The Effect of a Novel Platysma Hammock Flap During Extended Deep Plane Facelift on the Signs of Aging in the Neck.

BACKGROUND: Aging changes in the neck, including platysma banding (PB), skin laxity (SL), and submandibular gland visibility (SGV), have a high degree of recurrence after rhytidectomy. OBJECTIVES: The authors sought to assess the long-term improvement in PB, SL, and SGV with addition of aplatysmal hammock flap to the extended deep-plane facelift and assess patient satisfaction. METHODS: This was a prospective study of 123 consecutive patients undergoing extended deep-plane facelift incorporating platysma hammock flap with or without midline platysmaplasty. Standard 2-dimensional patient photographs were employed to assess PB, SL, and SGV preoperative and >12 months postoperative. A 1-year postoperative patient satisfaction survey was conducted. RESULTS: The platysmal hammock flap without midline platysmaplasty cohort had a significant (P < 0.01) reduction in mean preoperative PB, SL, and SGV scores from 1.03, 1.88, and 1.21 to 0.06, 0.03, and 0.15 at 21 months. The platysmal hammock flap with midline platysmaplasty cohort had a significant (P < 0.01) reduction in preoperative PB, SL, and SGV scores from 1.81, 2.43, and 1.81 to 0.10, 0.15, and 0.48 at 18 months. The platysmal hammock flap with and without midline platysmaplasty cohorts had 96.2% and 88.9% satisfaction, respectively. CONCLUSIONS: Extended deep-plane facelift with a platysmal hammock flap achieves long-term, sustained improvements in PB, SL, and SGV; is well-tolerated; and results in substantial patient satisfaction.

The Selection of Facelift Approach on the Basis of Midfacial Ptosis.

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

A Novel Extended Deep Plane Facelift Technique for Jawline Rejuvenation and Volumization.

BACKGROUND: Jawline aging is a complex process. We believe loss of posterior jawline definition and volume depletion is an underappreciated factor in the aging face. OBJECTIVES: The aim of this study was to describe a novel composite, rotational flap modification of an extended deep-plane rhytidectomy. We evaluated long-term efficacy on improving jawline contour and volumization of the posterior mandibular region overlying the gonial angle. METHODS: We performed a prospective study on patients who underwent our modification of extended deep-plane rhytidectomy. We define and introduce the mandibular defining line, a new anatomic metric in evaluating the mandibular contour. We define the area of the posterior lower face overlying the gonion and mandibular angle as the gonial area. Using 3-dimensional photography, we quantify contour changes along the mandibular border and volume change along the gonial area. RESULTS: Eighty-nine patients (178 hemifaces) were analyzed. The mean gonial area volume gained was 3.5 cc. Average follow-up was 19 months. There was a statistically significant change in the mean mandibular defining line from 7.1 cm preoperatively to 9.8 cm postoperatively. This represents a lengthening of the visual perspective of the mandibular contour of 2.7 cm. CONCLUSIONS: Composite, rotational flap modification of extended deep-plane rhytidectomy provides significant long-term augmentation of volume to the posterior mandibular region and lengthens the visual perspective of the inferior mandibular contour, creating a more youthful jawline. In selected cases, this may obviate the need for other volumization procedures used to improve jawline contour, such as autologous fat grafting.

T-Connector Modification for Reducing Recurrent Distal Shunt Failure: Report of 2 Cases.

BACKGROUND AND IMPORTANCE: Cerebrospinal fluid shunt placement is used to treat the various causes of hydrocephalus by redirecting the cerebrospinal fluid to the body, most commonly from the ventricle to the peritoneum. Distal catheter displacement from the peritoneal cavity can occur as a complication, necessitating reoperation. CLINICAL PRESENTATION: We report 2 such cases in obese patients involving retropulsion of the distal tubing. To address this complication, we implanted a T-connector to the distal catheter construct. CONCLUSION: This study supports the use of a T-connector catheter construct to decrease and prevent the possibility of distal peritoneal catheter retropulsion in cases of elevated intra-abdominal pressure, both prophylactically and in revisions.

Preoperative High-Resolution Ultrasound for the Assessment of Malignant Central Compartment Lymph Nodes in Papillary Thyroid Cancer.

BACKGROUND: The identification and removal of malignant central compartment lymph nodes (MCLN) is important to minimize the risk of persistent or recurrent local disease in patients with papillary thyroid cancer (PTC). While the diagnostic accuracy of preoperative ultrasound for the assessment of lateral compartment node metastases is well recognized, its role in the identification of central compartment node metastases in patients with PTC is less established. This study delineates the utility of high-resolution ultrasound (HUS) for the assessment of MCLN in patients with PTC. METHODS: A retrospective chart review was performed of 227 consecutive patients who underwent total thyroidectomy for biopsy-proven PTC by a single endocrine surgeon in an academic tertiary care center between 2004 and 2014. Preoperative sonographic results were compared to postoperative pathology reports to determine the accuracy of HUS for the assessment of MCLN. Statistical analysis also included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: HUS identified abnormal central compartment nodes in 51 (22.5%) patients. All 227 patients underwent a careful central compartment node exploration. One hundred and four (45.8%) patients had MCLN identified by surgery, of whom 65 (62.5%) had a negative preoperative central compartment HUS. The sensitivity and specificity of preoperative HUS for the assessment of MCLN were 0.38 and 0.90, respectively. The PPV and NPV were 0.76 and 0.63, with an accuracy of 0.66. CONCLUSION: Preoperative HUS is quite specific for the identification of MCLN in patients with PTC. The present findings emphasize, however, that a negative HUS does not obviate the need for careful exploration of the central compartment to minimize the risk of persistent or recurrent local disease.

Ischemia/Reperfusion-induced neovascularization in the cerebral cortex of the ovine fetus.

Information on the effects of injury on neovascularization in the immature brain is limited. We investigated the effects of ischemia on cerebral cortex neovascularization after the exposure of fetuses to 30 minutes of cerebral ischemia followed by 48 hours of reperfusion (I/R-48), 30 minutes of cerebral ischemia followed by 72 hours of reperfusion (I/R-72), or sham control treatment (Non-I/R). Immunohistochemical and morphometric analyses of cerebral cortex sections included immunostaining for glial fibrillary acidic protein and collagen type IV (a molecular component of the vascular basal lamina) to determine the glial vascular network in fetal brains and Ki67 as a proliferation marker. Cerebral cortices from I/R-48 and I/R-72 fetuses exhibited general responses to ischemia, including reactive astrocyte morphology, which was not observed in Non-I/R fetuses. Cell bodies of reactive proliferating astrocytes, along with large end-feet, surrounded the walls of cerebral cortex microvessels in addition to the thick collagen type IV-enriched basal lamina. Morphometric analysis of the Non-I/R group with the I/R-48 and I/R-72 groups revealed increased collagen type IV density in I/R-72 cerebral cortex microvessels (p < 0.01), which also frequently displayed a sprouting appearance characterized by growing tip cells and activated pericytes. Increases in cerebral cortex basic fibroblast growth factor were associated with neovascularization. We conclude that increased neovascularization in fetal cerebral cortices occurs within 72 hours of ischemia.