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Background Skin scarring can occur after punch biopsies, prohibiting their routine utilization, especially in the central face. Objectives This paper describes a scarless, 0.33-mm-diameter skin microbiopsy for molecular analysis of skin. Methods This is was single-center, randomized, prospective study with 15 patients receiving no biopsy or biopsy on the left or right nasolabial fold. Six blinded raters assessed participant photos at baseline, 1 month, and 3 months post biopsy to evaluate for a visualized scar. Patient and Observer Scar Assessment Scale was completed. Additionally, biopsies from various skin regions of body along with arm skin after treatment with a single Erbium-YAG laser were processed for molecular analysis. Results No patients exhibited scar formation based on evaluation of photographs and patient feedback. There was no mark at the biopsy site 7 days post-procedure. Optical coherence tomography showed a complete closing of the biopsy-punch wound 48 hours post-biopsy. One month post-biopsy, photography reviewers were unable to identify a scar, on average, 90% of the time at 3-month follow-up. Microbiopsies from various anatomical regions were successfully extracted for histology, electron microscopy, and gene expression analysis. Selected skin rejuvenation markers in the biopsies from Erbium-YAG–treated forearm skin resulted in significant gene upregulation in extracellular matrix molecules at 1 month posttreatment compared with untreated skin. Conclusions A core microbiopsy of 0.33 mm can be extracted reproducibly for histological, ultrastructural, and gene expression analysis without scarring. This allows repeated sampling for assessment of skin treatments and diseases, including aesthetics and wound-healing progress.

Background Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS Objectives The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS. Methods The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold. Results The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P Conclusions The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

BACKGROUND Nonsurgical fat reduction has become extremely popular among patients; however, a reliable method of measuring its efficacy has not been established. METHODS Ultrasound measurement of human female abdominal subcutaneous fat thickness was carried out on five volunteers. Forty-seven measurements were performed using a GE Venue 40 diagnostic ultrasound device with a 12-MHz transducer. Transducer pressure measurements were recorded simultaneously according to the protocol described by Toomey et al.. RESULTS Reproducible measurements of abdomen subcutaneous fat could be consistently achieved with a margin of error (95 percent CI) of ±0.558 mm. CONCLUSIONS Using a protocol with a transducer pressure less than 1 N (Toomey protocol) allows accurate and reliable measurement of subcutaneous fat. The authors further conclude that such a protocol is practically reproducible in the clinical setting and should be the standard for evaluating the results of nonsurgical fat removal, particularly in the abdomen. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, IV.

Background: It has commonly been assumed that deeper facelift dissection causes greater and more prolonged swelling. Objectives: In this preliminary report, the authors compare the lymphatic reconstitution after multiple techniques of rhytidectomy by means of dynamic lymphoscintigraphy. Methods: Three patients were enrolled in this study. All three were female, were similar in age, and exhibited similar signs and degrees of facial aging. Each woman underwent a facelift with a different technique: (1) subcutaneous dissection with superficial musculoaponeurotic system (SMAS) plication, (2) subcutaneous dissection with SMASectomy, and (3) a “high SMAS” composite facelift. Postoperatively, 99mTc-sulfur colloid was injected into a standardized infraorbital location in each patient to compare patterns of lymphatic drainage using lymphoscintigraphy. Postoperative scans at two weeks, six weeks, three months, six months, and one year were compared to the preoperative scans taken seven days prior to surgery. Results: All rhytidectomy techniques appeared to temporarily create a significant and similar degree of interruption in lymphatic drainage. There was a subtotal recovery of lymphatic pathways within three months and complete return to baseline drainage pattern after six months, regardless of surgical technique. Conclusions: Based on the results of this study, it appears that the extent of facial dissection, rather than the depth, is the most significant factor in postoperative edema.

