Synthetic soft tissue substitutes: 2001.

The human face ages in a predictable fashion. Well-described changes in the lip and perioral region include progressive deepening of the nasolabial folds and atrophy of the lips. Conventional face lifting and endoscopic and resurfacing techniques do not adequately address many of these changes. As such, soft tissue filler materials are often used. This article outlines the history of soft tissue augmentation and discusses the risks and benefits of current synthetic materials.

Bipolar radiofrequency resurfacing.

Bipolar radiofrequency resurfacing is a new technology for the treatment of facial skin changes, including photoaging, rhytids, scars, and selected facial lesions. It is efficacious in the treatment of these problems and offers a quicker recovery than that of carbon dioxide laser resurfacing.

Temporal brow lift using botulinum toxin A.

The objective of this study was to determine whether brow elevation occurs as a result of paralysis of brow depressors after botulinum toxin A injection. The study's design was a prospective case series with pretreatment and posttreatment outcome evaluation with statistical analysis at a university-based division of facial plastic surgery private clinic. Twenty-two patients of a consecutive sample desiring a cosmetic enhancement underwent injection of botulinum toxin A directed to brow depressors. Injections consisted of 7 to 10 units of botulinum toxin A (Botox, Allergan, Irvine, Calif.) into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. No patients withdrew for adverse effects. All patients were evaluated 2 weeks after treatment. The outcomes were measured by change in brow elevation along vertical axis extending from both midpupil and lateral canthus to the caudal row of brow hairs with eyes at neutral gaze and the head at Frankfort plane. Preintervention and postintervention brow height was measured by the primary clinical investigator. The average brow elevation from the midpupil observed after selected injection of brow depressors with botulinum toxin A was 1.02 mm (p = 0.038). The average brow elevation from the lateral canthus observed after selected injection of brow depressors with botulinum toxin A was 4.83 mm (p<0.0001). Significant temporal brow elevation occurs as the result of paralysis of brow depressors by using botulinum toxin A injection. This procedure may be considered an alternative to surgical brow elevation.

Softform for facial rejuvenation: historical review, operative techniques, and recent advances.

The deep nasolabial fold and other facial furrows and wrinkles have challenged the facial plastic surgeon. A variety of techniques have been used in the past to correct these troublesome defects. Advances in the last five years in new materials and design have created a subcutaneous implant that has excellent properties. This article reviews the development and use of Softform facial implant.

Epidemiology of facial injury in female blunt assault trauma cases.

BACKGROUND: Etiology of trauma in the female population differs from that of the male population. To date, domestic violence has been researched extensively, but little has been published about the epidemiology of facial injury in the female population. OBJECTIVES: To analyze the differences in the circumstances under which males and females are injured, to identify gender-specific patterns of injury, and to assess whether differences in the demographics, health status, and drug-use profile exist between female and male assault cases and whether these factors lead to a difference in outcome. METHODS: A cohort of 91 female assault cases was compared with a control group of 706 males with similar injuries resulting from blunt assault trauma. Information was gathered by retrospective review of 797 consecutive cases requiring admission for facial injuries resulting from blunt assault trauma. Fisher exact, chi 2, and t tests were used to assess statistically significant differences between the male and female cohorts. RESULTS: The female cohort comprised 12% of all cases admitted for blunt assault facial trauma. One third of female blunt assault facial trauma patients were subjects of domestic violence. Statistically significant differences were found between males and females for the type of assault (rape, domestic violence, altercation, etc) with P < .0001. Females were more likely to be admitted with soft tissue injury only but no fracture (P < .05), less likely to be assaulted with a weapon, and unlikely to be involved in an altercation, gang violence, arrest, or robbery. Females were also less likely than males to be injured while intoxicated (P < .05). Incidence of specific injury patterns and outcomes, however, were similar between the 2 groups. CONCLUSION: The present data support the hypothesis that the female blunt assault facial trauma population represents a distinct epidemiological entity, with significant differences in the circumstances of injury, mechanism of assault, and role of intoxication in the incidence of injury. The prevalence of facial trauma in female assault cases makes it critical for the facial plastic surgeon to be vigilant in the evaluation and treatment of these patients.

