Development of Facial Rejuvenation Procedures: Thirty Years of Clinical Experience with Face Lifts

Facial rejuvenation procedures can be roughly divided into face lift surgery and nonoperative, less invasive procedures, such as fat grafts, fillers, botulinum toxin injections, thread lifts, or laserbrasion. Face lift surgery or rhytidectomy is the procedure most directly associated with rejuvenation, due to its fundamental ability to restore the anatomical changes caused by aging. Various methods of face lift surgery have been developed over the last hundred years, thanks to advances in the understanding of facial anatomy and the mechanisms of aging, as well as the dedication of innovative surgeons. However, no generally applicable standard method exists, because the condition of each patient is different, and each operative method has advantages and disadvantages. Specific characteristics of the skin of Asians and their skeletal anatomy should be considered when determining the operative method to be used on Asian patients. Plastic surgeons should improve their ability to analyze the original aesthetic properties and problem areas of each patient, drawing on scientific knowledge about the aging process, and they should develop the skills necessary to perform various rejuvenative techniques. In the present article, we reviewed various face lift procedures and the current methods of modified double plane face lift, based on our clinical experience of over 30 years.

Face Reconstruction Using Lateral Intercostal Artery Perforator-Based Adipofascial Free Flap

BACKGROUND: The aim of this study was to determine the efficacy of lateral intercostal artery perforator-based adipofascial free flaps for facial reconstruction in patients with facial soft tissue deficiency. METHODS: We conducted a retrospective study of five consecutive patients diagnosed with facial soft tissue deficiency who underwent operations between July 2006 and November 2011. Flap design included the area containing the perforators. A linear incision was made along the rib, which had the main intercostal pedicle. First, we dissected below Scarpa's fascia as the dorsal limit of the flap. Then, the adipofascial flap was elevated from the medial to the lateral side, including the perforator that pierces the serratus anterior muscle after emerging from the lateral intercostal artery. After confirming the location of the perforator, pedicle dissection was performed dorsally. RESULTS: Dominant perforators were located on the sixth to eighth intercostal space, and more than four perforators were found in fresh-cadaver angiography. In the clinical case series, the seventh or eighth intercostal artery perforators were used for the free flaps. The mean diameter of the pedicle artery was 1.36 mm, and the mean pedicle length was 61.4 mm. There was one case of partial fat necrosis. No severe complications occurred. CONCLUSIONS: This is the first study of facial contour reconstruction using lateral intercostal artery perforator-based adipofascial free flaps. The use of this type of flap was effective and can be considered a good alternative for restoring facial symmetry in patients with severe facial soft tissue deficiency.

Human Cutaneous Protothecosis: Report of a Case and Literature Review

The Prototheca species is achlorophyllic algae and rarely causes human infection. Human protothecosis presents clinically as a cutaneous infection, olecranon bursitis, and disseminated systemic disease. We report a case of human cutaneous protothecosis involving the left wrist. A 68-year-old man presented with an ill-defined erythematous lesion with crust at the dorsal aspect of his left wrist. A punch biopsy was performed to reveal the histologic features of granulomatous inflammation with necrosis at the upper dermis, containing Prototheca organisms, of which, the characteristic features were highlighted by special staining. Through a molecular study, the Prototheca zopfii species was identified.

Onlay Rib Bone Graft in Elevation of Reconstructed Auricle: 17 Years of Experience

BACKGROUND: A cartilage wedge block and covering flap are standard procedures for firm elevation of the ear in microtia correction. However, using costal cartilage for elevation of the reconstructed auricle can be insufficient, and the fixed cartilage wedge block may be absorbed or may slip out. Furthermore, elevating covering flaps is time-consuming and uses up fascia, a potential source of reconstruction material. Therefore, we propose an innovative method using autologous onlay rib bone graft for auricular elevation of microtia. METHODS: From February 1995 to August 2012, 77 patients received a first stage operation with a rib cartilage framework graft. In the second stage operation, a small full thickness of rib bone was harvested through the previous donor scar. The bihalved rib bone was inserted into the subperiosteal pocket beneath the cartilage framework. RESULTS: The follow-up time ranged from 1 month to 17 years, with a mean of 3 years. All of the patients sustained the elevation of their ears very well during the follow-up period. Donor site problems, except for hypertrophic scars, were not observed. Surgery-related complications, specifically skin necrosis, infection, or hematoma, occurred in 4 cases. CONCLUSIONS: Onlay rib bone graft used to elevate the reconstructed auricle is a more anatomically appropriate material than cartilage, due to the bone-to-bone contact between the bone graft and the temporal bone. Postoperative minor correction of the elevation degree is straightforward and the skin graft survives better. Therefore, reconstructed auricle elevation using onlay rib bone graft is a useful and valuable method.