Introduction Clinical laser settings have traditionally been calibrated on abdominal skin to predict and anticipate patterns of injuries in facial skin. This experimental approach has limitations as facial skin and abdominal skin have differences that may influence the depth of laser injury. Objective The primary objective of this study is to analyze the acute pattern of laser injury in abdominal skin and facial skin samples from the same subject and detail the anatomical and biophysical properties that can influence the laser tissue interaction. The secondary objective is to develop a conversion factor that will allow the prediction laser column depths in facial skin based upon laser column depths in abdominal skin. Methods Fifteen healthy subjects were consented and screened. Two 2 mm spots on the face and abdomen were identified and measured and treated with a fractional CO2 laser (Lumenis Ltd, Yokneum, Israel), with an energy setting of 15 mj, 300 Hz at a density of 10. Treatment areas were biopsied and analyzed histologically using hematoxylin and eosin and TUNEL staining. Results Facial skin and abdominal skin have several significant anatomical and biophysical differences (concentration of pilosebaceous units, sebum concentration, and moisture content). Facial tissue demonstrated divergence of laser energy around pilosebaceous units and lateral spread of laser energy along blood vessels. These differences cause attenuation (28%) of the laser energy and result in column depths that are significantly (P

Background: Topical lidocaine is a common form of anesthesia for a wealth of procedures across a large number of disciplines, including laser treatments. Preparations can be purchased over the counter with no prescription necessary. It is considered a safer and more acceptable form of anesthetic than hypodermic injections; however, there have been reports of fatalities following its application. Above certain serum lidocaine concentrations, patients may experience effects of toxicity such as lightheadedness and paraesthesia; these effects can progress to seizures and cardiorespiratory depression, which can ultimately lead to death. The active metabolite of lidocaine, monoethylglycinexylidide (MEGX), can be almost as potent as lidocaine in terms of toxicity. Objectives: The authors examine the levels of both lidocaine and MEGX in blood serum after application of topical lidocaine. Methods: Twenty-five healthy volunteers were assigned to one of four groups (A, B, C, D). Group A had 2.5 g of 4% lidocaine topical anesthetic cream applied to the face for one hour without occlusion, Group B had 5 g applied to the face for one half-hour without occlusion, Group C had 5 g applied to the face for one hour without occlusion, and Group D had 5 g applied to the face for one hour with occlusion. To evaluate serum concentrations, blood was drawn every 30 minutes for four hours. Results: Group D showed the highest serum levels of lidocaine and MEGX, a three-fold increase compared with group C, which received the same dose (5g topical 4% lidocaine) but without occlusion. In group D, peak serum levels occurred at 90 minutes for serum lidocaine, which was also the fastest of the four groups. Serum MEGX levels peaked much later than serum lidocaine levels, at 210 minutes. Individual serum levels did not exceed 0.6 µg/mL. Across the groups, there was significant interindividual variation in both lidocaine and MEGX serum levels ( P = .061). Applications of 5 g of 4% lidocaine resulted in higher serum concentration of both lidocaine and MEGX. When comparing group A to group C, doubling the dose of 4% lidocaine from 2.5 g to 5 g resulted in double the serum levels of MEGX and a 50% increase in the serum lidocaine levels ( P = .021). When comparing groups C and D, the addition of an occlusive dressing resulted in a tripling of the serum lidocaine levels and a doubling of the serum MEGX levels, both of which were statistically significant ( P < .001). When comparing all four groups, there were significant differences between the combined serum concentrations of lidocaine and MEGX ( P < .001). Conclusions: Topical lidocaine preparations are increasingly being employed to provide a patient-friendly form of noninvasive analgesia for a multitude of procedures. Some preparations are available over the counter for unsupervised patient application. Our study has demonstrated significant interindividual variability for a given dose, especially when occlusion is applied. There have been fatalities resulting from topical lidocaine application, and our study suggests that this is the result of the unpredictability of lidocaine metabolism between individuals. Therefore, we recommend that caution be exercised with topical lidocaine preparations, in particular when applied in conjunction with occlusive dressings.

Background: This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. Methods: The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. Results: The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. Conclusions: The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.

