Less Invasive Superficial Musculoaponeurotic System Approaches in Rhytidectomy: How, When, and Why.

As a facial plastic surgeon gains experience, further improvements can be gained with more aggressive surgery, but complications begin to occur when more aggressive measures are undertaken. Therefore, the ideal technique is one that maximizes rejuvenation while minimizing adverse effects. The senior author has found that the aggressive techniques in the region of the neck have improved dramatically the overall initial and long-term results for the neck portion of the rhytidectomy. More aggressive treatment of the midface during the modified deep plane rhytidectomy does not necessarily improve the overall long-term results, however, and can increase the complication rate.

Chemical Peel (Deep, Medium, Light).

With modern medicine increasing both the average life span and quality of life, there has been a greater demand for treatment of age-related skin changes. As many new options in skin resurfacing are developed annually, it is chemical peeling that has withstood the trials of time and scrutiny. The different variations of chemoexfoliation have been used for rhytids, actinic damage, lentigos, and dyschromias. This article describes the most recent knowledge about chemical peeling, and exposes previously accepted yet incorrect dogmas. Chemical peeling, when practiced with knowledge and good technique, can yield excellent results in skin rejuvenation.

Chemical Peels: Deep, Medium, and Light.

Chemical peels, laser resurfacing, and dermabrasion all offer unique options for skin resurfacing for rhytids and dyschromias. Laser resurfacing has developed over the previous decades, but it is the chemical peel against which all modern forms of skin resurfacing are measured. Phenol-croton oil peels have been modernized and depend on croton oil concentration to minimize risks. Complications associated with skin resurfacing are uncommon with proper technique and postoperative management.

Laser and face peel procedures in non-Caucasians.

Facial resurfacing procedures are becoming increasingly popular. The percentage of non-Caucasian individuals seeking these treatments continues to rise. Patients with darker skin types (Fitzpatrick skin types IV-VI) face unique challenges for successful facial skin resurfacing. Common issues encountered by non-Caucasian patients include dyschromias, acne scars, photoaging, keloid and hypertrophic scars, benign cutaneous tumors, and hair-related disorders. This article discusses the most frequently used lasers and chemical peels used to address these problems.

Chemical peels: panel discussion.

Edwin Cortez, Fred Fedok, and Devinder Mangat address questions for discussion and debate. Do you agree or disagree, and why, with the following: "The best method to improve moderate to deep rhytids is the croton oil-phenol peel." "There are no problems with cardiotoxicity with croton oil-phenol peels if done appropriately." "Do not do spot testing with chemical peel agents." How do you handle peels in advanced Fitzpatrick skin types III, IV, V? What is the main factor for rate of reepithelialization: (1) depth of peel, (2) depth of laser, (3) depth of dermabrasion? How has your approach to or technique in chemical peels evolved over the past several years?

Calcium hydroxyapatite fillers.

Calcium hydroxyapatite fillers have unique advantages over other fillers in regards to duration of action and volume of product required for augmentation, especially in the midface and lower face. In this article, we describe our experience with calcium hydroxyapatite fillers and compare them with other available filler products.

Current chemical peels and other resurfacing techniques.

The currently available methods for resurfacing will be addressed in this article, which has been divided into three areas of focus: chemical peels, lasers, and dermabrasion. Emphasis will be placed on chemical peels, a technique with a long history that provides a very reliable method of resurfacing and that every facial plastic surgeon should be familiar with.

Soft-tissue augmentation with calcium hydroxylapatite: histological analysis.

OBJECTIVE: To evaluate histologically the extent and character of tissue in-growth after injection of calcium hydroxylapatite for soft-tissue augmentation. METHODS: Prospective case series of 8 patients from a private facial plastic surgery practice. Each patient was injected subdermally between the dermis and the subcutaneous fat with 0.1 mL of calcium hydroxylapatite in the superior postauricular sulcus. One month later, 2 patients underwent excision of the injected material, which was submitted for routine histological evaluation by an independent dermatopathologist. The material was stained with hematoxylin-eosin and trichrome to assess new collagen deposition. One of these patients was reinjected in the contralateral postauricular sulcus. Six and 18 months after injection, 3 patients and 1 patient, respectively, underwent excision of the injected material, which was then submitted for histological evaluation of the degree and character of tissue in-growth and tissue reaction. RESULTS: The calcium hydroxylapatite particles were found to be surrounded by a lymphocytic infiltrate with multiple foreign body giant cells. There was no evidence of new collagen formation, migration, or heterotopic bone growth. Two patients were lost to follow-up. CONCLUSIONS: Calcium hydroxylapatite is a stable soft-tissue filler that stimulates an immune response with lymphocytic infiltration and foreign body giant cell formation. We found no evidence of new collagen formation 1, 6, or 18 months after injection.

Facial implants.

By offering safe, long-term correction of volume depletion and contour defects, facial implants maintain a unique position in the armamentarium of the cosmetic surgeon. Careful patient assessment and selection of the appropriate implant type, size, and shape maximize results. Proper postoperative follow-up helps to treat any complications before they become a serious problem. Most patients have volume loss as part of their facial aging. Facial implants play an important role in panfacial rejuvenation.

Endoscopic forehead-lift using a bioabsorbable fixation device.

Endoscopic brow-lift is the method of upper face rejuvenation preferred by facial plastic surgeons and patients alike. The technique has undergone significant scrutiny regarding methods of fixation. Many techniques have been described, including external bolster dressings, tissue adhesives, Kirschner-wire fixation, cortical tunnels and troughs, and permanent or temporary screw and plate fixation. Many of these techniques are associated with postoperative alopecia, poor reliability, possible intracranial complications, and palpable hardware. Thus, the search for a safe, effective, reliable, and straightforward procedure continues. We describe our experience with an easy-to-insert bioabsorbable device that is fixed to the calvaria and provides multipoint fixation to the soft tissue.