An anatomical approach to glabellar rhytids.

OBJECTIVE: To identify surface landmarks that can serve as reference points to the underlying musculature in the treatment of glabellar rhytids. METHODS: Fifty cadaver hemibrows were dissected to assess the location, disposition, and relationships of the brow muscles, along with their variations at each of several consistent locations. Particular attention was paid to the corrugator supercilii, frontal belly of the frontalis, and procerus muscles. CONCLUSIONS: The information gained here may be applied to the pharmacological or surgical treatment of glabellar rhytids. Knowledge of the frequent location of the muscles involved, relative to easily identifiable surface landmarks, allows a more precise approach.

Correction of the twisted nose deformity: a surgical algorithm using the external rhinoplasty approach.

Successful correction of the twisted nose is challenging due to the complex nature of the underlying anatomic deformity. Although the literature has in general supported endonasal rhinoplasty techniques for the twisted nose, we propose a surgical algorithm using the external rhinoplasty approach. The algorithm offer a stepwise, structured method that is adaptable to individual variations in anatomic deformity. The advantages and relative disadvantages of the external rhinoplasty approach are discussed, and a clinical experience of 30 patients is reviewed. Application of the external rhinoplasty algorithm in correction of the twisted nose can yield consistently satisfactory functional and aesthetic results.

Evaluation of expanded polytetrafluoroethylene as a soft-tissue filling substance: an analysis of design-related implant behavior using the porcine skin model.

Soft-tissue augmentation using the synthetic nonfluid biomaterial expanded polytetrafluoroethylene (ePTFE) has been supported by number of recent reports citing the favorable characteristics of biocompatibility, soft and natural feel, ease of use, and permanent augmentation. Concern has been expressed about this application for ePTFE material because of the proximity of the implants to the skin surface and potential problems with infection and extrusion. We evaluated the behavior of a series of specific ePTFE implant designs using a long-term subcutaneous augmentation model. By using a porcine model, 466 implants of ePTFE in the form of strips, rolls, or tubes were placed using a percutaneous insertion device subcutaneously over the dorsum and face. The animals were divided into three study groups by length of implantation (3 weeks, control; 6 months, intermediate term; and 12 months, long-term) and en-bloc tissue specimens, including skin, implants, and underlying soft tissue, were harvested for gross and histologic examination. Implants were removed at the earliest sign of infection, exposure, or extrusion and the difficulty of removal was ascertained and recorded. These data reveal that ePTFE material elicits acceptable levels of tissue activity with low extrusion rates over the short and long term supporting its use for soft-tissue augmentation. The data show a clear difference, however, in the host response and behavior of the implants for this application based on shape or design. A statistically significant difference in the low, but measurable, extrusion rates was observed amongst these implant designs. ePTFE tubes showed greater stability and predictable augmentation over other implant designs for soft-tissue augmentation and seem to represent a substantial improvement for this application.

Total nasal reconstruction with alloplastic and autogenous grafts.

The basic principles of successful total nasal reconstruction include providing a sufficient amount of tissue coverage, creating an adequate structural framework, and fashioning a viable inner lining. Relative uniformity of opinion exists regarding sources for tissue coverage and nasal lining. A variety of options exists, however, regarding the type of material used for nasal framework. Alloplastic metals, such as vitallium or titanium mesh, combined with autogenous soft tissue coverage, are reliable alternatives for use in total nasal reconstruction.

Complications of injectable synthetic polymers in facial augmentation.