Background: The frontal branch has a defined course along the Pitanguy line from tragus to lateral brow, although its depth along this line is controversial. The high-superficial musculoaponeurotic system (SMAS) face-lift technique divides the SMAS above the arch, which conflicts with previous descriptions of the frontal nerve depth. This anatomical study defines the depth and fascial boundaries of the frontal branch of the facial nerve over the zygomatic arch. Methods: Eight fresh cadaver heads were included in the study, with bilateral facial nerves studied (n = 16). The proximal frontal branches were isolated and then sectioned in full-thickness tissue blocks over a 5-cm distance over the zygomatic arch. The tissue blocks were evaluated histologically for the depth and fascial planes surrounding the frontal nerve. A dissection video accompanies this article. Results: The frontal branch of the facial nerve was identified in each tissue section and its fascial boundaries were easily identified using epidermis and periosteum as reference points. The frontal branch coursed under a separate fascial plane, the parotid-temporal fascia, which was deep to the SMAS as it coursed to the zygomatic arch and remained within this deep fascia over the arch. The frontal branch was intact and protected by the parotid-temporal fascia after a high-SMAS face lift. Conclusions: The frontal branch of the facial nerve is protected by a deep layer of fascia, termed the parotid-temporal fascia, which is separate from the SMAS as it travels over the zygomatic arch. Division of the SMAS above the arch in a high-SMAS face lift is safe using the technique described in this study.

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: 1. Identify the essential anatomy of the face as it relates to facelift surgery. 2. Describe the common types of facelift procedures, including their strengths and weaknesses. 3. Apply appropriate preoperative and postoperative management for facelift patients. 4. Describe common adjunctive procedures. 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.

After studying this article, the participant should be able to: 1. Identify the essential anatomy of the aging face and its relationship to face-lift surgery. 2. Understand the common operative approaches to the aging face and a historical perspective. 3. Understand and describe the common complications following face lifting and treatment options.Surgical rejuvenation of the aging face remains one of the most commonly performed plastic surgery procedures. This article reviews the anatomy of the face and its impact on surgical correction. In addition, this review discusses the evolution of various face-lift techniques and the current surgical approach to the aging face. Finally, this article discusses potential postoperative complications after rhytidectomy and management solutions.

The medical charts of 267 patients who had primary high-superficial musculoaponeurotic system (SMAS) rhytidectomies were reviewed. The depth of the nasolabial fold was used as an indicator of the degree of descent of the subcutaneous cheek mass, as a guide in procedure selection, and as a method of judging the operative results. Fold depth was assigned a score of 0 to 3, with 3 being most severe. According to their preoperative fold depth, patients were operated on using one of three variants of the high-SMAS technique: sub-SMAS dissection up to the nasolabial fold, sub-SMAS dissection up to the nasolabial fold plus transnasal SMAS graft, or sub-SMAS dissection across the nasolabial fold. An independent trained observer rated the postoperative fold depth in each case from photographs taken at the 6-month follow-up visit. Of patients with fold scores of 2 or 3, 97 percent (183 of 189 patients) showed visible improvement in nasolabial crease depth after the operation.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

The practice of breast-pocket irrigation with various antibiotic solutions is supported by good literature and extensive clinical practice among most plastic surgeons. Unfortunately, recent restrictions on the use of Betadine (povidone-iodine) for breast-pocket irrigation have left many plastic surg

Subclinical infections have been implicated in the etiology of capsular contracture. Intraoperatively, breast pocket irrigation with povidone-iodine or other antibiotic solutions has been popularized; however, detrimental effects on wound healing for these agents have been reported and their efficacy against common organisms found around breast implants has not been studied. The purpose of this study was to compare the in vitro efficacy of serial dilutions of povidone-iodine and two double antibiotic solutions DAB-1 (gentamicin/polymyxin B) and DAB-2 (gentamicin/cefazolin), against organisms most commonly found around breast implants. In phase I trials, serial dilutions of povidone-iodine and DAB were combined 1:1 with cultures of five common organisms found around implants. In phase II, povidone-iodine was serially diluted in DAB-1 rather than saline. In phase III, povidone-iodine was serially diluted with DAB-2. Efficacy for all phases was determined by plating the mixture onto agar plates and incubating at 37 degrees C for 48 hours. Povidone-iodine was 100 percent effective at a dilution of 12.5% against Staphylococcus epidermidis and 25% against Staphylococcus aureus but relatively ineffective against Escherichia coli and Pseudomonas, DAB-1 was found to be ineffective against S. epidermidis but effective against S. aureus, Propionibacterium acnes, E. coli, and Pseudomonas. In phase II trials, a concentration of 12.5% povidone-iodine in DAB was effective at killing all experimental bacteria. In phase III trials, 10% povidone-iodine in DAB-2 was effective at killing all bacteria tested. In conclusion, to maximize bacterial control of common breast implant organisms and to minimize the detrimental effects on wound healing, 10% povidone-iodine in gentamycin/cefazolin may be used with excellent results and its use clinically may reduce the incidence of capsular contracture.