Dual-vector Foreheadplasty for Reducing the Vertical Height of the Forehead with Concomitant Mid-facelift

The object of this study is to introduce a novel method of foreheadplasty. The new foreheadplasty can lower the anterior hairline and results in reduction of the vertical forehead length and mid-face lift can be performed at the same time. A 54 year-old female who had a long forehead visited the clinic for rejuvenation of the mid-face. The authors performed dual-vector foreheadplasty and were able to lower the anterior hairline by the advancement of the posterior scalp flap. Mid-face lift was performed by elevation of the malar fat pads. The surgical results were analyzed by measuring the length of the forehead before and 2 years after the surgery. Medical photographs were taken at the same period. The preoperative length of the forehead was 75.5 mm and decreased to 63.0 mm after the surgery. The shortened forehead was well maintained even 2 years after the operation (63.3 mm). The patient suffered from partial sensory loss of the parietal region but resolved simultaneously after 2 months. No other complications, such as, hypertrophic scarring, infection, prolonged inflammation and alopecia occurred. In conclusion the dual-vector foreheadplasty is a relatively simple and safe way to lower the anterior hair line with the elevation of the mid-face.

Baseblock Sculpturing Using the Scoring Technique for the Reconstruction of Ear

Total auricular reconstruction with autogenous tissue remains one of the greatest technical challenges for reconstructive plastic surgeons because of the ear's complex morphology with delicately convoluted cartilages and very thin skin. In a successfully created ear, a natural three-dimensional illusion visualized from the patient's profile, frontal, and posterior views is crucial. Accordingly ear framework should have adequate lateral aspect as well as suitable frontal aspect even before being lifted to this purpose. For this goal, rib cartilage should be harvested from three-dimensionally adequate area. It is the most essential point in framework fabrication that the baseblock should have semi-cup curvature via multiple parallel cuts made on its medial surface. Between January 1999 and May 2003, we performed 29 cases of total ear reconstruction with autogenous rib cartilage graft using this scoring technique and obtained satisfactory results, which showed more natural appearance visualized from the patient's profile, frontal, and posterior views.

Experimental Craniosynostosis and Sutural Growth After Distraction Osteogenesis in Growing Rabbits

Suturectomy and distraction was thought to be an optimistic solution in craniosynostosis during growth period, but there is no protocol when to stop distraction. Twelve six-week-old New Zealand white rabbits were randomly assigned to four groups; control, suturectomy, distraction, overdistraction. Immobilization was made by methyl cyanoacrylate adhesive for 6 weeks. The last two groups were mechanically distracted with custom-made spring expanders for 3 and 6 weeks. Subsequent growth effects of coronal suture separation were assessed by serial radiographic cephalometry. Cephalometric analysis revealed that there were statistically significant differences in the inclinations of growth distances between four groups, but there is no statistically significant difference between four groups in distance between defined cephalometric points at the beginning and 18 weeks later. In histomorphologic studies, widened intersutural spaces were filled and stabilized with newly deposited bone. In conclusion, growth rates were adapted in experimental craniosynostosis after distraction osteogenesis in growing rabbits, having no concern with presence of distraction, extent of distraction after suturectomy.

Correction of Nonunion of Zygoma Body after Aesthetic Reduction Malarplasty

The Asian face is generally shorter and wider than western face whose face is dolichocephaly. Therefore the reduction malarplasty is one of the common aesthetic surgery performed in Asians. As the number of cases of aesthetic reduction malarplasty including osteotomy technique of zygoma body increase, the complications related to the osteotomy also increase. Among the various complications, if the ostotomized zygoma body does not heal or reunite, it may cause a serious problem not only to the surgeon but also to the patients. From June 2002 to July 2003, the authors experienced 5 patients whose zygoma body did not reunite after reducing their malar prominence at other clinic. Their major complains were subjective discomfort at the operated site, depression on malar eminence, abnormal click sound on mouth opening, etc. None of them had any evidence of rigid fixation on their osteotomy of the zygoma body. The Rib bone was harvested and grafted to the bone gap due to the nonunion of zygoma body. All grafted bones were rigidly fixed and survived. In conclusion, bone to bone contact without soft tissue impingement should be preserved for the bone healing after zygoma body osteotomy. Therefore the rigid fixation method of osteotomy is the fundamental element during the operation. The rib bone interpositional graft can be one of the solution methods in the unfortunate nonunion cases.

