les chercheurs ont évalué les résultats en les comparant à leur expérience de chirurgies similaires.Quarante-neuf sujets ont participé à l’étude : 34 ont subi seulement une chirurgie mammaire et 15, une abdominoplastie accompagnée ou non d’une chirurgie mammaire (six ont subi une chirurgie mammaire en plus de l’abdominoplastie). Les scores de douleur moyens sur l’échelle numérique ne dépassaient pas 4,3 entre le congé et le troisième jour postopératoire. La consommation quotidienne médiane d’opioïdes par voie orale après l’opération était d’environ 1,0 comprimé le jour de la chirurgie et d’environ 2,0 comprimés le troisième jour postopératoire. Les avantages globaux moyens du score analgésique se situaient entre 2,8 et 4,9 tout au long de l’étude.Au sein de cette population de sujets, la bupivacaïne liposomique s’associait à de faibles scores d’intensité de la douleur et à une consommation réduite d’opioïdes par rapport aux expériences passées des chercheurs. Les sujets étaient très satisfaits de l’analgésie postchirurgicale et présentaient un faible fardeau d’effets secondaires liés aux opioïdes.

Rod J. Rohrich, William P. Adams Jr., Jamil Ahmad, and Jack P. Gunter, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters , 3rd edition. Boca Raton, FL: CRC Press; 2014. ISBN-10: 1576263843, ISBN-13: 978-1576263846. $475.00. ![Graphic][1] The third edition of Dallas Rhinoplasty: Nasal Surgery by the Masters is a 2 volume set co-edited by Drs Rohrich, Adams, and Ahmad (who is new to this edition), with Dr Gunter recognized as an editor emeritus. The set also includes 4 DVDs and a full-text electronic book edition. Publication in 3 media formats provides multiple ways for the reader to digest this extensive and comprehensive treatise on rhinoplasty. There are 68 chapters, several of which are written by multiple authors. Many of the 46 authors are nationally recognized experts in rhinoplasty. Volume 1 is divided into 7 parts, the first of which covers basic concepts, such as nasal anatomy and analysis, nasal physiology, digital imaging, and coding. Parts 2-6 cover basic surgical concepts and address the dorsum, tip, alar rims, and alar base separately. The section on the tip is the most extensive and comprises 10 chapters. The last section covers surgery of the chin. Volume 2 is divided into 4 parts that cover secondary rhinoplasty, management of the airway, special topics and advances, and the personal approaches of 7 rhinoplasty experts (each with their own chapter). The 4 included DVDs cover numerous surgical techniques, including primary and secondary rhinoplasty, harvesting cartilage, and tip grafting. As a 2-volume set with 4 DVDs, Dallas Rhinoplasty: Nasal Surgery by the Masters … Corresponding Author: Dr Farzad R. Nahai, The Center for Plastic Surgery at MetroDerm, 875 Johnson Ferry Rd, Suite 300, Atlanta, GA 30342, USA. E-mail: drnahai{at}gmail.com [1]: /embed/inline-graphic-1.gif

Numerous options in brow lifting exist that can be broadly categorized as open and minimally invasive or endoscopic. Proper patient evaluation, procedural goals, and surgeon preference all play into procedure choice. There are common desirable traits of the esthetic brow. One must take into account gender differences when considering alteration of the brow. Multiple options exist for brow fixation. One must take into account 3 factors during brow lift: release of the brow, brow fixation after advancement, and depressor muscle release. A brow lift will affect the amount of excess upper lid skin and pretarsal lid show.

With a clear understanding of the anatomy and thorough patient evaluation, a safe and effective surgical plan can be constructed. There are several options available to reduce or augment the chin, and often the choice is based on patient presentation and surgeon comfort and familiarity with a given procedure.

Manipulations affecting olfaction, as well as bilateral lesions of the medial preoptic anterior hypothalamic (MPAH) continuum, decrease intermale aggression in mice. In the present study, unilateral removal of an olfactory bulb was combined with a contralateral lesion of the MPAH. This surgery, like bulbectomy and bilateral lesions of the MPAH, substantially decreased aggressive behavior. This surgery bilaterally destroys the ipsilateral links between the olfactory bulbs and the MPAH, and it is this disruption that presumably causes the decrease in aggression. The effect is not due to removal of an olfactory bulb combined with hypothalamic damage per se, because ipsilaterally lesioned/bulbectomized males continued to fight without decrement after surgery. These results provide compelling evidence that multisynaptic neural pathways linking the chemosensory systems of the olfactory bulbs with the rostral hypothalamus are involved in the regulation of intermale aggression in mice.

Knowledge of abdominal anatomy is key to achieving optimal results in abdominoplasty. With adequate knowledge of the anatomy, the surgeon can tailor his or her techniques to fit the needs of the patient while still maximizing the blood supply to the abdominal flaps and minimizing complications.

The care of children with cleft deformities is best managed by a dedicated team of specialists committed to their care from the time of diagnosis until adulthood. This craniofacial team works together to orchestrate the complicated treatment plan. Certain patterns of management and clinical intervention emerge as a child with a cleft grows up and develops. What follows is a brief overview of the time line of care and interventions that children with clefts experience in our craniofacial center.

Hsiao and colleagues have presented a simple, clear, and effective algorithm for managing the traumatic twisted nose. Their results are excellent and exemplary of a sound approach to a difficult problem. Their argument for the management of these cases using an open approach is sensible and in line with the practice of many rhinoplasty surgeons. The results for 92 patients who underwent open rhinoplasty for correction of a twisted nose are presented. It is not surprising that 95% of the patients were male, indicating that men pursue a riskier lifestyle than women. All the patients underwent a complete history and physical examination including preoperative photo documentation of the nose. Frontal, basal, lateral, and oblique views were recorded. An additional view that proves to be helpful in assessing the twisted nose is the frontovertex view, with the nasion proximal and the tip distal taken from the top of the head. It is the same view the surgeon has from the head of the operating table, and it offers an excellent way to asses the curvature of the nose. The authors infiltrate the nose with the minimum amount of local anesthetic to avoid distortion. This is especially meaningful for a patient population that tends to have thick soft tissue coverage of the bony and cartilaginous framework. In these cases, it can be very helpful to tattoo the midline of each nasal segment (upper, middle, and lower) before injection. These tattoo marks then can be used to assess nasal curvature during surgery. When the three dots are in alignment, straightening has been achieved. The authors algorithm for straightening the twisted nose makes sense and incorporates a top to bottom anatomic approach. Management should start with the bony nasal pyramid, then proceed to the septum, the tip cartilage, the skin and soft tissue, and finally closure. This approach takes into account open exposure of all anatomic landmarks in an effort to correct curvature in a stepwise pattern, with reassessment performed after each anatomic site has been addressed. I agree with the surgical techniques described and offer two points of advice for anyone considering correction of the twisted nose. First, in the case of a deviated nasal pyramid with asymmetric nasal bones, bilateral medial and lateral osteotomies should be undertaken with caution, especially in patients with a flattened nasal dorsum. In performing medial and lateral osteotomies, care must be taken to avoid a ‘‘floating’’ nasal bone that has been completely osteotomized from any bony attachment. This bone can collapse entirely and then be very difficult to restore to an anatomic location.