Several series have documented the ability of the carbon dioxide laser to smooth facial rhytids; however, follow-up has been limited to several months. Since 1995, more than 600 full or partial facial resurfacings were performed with the pulsed CO2 laser. To assess the long-term efficacy and safety of this procedure, the results of 211 resurfacings were retrospectively reviewed using a custom-designed database. Variables that were input included patient demographics, Fitzpatrick skin type, smoking history, prior and concurrent facial procedures, laser pass data, and postoperative complications. Short and long-term aesthetic results were graded by a blinded panel of plastic surgery reviewers (none of whom performed the laser resurfacing) using a standardized photographic rhytid scale. For each facial region, this scale consisted of eight high-resolution photographs depicting increasingly severe wrinkling. Facial rhytids were almost completely ablated at the 3 and 6 month follow-up. Some relapse was seen at 1 year, but the overall aesthetic result remained very good. Regions with dynamic rhytids (e.g., the perioral region) showed more recurrence. The best and most durable results were seen in the cheeks. Infection and scleral show each occurred in 13 patients (6 percent). Forty-five patients (21 percent) developed postprocedure hyperpigmentation, but the overwhelming majority of this group were treated before our postoperative antipigment regimen. Hypopigmentation was noted in 17 patients (8 percent) in this early follow-up group. Two patients (1 percent) developed postoperative scarring. It is hoped that these data will serve to provide additional information on the long-term results of laserbrasion.

An anatomical evaluation involving the nasolabial fold was performed on three fresh cadavers. Both gross and histologic analyses were made. The mimetic muscles were noted to have dermal extensions to the skin overlying the nasolabial fold. The dynamics of these mimetic muscles were evaluated subsequently in the clinical setting. Marked dimples and contour irregularities could be elicited by selectively contracting these muscles. Our findings suggest that it may be possible to improve the contour over the nasolabial fold during rhytidectomy procedures by severing the dermal extensions of the mimetic muscles along the nasolabial fold. This may allow better gliding of the skin and subcutaneous tissue over the nasolabial fold, thereby resulting in a smoother crease.

Background: Body contouring that involves abdominoplasty and/or liposuction is a common cosmetic surgery procedure. Although single-staged lipoabdominoplasty has gained popularity, safety concerns remain. Objectives: The authors compared abdominal flap perfusion and overall complication rates for traditional abdominoplasty and limited-undermining lipoabdominoplasty. Methods: Eighteen abdominoplasty patients were evaluated in a prospective study. All patients were nonsmokers and lacked major comorbidities. The control group (n = 9) underwent traditional abdominoplasty with wide undermining. The study group (n = 9) underwent abdominoplasty with limited undermining as well as liposuction of the abdominal flap. The groups were similar with respect to age and body mass index. Patients received follow-up for an average of 97 days. Fluorescence imaging was utilized for perfusion studies. Results and complications were documented, and statistical significance was ascertained via the Student t test. Results: Neither group had major complications or revisions. Minor complications included an exposed suture, resulting in delayed wound healing, in the control group. A patient in the study group had a small area of fat necrosis and a small seroma, neither of which required further treatment. No significant difference in abdominal flap perfusion was found between the control (57%) and study (50%) groups based on fluorescence levels relative to a designated baseline reference marker. Conclusions: Results of the study indicate that no significant differences exist between the 2 operations with respect to the rates of abdominal flap perfusion or complications. Level of Evidence: 3 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Thomas J. Baker, MD Henry Steve Byrd, MD Fritz E. Barton, Jr., MD T. Roderick Hester, MD Dr. Baker: I'd like to start by discussing the first patient (Figure 1). Dr. Barton, what is your analysis of this patient's neck and face—particularly the cheek area with attention to the nasolabial fold—and how would you avoid them? Figure 1 This patient, who had a previous face lift and blepharoplasty, has moderately deep nasolabial folds and a “minus orbit.” Dr. Barton: It looks to me like this patient has already had a primary face lift and blepharoplasty. It is important to note that she has a thin face with very little facial fat. Her hairline is high, her brows are low, and she has high sideburns. I would consider her nasolabial fold to be moderately deep, and because her face is so thin, I don't believe she has a significant malar fat pad. She has what would be described as a “minus orbit” with a weak zygomaticomaxillary complex. She also has some ptotic orbicularis. Her jowls appear to be mainly skin with a small amount of platysma and minimal fat, and she has a little bit of upper platysmal banding. I would perform a subgaleal brow lift through a frontal hairline incision with orbital rim release and suspension of the orbicularis. In addition, she is a candidate for a subcutaneous face lift with suture imbrication of the SMAS. Dr. Baker: Dr. Byrd, you are an advocate of the subperiosteal and endoscopic approach to these areas. Would you assess the face, particularly the nasolabial fold and malar area, with reference to the type of surgery that you are currently performing? Dr. Byrd: My technique is a deep endoscopic approach with dissection above the periosteum. This is the type of secondary face lift patient who has …