BACKGROUND: Injectable synthetic materials have been used for augmentation of soft tissue defects, correction of wrinkles, and augmentation of facial features such as the nasal dorsum. Success has been limited by inflammatory reactions, material migration, and the difficulty of removal should complications occur. OBJECTIVE: To evaluate complications resulting from soft tissue augmentation with injectable alloplastic materials. METHODS: Retrospective review of seven cases. Clinical history, treatment, histopathologic findings, and outcomes are assessed. RESULTS: Inflammatory reaction and tissue damage were refractory to antibiotics and steroids, and surgery was required to remove the foreign material. Histologic examination revealed giant cell foreign body reaction in all cases. CONCLUSION: Injectable synthetic polymers can produce significant complications including deformity and inflammatory tissue destruction, the control of which is complicated by the difficulty of removing the materials. Removable tissue fillers, such as e-PTFE, or natural materials such as collagen, autologous, fat, or Alloderm, should be considered instead.

Refinement in the rehabilitation of the paralyzed face using botulinum toxin.

A number of surgical procedures exist to improve facial symmetry for patients with facial paralysis. Whereas static symmetry is often improved, dynamic asymmetry frequently persists because of the imbalance of complex coordinated movements of facial expression. The paralyzed face is often distorted by the excessive pull of the normal contralateral face during emotional expression. This study reports an expanded clinical indication for botulinum toxin in patients with unilateral facial paralysis. Ten patients with facial paralysis and markedly asymmetric smiles were treated with botulinum toxin A injections into the contralateral zygomaticus major, levators labii superioris and angulii oris, or risorius muscles. Eight of the 10 patients noted improvement in the symmetry of their smiles and underwent repeat injections. The onset and duration of effect averaged 5.9 days and 3 months, respectively. Botulinum toxin therapy provides a safe and efficacious modality for refining the appearance of the paralyzed face during mimetic activity.

Epidemiology of facial injury in blunt assault. Determinants of incidence and outcome in 802 patients.

BACKGROUND: Facial assault trauma has reached epidemic proportions. While the biomechanics of injury, methods of repair, and general demography of blunt facial trauma are well known, statistical associations between epidemiological factors, incidence, and outcome are poorly understood. OBJECTIVES: To provide a comprehensive epidemiological survey of this patient population. To assess factors determining outcome and pattern of injury. DESIGN: Retrospective review of 802 patients admitted with blunt assault facial trauma. Statistical analysis of associations between epidemiological factors, incidence, and outcome with chi 2 test, 2-tailed t test, and Fisher exact test. SETTING: Urban university and county hospital. RESULTS: Statistically significant associations are demonstrated between gender and the context of assault, incidence of armed assault, presence of fracture, and rate of intoxication at injury. Poor prognostic indicators for outcome include use of tobacco and presence of a mandible fracture. Open reduction and internal fixation were found to bear a higher complication rate only in mandible fractures. CONCLUSIONS: While choice of treatment carries a statistically significant association with outcome, social variables, including gender, tobacco use, intoxication, and low socioeconomic status, produce dramatic worsening of both injury incidence and outcome.

Nasal reconstruction using a combination of alloplastic materials and autogenous tissues: a surgical alternative.

Re-creation of a functional and aesthetically acceptable nose after partial nasal defect requires accurate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near-total nasal defects combining both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue-expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near-total nasal defects.

Biomechanical effects of e-PTFE implant structure on soft tissue implantation stability: a study in the porcine model.

Successful implantation of biocompatible materials depends on physical aspects of its structure. Meshed implants are stable but cannot be easily removed. Nonporous materials are easily removed, but subject to extrusion. We hypothesized that the microporous structure of expanded polytetrafluoroethylene (e-PTFE) would permit limited fibrous ingrowth into the substance of the material, and that tubular implant shape would increase tissue integration while preserving ease of removal. A two-tailed in vivo study was done comparing implant retention, strength of fixation, and removability between tubular and solid-strip e-PTFE implants. Differences in implant retention within tissues were assessed by implanting 396 implants subcutaneously in five swine for observation periods ranging from 3 weeks to 12 months. Strength of implant attachment to host soft tissues was measured at 52 sites by extraction with a tensiometer with forces both parallel and perpendicular to the implant used. Implant porosity was assessed with scanning electron micrography of tubular and solid-strip e-PTFE implants. Measurements of the force and stress tolerances of the implant-tissue interface demonstrated significantly stronger attachment in tubular than strip-shaped implants (P < 0.005). The 11 N (2.75 lb) force sustained by the tubular implant exceeded the 3.4 N (<1 lb) force for the e-PTFE strip by a statistically significant margin on two-tailed Student's t-test (P < 0.005). Even greater forces were tolerated when applied at right angles to the axis of the tubular implant, emulating tissue suspension (21 N, 5.25 lb). The forces and stresses tolerated by both e-PTFE implants far exceeded the fracture stress measured for the implants. Implant extrusion rates were significantly smaller in tubular (0.85%) than in strip-shaped (4.4%) e-PTFE implants (P < 0.05). Standard error of the mean (SEM) demonstrated lesser porosity in tubular than strip implants, suggesting lesser direct tissue attachment. Tubular e-PTFE implant structure facilitates ingrowth of soft tissue through the tube's lumen. This increases the attachment to surrounding soft tissues, increasing fixation strength, decreasing extrusion rate, but still allowing easy removal. These properties may improve clinical applications in facial implantation.

