Current practices in endoscopic brow and temporal lifting.

This article describes new innovations in the endoscopic treatment of the ptotic brow and temple. Extensive release of upper midface ligamentous structures and wide undermining of the orbicularis oculi are maneuvers that have been added to the standard brow lift procedure. Suspension sutures have improved brow tail and cheek fat elevation. Radiofrequency instrumentation and fibrin glue have allowed the minimization of tissue trauma during depressor muscle lysis and brow and temple fixation. Brow lowering techniques also have been developed to reverse the effects of aggressive endoscopic and coronal brow lifting.

Autologous cultured fibroblasts as cellular therapy in plastic surgery.

Autologous cultured fibroblasts serve as injectable protein repair systems for correction of acne scars, rhytids, and other facial scars. The system uses the patient's own cultured fibroblasts to correct contour deformities over time.

Autologous fibroblasts for treatment of facial rhytids and dermal depressions. A pilot study.

OBJECTIVE: To assess effectiveness of intradermal injections of autologous fibroblasts for the treatment of facial rhytids and dermal depressions. DESIGN: Six-month prospective pilot study. Photographs and silicone molds were taken of a prominent rhytid or dermal depression from each patient prior to treatment and at 6 months after treatment. SETTING: Specialty clinic in academic medical center. PATIENTS: Ten adults (age range, 24-69 years) who each exhibited a prominent rhytid or depressed facial scar. INTERVENTION: A 3-mm postauricular skin biopsy specimen from each participant was sent to Isolagen Technologies, Inc, laboratories, where a fibroblast cell line was developed. Three injection sessions were performed at 2-week intervals; target areas were the study site as well as behind the ear. MAIN OUTCOME MEASURES: Subjective improvement scores were obtained by each patient and 2 clinicians at every follow-up visit. Skin surface topographical features were evaluated with optical profilometry by comparing silicone molds before and after injection. Histological analysis was performed on a biopsy specimen of the postauricular injection site. RESULTS: Nine of 10 patients noted a 60% to 100% improvement with the treatment; clinicians made similar observations. Size reduction of 10% up to 85% of the study site was demonstrated by optical profilometry for every patient. Microscopically, there was evidence of increased thickness and density of dermal-layer collagen. CONCLUSIONS: Intradermal injection of autologous fibroblasts may be an effective treatment option for facial rhytids and depressed scars.

The John Charnley Award. Natural history of thromboembolic disease after total hip arthroplasty.

In 1079 consecutive patients undergoing total hip arthroplasty between 1984 and 1992, complications of thromboembolic disease and related anticoagulation were reviewed for 6 months after hospital discharge, including cost data. Of 347 patients having venograms, 78 (22.5%) had positive results and 269 (77.5%) had negative results for deep venous thrombosis. In patients with negative venograms, 3 (1.1%) were readmitted with 2 symptomatic deep venous thromboses and nonfatal pulmonary embolism. There were no readmissions among the 55 patients who had venographically evident deep venous thrombosis diagnosed and treated with outpatient warfarin. Overall, 3 of 324 (0.9%) patients with true positive or negative venograms were readmitted for complications of thromboembolic disease. In contrast, 12 of 732 (1.6%) patients not receiving contrast venography were readmitted, including 9 (1.2%) deep venous thromboses and 3 (0.4%) nonfatal pulmonary embolisms. Four of 23 patients (17.4%) with untreated calf deep venous thrombosis suffered 2 nonfatal pulmonary embolisms resulting in readmission and 2 fatal pulmonary embolisms outside the hospital. Untreated calf deep venous thrombosis after total hip arthroplasty represents a significant threat of extension to more proximal veins and distant embolization. Routine thromboembolic disease prophylaxis combined with screening contrast venography and selective therapeutic anticoagulation is effective in preventing late thromboembolic disease complications and, compared with a strategy of extended prophylaxis for all, is cost effective management by reducing exposure of the elderly population to outpatient anticoagulant therapy.

Endoscopic techniques in facial rejuvenation surgery.

The endoscopic approach to rejuvenation surgery of the forehead is standing the test of time. We feel that aesthetic results obtained from this procedure are equal to or better than results associated with the conventions coronal lift, while remarkably reducing recovery time and incision-related morbidity (Figs. 9,10).

Suprafibromuscular facelifting with periosteal suspension of the superficial musculoaponeurotic system and fat pad of Bichat rotation. Tightening the net.