BACKGROUND The superficial musculoaponeurotic system (SMAS) has inherent viscoelastic properties, although the optimal tension levels to minimize tissue relaxation have not been defined. This study evaluated the viscoelastic properties of the SMAS within the biomechanical parameters of the high-SMAS rhytidectomy. METHODS Patients (n = 30) underwent a high-SMAS face lift performed by the senior author (F.E.B.) with intraoperative tension at the superior (preauricular) and inferior (mastoid) points of SMAS fixation sequentially measured with a tensiometer. Fresh samples of lateral, preparotid SMAS were then harvested and evaluated ex vivo for bursting strength, stress relaxation, and creep. RESULTS The force applied to the superior, preauricular SMAS intraoperatively (7.21 ± 0.87 N) was significantly lower than that of the inferior mastoid point of fixation (9.59 ± 1.8 N) (p < 0.001). The bursting force of the SMAS was 55.7 N, with the average bursting pressure of 224.97 PSI. The in vivo force applied to the SMAS was found to be only 15 percent of its total bursting strength. The deformational load of the high-SMAS face lift caused only a 14 percent creep in the tissue ex vivo. CONCLUSIONS The in vivo tension in a high-SMAS face lift is predictable, with the force applied to the mastoid point being significantly greater than that of the superior preauricular point. This intraoperative force is only a fraction of the tissue's inherent bursting strength, contributing to the minimal stress relaxation and creep observed in this study. These biomechanical properties likely contribute to the effective and long-lasting correction of facial aging with the high-SMAS technique. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

In a series of histologic sections and clinical and cadaver dissections, the superficial musculoaponeurotic system (SMAS) is seen to become the investing fascia of the zygomaticus major and minor muscles in the medial cheek. The pull on the cheek flap during rhytidectomy is diffused by the attachment of the SMAS to these muscles. I believe that this attachment accounts for the minimal change in the nasolabial crease after a Skoog-type sub-SMAS face lift.

In the classic rhytidectomy procedure, upward and lateral progress of the skin is hindered by strong fascial attachments of the SMAS to the zygoma. To counteract these tethers, surgeons can go below them in a subperiosteal dissection or above them by dissecting subcutaneously. The author believes a superficial approach to the periorbital area is safer and simpler than a subperiosteal dissection and permits a similar amount of skin advancement.

The "high SMAS" face lift technique suspends the cheek mass securely, leaving the skin and subcutaneous mass attached to the SMAS without placing the skin under greater than normal tension. The author provides the surgical steps. (Aesthetic Surg J 2002;22:481-486.).