Implants in rhinoplasty.

A variety of materials have been employed in rhinoplasty for augmentation and reconstruction. While autogenous tissue remains the mainstay of nasal implants and are the clear choice for structural and augmentation grafting of the nasal tip, limited availability and unpredictable resorption or remodeling have made homologous and synthetic implants important considerations for dorsal augmentation grafting. This section discusses categories of graft materials, their physical properties, harvesting and preparation technique, and advantages and disadvantages. An algorithm for nasal implants for specific indications in support and augmentation is presented.

The human immunodeficiency virus and facial plastic surgery.

The Human Immunodeficiency Virus (HIV) has imparted a number of concerns involving patient care and management as well as health care worker safety upon most surgical practices. Although these concerns are not often discussed in the context of facial plastic surgery (or particularly cosmetic surgery), they remain important issues. These issues are discussed with respect to public health policy, ethics and legality. The pathophysiological considerations for decision-making and care for HIV disease in the facial plastic surgery practice are addressed.

Primary surgical management for rehabilitation of the paralyzed eye.

Protection of the eye is the primary concern in managing the patient with facial paralysis; however, the aesthetic consequences cannot be overlooked. Lagophthalmos has traditionally been treated with frequent ocular lubrication, medical eye care, and tarsorrhaphy. This approach is fraught with the difficulties of poor patient compliance and unacceptable cosmesis. We suggest a protocol for the complete ocular management with emphasis on immediate rather than delayed surgical rehabilitation as a primary therapy in facial paralysis. Gold weight implantation to the upper lid and tightening of the lower lid at the lateral canthus are simple and reliable procedures that provide immediate functional and aesthetic improvement. This surgical technique has extremely low morbidity and is reversible should facial function return. We have used this protocol in more than 30 patients with excellent results.

Expanded polytetrafluoroethylene (Gore-Tex soft-tissue patch) in facial augmentation.

BACKGROUND: Expanded polytetrafluoroethylene (EPTFE) (Gore-Tex soft-tissue patch) has received favorable clinical reports for use in facial augmentation procedures. We evaluated the EPTFE soft-tissue patch in short-term (3-week), intermediate-term (6-month), and long-term (12-month) animal models. METHODS: Nine pathogen-free male and female New Zealand white rabbits weighing 2 to 4 kg were used. After implantation of the EPTFE soft-tissue patch, the animals were carefully observed on a daily basis for signs of wound infection, seroma, or hematoma formation. The stability of the implant was evaluated and graded after the animals were killed. Tissue specimens, including skin, implant, and underlying bone, were removed en bloc. These blocks were sectioned and stained for histologic evaluation. A portion of these blocks were used for scanning electron microscopy. RESULTS: The material increased in stability over time and showed minimal inflammatory cell response and only a delicate fibrous capsule, even in long-term implants. Ultrastructural analysis demonstrated close apposition of the material to tissue, suggesting good interface bioactivity. CONCLUSIONS: The EPTFE soft-tissue patch appears to be safe and reliable material for augmentation, demonstrating high biocompatibility, low tissue reactivity, and increasing stability over time.