Dermtosurgical Treatment of Hypotrichosis of Pubis and Atrichia Pubis with the Additive Effect of Testosterone Cream / 대한피부과학회지

BACKGROUND: The incidence of hypotrichosis of pubis and atrichia pubis is relatively higher in oriental countries including Korea. OBJECTIVE: The aim of this study was to develop a treatment method to increase the density and to improve the distribution pattern of pubic hair in these patients. METHODS: Testosterone cream(5%) was applied to ten patients for six months. Then, the individual hair transplantation from the parietotemporal region of the scalp with the specially devised mini-punch was performed. Around the mons pubis, transplantation with 2-3mm punch was done. Postoperatively, the application of testosterone cream was done twice a day. RESULTS: Nine of ten patients were satisfied with the final results. Testosterone cream helped to increase the density of pubic hair. Transplanted hairs showed curling to some extent and did not grow like as it were at donor site. CONCLUSION: The advantage of this method is to make the appearance of pubic hairs more natural by controlling the direction and numbers of transplanting hairs at the time of operation and by making the hair denser with pre- and post-operative application of testosterone cream. The authors hope many dermatologic surgeons to use this new treatment approach for atrichia pubis and hypotrichosis of pubis.

Reduction Mammoplasty using Modified Round Block Technique

The goals of reduction mammoplasty are to remove the appropriate amount of breast tissue and to make the nice cone-shaped breast. For these goals, various methods have been used and newly introduced. Recently, as women's interest in cosmetic attractiveness increases, surgeons make attempts to minimize postoperative scars. Periareolar approach has an advantage of invisible postoperative scar, but has many disadvantages - flattening of breast shape, recurrence of breast ptosis, hypertrophy and widening of periareolar scar, enlargement and distortion of areola caused by tension. After Benelli introduced Round block technique, this approach became one of the most popular methods. The characteristics of Round block technique are periareolar approach, superiorly based dermoglandular pedicle, criss-cross mastopexy, and Round block suture. Authors modified periareolar Round block technique to adjust to Korean women and have operated on 11 patients since 1997. We focused on medializing the lateral portion of inframammary fold and avoiding asymmetry and protrusion of nipple-areolar complex. Round block suture with uniform thickness and length must be applied at the same time to prevent areolar complications. In design, authors referred to the statistical analysis on Korean female. The results are aesthetically and functionally satisfactory and there has been no significant complication. In conclusion, this method is effective for young woman or mild macromastia with moderate ptosis. Besides, an accurate understanding of each step of operative procedure and enough knowledge of anatomy and physiology of the breast are essential.

How to Make the Blockage between the Nasal Cavity and Intracranial Space in Craniofacial Surgery

Craniofacial surgery for facial advancement or correction of severe craniofacial malformations such as orbital hypertelorism, Crouzon's disease and Apert's syndrome may bring about great risk. Especially postoperative infection in the craniofacial surgery is a life threatening complication. Ascending infection via nasofrontal communication in frontofacial monobloc advancement, intracranial Le Fort III osteotomy, correction of hypertelorism(intracranial approach) and acute trauma of cribriform plate can lead to life threatening meningitis and meningoencephalitis. A 4 layer sealing technique for the closure of nasofrontal communication using Gelfoam , the inferiorly based, galeo-pericranial flap, rib bone graft, Tissel is a very effective method. Until the rib bone graft is completely uptaken, Gelfoam is used as a temporary blockage of bony defect and prevents displacement of rib bone graft. We used galeo-periosteal flap for the sufficient blood supply to the rib bone graft. And Tissel is used as a biologic adhesive and blockage of the surrounding gaps.