Fritz E. Barton, Jr., MD, Dallas, TX , is a board-certified plastic surgeon and an ASAPS member. My surgical approach differs significantly from that of Dr. Kaye. My choice of technique is probably related to the type of face lift that I perform customarily. Whether one performs more primary face lifts or secondary procedures clearly influences the choice of incisions. I prefer a scar that is hidden in the temporal hair rather than an anterior scar. I am especially influenced by the high, thin temporal hair and the need to do a brow lift. It is very important that the temporal recess not be violated. Because the sideburn and widow's peak on most people consist of fairly substantial hair, you can obtain very acceptable scars around those …

Dr. Eaves: The first patient (Figure 1) has concerns about his high hairline and low, heavy brows, and he refuses any incisions in the scalp. Dr. Paul, would you explain your approach to treating this patient? Felmont F. Eaves III, MD Fritz E. Barton, Jr., MD David M. Knlze, MD Malcolm D. Paul, MD Rod J. Rohrich, MD Figure 1 A male patient with concerns about his high hairline and low, heavy brows. Dr. Paul: This is a patient with male pattern baldness, heavy upper lid hooding with thickened orbital orbicularis, and a very heavy fat pad, as well as a relatively low medial brow. My approach would be to elevate his brows through the upper lid. I would resect the corrugator and perform a subperiosteal forehead lift through the upper lid without any counterincisions. This would elevate his brow a few millimeters, but not as much as if the patient had thinner tissue or underwent an endo scopic brow lift. With this approach you can't accomplish the fixation as well as you could if you pulled the flap up and anchored it superiorly. Dr. Eaves: Could you give a little more detail on how you would actually fix the brow in addition to how you would control the relative elevation of the medial versus lateral portions of the brow? Dr. Paul: First I would judge how much excess upper eyelid skin is present after the brow is held at the correct level, and then perform the skin/muscle resection, taking out some of the preseptal muscle. Then I would work on the preaponeurotic fat pad. After that I would make an incision in the periosteum about 3 mm above the supraorbital rim, leaving a cuff of periosteum to sew to. I would then elevate the forehead subperiosteally all the way back to …

Dr. Barton: The first patient is a 40-year-old woman who is looking for options to increase the fullness in her lips (Figure 1). Dr. Coleman, what would you suggest? Figure 1 This 40-year-old woman desires more lip fullness. Fritz E. Barton, Jr., MD Dr. Coleman: Her lips are not as easy to improve as atrophic lips in which you simply fill in the fat, like filling an envelope. Here, the structure of the lip actually has to change. First, I would focus on flipping out the lip. Getting the vermilion to evert would be the primary focus. I would place fat under the vermilion, primarily, and the mucosa, secondarily, paying attention to eversion. Second, I would create a clear white roll by intradermal fat placement. Third, I would focus on lower lip volume enhancement more than upper lip. I think it is a common error to focus on the upper lip and forget about the lower lip; if you do not get eversion of the lower lip, you will have a very funny-looking lip. Sydney Coleman, MD Dr. Barton: Dr. Coleman, when you counsel a patient such as this, what do you predict will be the percentage of success or retention with the first injection? How many injections do you routinely need to do? Dr. Coleman: In my hands, one treatment usually suffices. I prepare patients for a second treatment, but one application is usually enough, although, occasionally, patients may want further enhancement. Dr. Barton: Approximately what volume will you use in a lip complex like this? Dr. Coleman: I would probably use between 5 and 7 mL over the whole lower lip. I would probably use about half that amount in the upper lip, between 2.5 and, maybe, as much as 3 mL. Dr. Barton: Dr. Graivier, what would be your …

Joel E. Pessa, Rod J. Rohrich Facial Topography: Clinical Anatomy of the Face. St Louis, MO: Quality Medical Publishing, 2012. ISBN-13: 978-1576263440 ![][1] Joel Pessa is a surgical anatomist who has published many detailed studies of human anatomy, particularly of the face. I believe that the book he has coauthored with Rod Rohrich, Facial Topography: Clinical Anatomy of the Face —which I will review in detail here—will take its proper place aside other classic studies of human microcirculation in the trunk and extremities, namely those of Manchot,1 Salmon,2,3 and Taylor and Plamer.4 The basic premise of the book, and what makes it stand out from other texts in the field, is that subunits of the face are partitioned by fascial planes. The presumed purpose of these planes is to protect the embedded vascular and nervous structures from shear forces. The fascial protection of vessels and nerves coursing through movable tissue was previously noted by both Manchot1 and Salmon.2,3 … [1]: /embed/graphic-1.gif

Arcus marginalis release, fat extrusion, and septal reset were applied to 71 selected patients with a constellation of orbital deformities the authors term a "tear trough triad." Of the initial 71 patients, 59 had complete follow-up records. Evaluated by means of a proportional topographic scale, 95 percent of patients achieved significant improvement. Equally important, no incidence of middle lamella contracture occurred in the entire series. The authors conclude that the procedure is safe and effective in selected patients.