OBJECTIVE: To design a facelifting technique that improves the safety of the facial nerve in extended facelifting; improves methods of fixation of the elevation of the nasolabial folds, the melolabial folds, the corner of the mouth and the malar fat pad; and augments the malar and submalar areas without implants. DESIGN: After a retrospective review of previous modified "composite" technique facelift results (307 patients over 4 years), a suprafibromuscular facelift technique was evolved through 22 fresh cadaver dissections. The resulting technique was applied to 73 patients, 61 females and 12 males, who were followed up for 6 to 18 months. METHODS: Preauricular dissection was subcutaneous for about 4 cm. An incision was made through the superficial musculoaponeurotic system (SMAS) at the level of the body of the zygoma. Dissection over the malar eminence was performed under the orbicularis muscle. Mid-cheek dissection was performed over the fibromuscular SMAS in th layer of areolar tissues that lines it. A rotation of the fat pad of Bichat (or buccal fat pad) was used, when indicated, to augment the cheek. Stabilization of the elevation of the nasolabial fold, the melolabial fold, and the corner of the mouth was obtained by the use of suspension sutures from the SMAS to the malar eminence. Stabilization of the malar fat pad was provided by the laterally directed flap of SMAS that was sutured to the temporal fascia. The patients were followed up for 6 to 18 months and evaluated for stability of the correction and facial nerve complications. RESULTS AND CONCLUSION; The facelift corrections (nasolabial fold, melolabial fold, malar fat pad shift) were stable over the follow-up period. No facial nerve injuries were seen.

Small incision laser lift for forehead creases and glabellar furrows.

A new technique for eliminating or reducing glabellar frown lines and forehead creases with a small (3- to 5-cm) incision, KTP (potassium [K]-titanyl-phosphate) laser (Laserscope), and endoscope (Karl Storz) has been performed on 62 patients over the last 18 months. This endolaser technique takes advantage of the unique properties of the frequency-doubled Nd:Yag (neodymium:yttrium aluminum garnet) (KTP) laser coupled with an optimized quartz contact probe. It enables the surgeon to incise or excise the procerus, corrugator, and frontalis muscles, with little or no bleeding, at a distance from a small incision immediately behind the hairline. This small incision frontal lift has been as effective as the standard forehead lift in rejuvenation of the upper face, avoiding the paresthesias, scalp itch, headaches, periorbital ecchymosis, and hair loss that are common sequelae of the forehead lift. Recovery time has been markedly reduced.

Treatment of vascular lesions with a CW yellow dye laser--initial trials.

Thirteen patients with vascular lesions were treated with a CW yellow dye laser. Most of these patients were either poor candidates for argon laser treatment (ALT) or had undergone unsuccessful argon laser treatment. Twelve patients responded with a "desirable" treatment result. One patient did not respond adequately to have his result classified as "desirable," though all patients experienced fading of their lesions. None of the patients experienced scarring, epidermal thinning, or hypopigmentation. This lack of complications, associated with an incidence of desirable results in twelve of the thirteen patients, is noteworthy because all but one of the patients with portwine stain had difficult-to-treat lesions whose treatment is not attempted by many ALT centers. We believe that yellow light has certain advantages over blue-green argon laser light for the treatment of vascular lesions and think that further study is warranted.

Photodynamic therapy in otolaryngology--head and neck surgery.

Photodynamic therapy utilizes a photosensitizing drug, hematoporphyrin derivative, and laser light to diagnose and treat cancer. We used treatment and diagnostic instrumentation and techniques developed during the last seven years to treat 31 patients over the last two years. Diffuse, superficial tumors of the head and neck responded well to photodynamic therapy as did localized bulk lesions of this area. Photodynamic therapy achieved initial control in patients with early lung cancer and opened up bronchi in those with obstructive lung cancer. Widespread, bulky tumors responded inconsistently. Neck metastases responded poorly when treated for tumor control. The beneficial effects of phototherapy and its general lack of severe complications may, however, warrant its use for limited palliative goals in the patient with far-advanced head and neck cancer, especially when irradiation and surgery have failed.

Advances in laser skin surgery for vascular lesions.

Recent advances in laser techniques for the treatment of vascular lesions have attempted to overcome the disadvantages of argon laser therapy. The trend toward a more selective treatment of these lesions, with preservation of as much normal tissue as possible, has been set. Minimal argon laser methods, yellow-dye lasers, and treatment with hematoporphyrin derivative photodynamic therapy extend the abilities of the laser surgeon to treat port-wine stains and other vascular lesions safely.