Auricular Reconstruction with Autogenous Rib Cartilage Graft using Tissue Expander after Canaloplasty in Microtia

Along with aural atresia, abnormalities of the middle ear and external ear canal can impede the audition of the developing infant. In cases of bilateral atresia when bone-conduction aids fail to adequately restore impaired hearing, unilateral canal reconstruction may be required at a very early age to enable proper speech and language development. We are often confronted by cases in which canaloplasty has previously been performed by ENT surgeons, leaving auricular canals of various locations and sizes in addition to scars. In such cases, it can be difficult to prepare a skin flap sufficient in size to cover the cartilagenous framework for auricular reconstruction. Scar tissues with relatively poor vascularity induced by a prior incision and elevation of the soft tissue may compromise the ultimate result of auricular reconstruction. To obtain the sufficient, thin, pliable and well vascularized skin, we used tissue expansion at the first stage of the auricle reconstruction in microtia patients who previously received canaloplaty. From December, 1988 to February, 1999, we attempted tissue expansion using volume 35cc, cresent- type inflatable silicone expanders(SebbinR) in 12 patients who previously received canaloplasty. Ear frameworks were prepared using autologous rib cartilage. The expanded skin provided sufficient, thin, pliable, and well vascularized skin for easy draping and better contouring. The reconstructed auricle was satisfactory in both color and texture and had nearly normal sensation. No resorption of the inserted rib cartilage has been observed from 7 months to 9 years and 9 months after the operation.

A New Path of Dissection in the Temporal Region to Avoid Injury of the Temporal Fat Pad

The coronal incision is a useful approach to the upper and middle thirds of the facial skeleton, but injury of the frontal branch of the facial nerve can be possible. The authors experienced 56 cases from 31 patients in which trauma to the temporal fat pad and the facial nerve was avoided by dissecting beneath the deep layer of the deep temporal fascia during temporal dissection in subperiosteal face lift, frontofacial monobloc advancement, Le Fort III osteotomy, and open reduction of zygomatic arch fracture. The advantages of this approach include avoiding injury to the facial nerve and minimal bleeding, thereby allowing for an easy and more rapid procedure. Furthermore, there was no development of postoperative temporal depression. This approach is particularly useful for subperiosteal face lifts, procedures requiring exposure of the zygomatic arch, or procedures requiring access to the mid face.

Distraction Osteogenesis of Mandible using Short-Sagittal Osteotomy for the Patient with Hemifacial Microsomia

Since osteogenesis in the distraction site of the membranous bone has been well proved in histological studies, distraction osteogenesis of the craniofacial skeleton has become popular as an alternative to conventional orthognathic surgical procedures. Nowadays, mandibular distraction has been applied to balance the mandibular asymmetry in various methods. Bone distraction is not a new idea. The technique was already described by many other authors. One of the most important points of view in the distraction osteogenesis is effective elongation of hypoplastic mandible with preservation of the inferior alveolar nerve and tooth bud. From May 1997 to November 2000 we performed 15 distraction osteogenesis of mandible using our new short sagittal ramus osteotomy in patients with hemifacial microsomia. Our short sagittal ramus osteotomy could effectively lengthen the hypoplastic mandible and avoid the injury to the inferior alveolar nerve or tooth bud.

Correction of Constricted Ear using the Reversed Banner Flap

There exist many methods reconstructing a constricted ear. But those methods are usually lack of considerations about various components: shape of ear, height, width and circumference. Therefore we contrived a new method which we called 'a reversed banner' flap, modifying the banner flap by Tanzer. The banner flap considers only the increase of height. Moreover the transition of the flap is unnatural because of the base of the flap located medially. A total of 7 earswere reconstructed. Four patients were group I, and three patients were group II(by Tanzer's classification). To increase width and circumference as well as height, our method consists of steps as follows: (1) V-Y advancement skin flap on the root of helix. (2) Laterally based banner flap on the deformed helix, preserving the superior crus of antihelix. (3) Pooling out designed flap from root of helix and fixation to the inferior crus of antihelix. (4) Expansion of hooded helix lateral to superior crus. (5) Conchal cartilage grafts to the newly formed cartilage gaps. (6) Reinforcement of superior crus with a mattress suture. With this method we could make a more natural shape of ear and maintain the form of reconstructed ear.