This study was designed to evaluate the short- and long-term histologic consequences of some common skin resurfacing methods. Grids were tattooed on the sides of a Yucatan minipig, the standard model for human skin experiments. Each grid cell was treated with one of the following: Jessner's solution, lactic acid, glycolic acid, trichloroacetic acid with and without Retin-A® pretreatment, phenol, dermabrasion, or carbon dioxide laser (Sharplan SilkTouch® or Coherent UltraPulse®). All treatments were given at the usual doses or strengths recommended for human skin. Each treatment method was represented by two grid cells on either side. Biopsy specimens were obtained from each area immediately after treatment and at 1 week, 1 month, and 3 months. The histologic sections were read by an experienced dermatopathologist. The superficial peeling agents (glycolic acid, lactic acid, and Jessner's solution) barely penetrated the epidermis. Wound depth from dermabrasion and laserbrasion could be traced to the papillary-reticular junction of the dermis in the early sections, but by 3 months the skin in these areas had resumed its normal architecture. In contrast, phenol and trichloroacetic acid produced changes to the upper reticular dermis, and these findings persisted for the duration of the observation period. The effects of treatment with the carbon dioxide lasers had dissipated by 3 months. Higher levels of laser energy are apparently needed to induce resurfacing in this model.

I describe a technical modification in the Skoog face lift procedure that releases the deep attachments of the SMAS to the muscles of facial expression for maximal mobility of the medial cheek yet elevates the cheek flap as a composite of skin, subcutaneous tissue, and SMAS to enhance skin perfusion. My results with the procedure in 100 patients are analyzed by using functional zones of the nasolabial fold corresponding to underlying musculature and a simple grading system based on preoperative and postoperative photographs. Marked improvement in the nasolabial fold was noted in over 80 percent of patients by 6 and 12 months postoperatively. This effect seemed to last up to 4 years.

In a prospective study, 15 consecutive patients who underwent simultaneous open rhinoplasty and alar base excision were included to investigate whether there is a problem with the blood supply of the nasal tip and columellar skin. During the surgical procedure in these patients, there was transection of the columellar arteries and external nasal arteries, and frequently of the alar branches of the angular artery. Yet, none of the patients had any evidence of ischemia of the nasal tip or columellar skin, and there was primary wound healing with a thin-line transcolumellar scar in all patients. Techniques to avoid injury to the lateral nasal artery and nasal tip plexus are discussed. It was concluded that simultaneous open rhinoplasty and alar base excision is safe as long as certain surgical principles are applied.

Total glandular mastectomy and modified radical mastectomy were compared for the amount of breast tissue remaining after surgery. Multiple biopsies were taken from the anterior chest walls of women following total glandular mastectomy (N = 27) and modified radical mastectomy (N = 28) to try to detect any residual glandular tissue. Regardless of procedure performed, breast tissue was identified histologically in 5 percent of all biopsy specimens (159 and 161, respectively). One of every five operative fields was shown to have glandular elements in at least one of the biopsy sites; the positive biopsies did not form a discernible pattern. The residual breast tissue in each of these patients averaged less than 1 gm. On the basis of this study, modified radical mastectomy and total glandular mastectomy appear to be equally effective in removing most of the breast.

The nasolabial fold varies considerably from person to person. Three main groups may be distinguished: convex, concave, and straight. It is the muscles of smiling that are directly responsible for the shape and depth of the fold, and in their absence of function, as in facial palsy, the nasolabial fold disappears. Cadavers were selected in accordance with the nasolabial fold they presented and were dissected to analyze the difference in underlying anatomy between one fold shape in one cadaver and another fold shape in another. The study demonstrates that the nasolabial fold is the result of a conflict between soft and dynamic tissues of the middle face or an interaction between the skin and fat envelope on one side and the underlying muscles on the other. The greater this conflict, the more excess there is of cheek skin and the more pronounced a nasolabial fold. The mechanism that creates the nasolabial fold and the anatomy of the fold are described in this paper.