Correction of Constricted Ear using the Reversed Banner Flap

There exist many methods reconstructing a constricted ear. But those methods are usually lack of considerations about various components: shape of ear, height, width and circumference. Therefore we contrived a new method which we called 'a reversed banner' flap, modifying the banner flap by Tanzer. The banner flap considers only the increase of height. Moreover the transition of the flap is unnatural because of the base of the flap located medially. A total of 7 earswere reconstructed. Four patients were group I, and three patients were group II(by Tanzer's classification). To increase width and circumference as well as height, our method consists of steps as follows: (1) V-Y advancement skin flap on the root of helix. (2) Laterally based banner flap on the deformed helix, preserving the superior crus of antihelix. (3) Pooling out designed flap from root of helix and fixation to the inferior crus of antihelix. (4) Expansion of hooded helix lateral to superior crus. (5) Conchal cartilage grafts to the newly formed cartilage gaps. (6) Reinforcement of superior crus with a mattress suture. With this method we could make a more natural shape of ear and maintain the form of reconstructed ear.

Surgical Correction of Submucous Cleft Palate with Furlow's Palatoplasty

Furlow's palatoplasty has been used as the primary treatment for cleft palate. From 1991 to 1999, 24 submucous cleft palate patients underwent Furlow's palatoplasty. The follow-up period was 3 months to 8 years (mean 24 months). Patients were selected after a thorough study for velopharyngeal insufficiency including intraoral examinatioin, speech assessment, digital subtraction radiography (DSR). Postoperatively velopharyngeal function was reevaluated with speech assessment and digital subtraction radiography in the 7 cooperative patients. Speech parameters including hypernasality, nasal emission, and Allison scale were improved after surgery. Digital subtraction radiography provided the value of velopharyngeal gap and the degree of the motion of lateral pharyngeal wall, both of which were improved after surgery. Furlows palatoplasty has advantage such as no impairment of nasopharyngeal physiology, no hannful effect on the hard palate and the realignment of the levator muscle which plays important role on the movement of the soft palate. The results show that a Furlow's palatoplasty can satisfactorily correct velopharyngeal insufficiency in carefully selected submucous cleft palate patients.

Two-Plane Lipoplasty with Superficial Ultrasonic Liposculpturing

No abstract available.

The Role of Various Osseous Genioplasty Combined with Orthoganthic Surgery

Although orthognathic surgery has been performed at the maxilla and the mandibular ramus to obtain a normal functional occulsion and aesthetic improvement of the face, deformities of the chin and disproportion of the soft tissue have been left. Mandibular set-back or advancement usually leaves soft tissue redundancy or deficiency along with its displacement. We have combined genioplasty with orthognathic surgery after intermaxillary fixation through a separate incision to get aesthetic improvement in the chin area in 28 patients. The authors obtained the aesthetic profile of the chin and lower lip according to various soft tissue analysis as follows: 1) The depth of the mentolabial fold 2) The distance from the E-line to labrale inferius (LI) 3) N-ANS/ANS-Me The soft tissue disproportion and residual deformities which were not usually corrected by the orthognathic surgery alone could be improved by combining it with genioplasty.

The Histomorphologic Evaluation of Hair Follicles Before and After Tissue Expansion in the Human Scalp

Soft tissue expansion technique has been a very useful method for the reconstruction of scalp defects and alopecia since the scalp is an unyielding tissue allowing minimal distension in traditional local flap surgery. As a result, there has been wide use of the tissue expansion method in the reconstruction of scalp defect and treatment of alopecia in the plastic surgery. There have been many concerns about histomorphologic changes of the overlying skin and the underlying structure resulting from tissue expansion. We also know that progressive tissue expansion induces increased mitotic activity of the epidermis and thining of the dermis in the overlying skin, as well as significant gross, histologic bony erosion in the underlying structure. However, little informations have been reported about the changes of the hair and pilocebaceus units in scalp expansion. We compared the horizontal sections of the expanded scalp and its longterm histologic changes with a normal unexpanded scalp specimen as a control. The terminal hair proportions to the vellus hair both increased. There was a 32% decrease in follicular units, a 24% decrease in terminal hair, and a 23% decrease in total hairs 8 week after scalp expansion compared to the normal unexpanded scalp. The perifollicular inflammatory changes and fibrosis observed in the full expanded scalp specimen disappeared within 12 weeks after removal of the expander and the flap transposition. In our observation, tissue expansion at the hair-bearing scalp did not precipitate any adverse changes on the hair follicles. On the contrary, we observed that secondary scalp expasion could be safetly performed 3 months after the first scalp expansion.