Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation.

The SMAS was described more than 25 years ago, yet its full potential in face-lift surgery has become appreciated only more recently. A reappraisal of the various aspects of SMAS surgery is now appropriate. These include aspects of its release from the deep fascia, the several considerations underlying the vectors of flap redistribution, and the rationale underlying the methods of flap fixation. These are unique, compared with the traditional considerations in subcutaneous face lifts and en bloc subperiosteal lifts.

Body-esteem scale for adolescents and adults.

Body esteem (BE) refers to self-evaluations of one's body or appearance. This article outlines a BE questionnaire for adolescents and adults that has 3 subscales: BE-Appearance (general feelings about appearance), BE-Weight (weight satisfaction), and BE-Attribution (evaluations attributed to others about one's body and appearance). The subscales have high internal consistency and 3-month test-retest reliability. Females scored lower than males on BE-Weight and BE-Appearance. BE-Weight was the only subscale uniquely related to weight, especially in females, with heavy individuals tending to be dissatisfied with their weight. BE-Appearance was the only subscale that consistently predicted self-esteem. BE-Appearance and BE-Weight covaried more with Neeman and Harter's (1986) Appearance subscale than with other self-esteem subscales; BE-Attribution covaried more with social self-esteem subscales than did BE-Appearance and BE-Weight.

Fat preservation technique of lower-lid blepharoplasty.

This refinement of lower-lid blepharoplasty replaces bulging fat of the lower lid back into the orbit. Capsulopalpebral repair strengthens the orbital septum to retain the orbital fat in the orbit. The author describes his operative technique, focusing closely on relevant anatomy. (Aesthetic Surg J 2001;21:450-459.).

Immunofluorescent microscopic investigation of the distal arrector pili: a demonstration of the spatial relationship between alpha5beta1 integrin and fibronectin.

Currently there is limited knowledge regarding the anatomy of the distal arrector pili (AP) muscle. A previous study implicated fibronectin and alpha5beta1 integrin binding as the anchor between the AP and the extracellular matrix (ECM). The purpose of this study was to strengthen this hypothesis. Serial frozen sections of human scalp skin were double-labeled via immunofluorescent staining for alpha5beta1 with fluorescein and fibronectin with rhodamine, followed by fluorescent microscopy. Granular staining for alpha5beta1 with fluorescein and smooth staining for fibronectin with rhodamine were seen at the periphery of the AP muscle bundles and along the distal fibers. Precise co-localization of alpha5beta1 and fibronectin was observed at the AP-ECM interface by means of a dual filter. Analysis of variance was used on the relative density of staining for each epitope. Staining for both epitopes was significantly brighter at the distal fibers than at the middle or proximal portions of the muscle. A computerized three-dimensional reconstruction provides a detailed picture of the microanatomy of the distal AP, which allows mathematical evaluation of the forces of contraction. The anatomic co-localization between alpha5beta1 and fibronectin strengthens our hypothesis that interaction of these epitopes mediates the attachment of the distal AP to the ECM.

Surgical anatomy of the ligamentous attachments in the temple and periorbital regions.

This study documents the anatomy of the deep attachments of the superficial fasciae within the temporal and periorbital regions. A highly organized and consistent three-dimensional connective tissue framework supports the overlying skin and soft tissues in these areas. The regional nerves and vessels display constant and predictable relationships with both the fascial planes and their ligamentous attachments. Knowledge of these relationships allows the surgeon to use the tissue planes and soft-tissue ligaments as intraoperative landmarks for the vital neurovascular structures. This results in improved efficiency and safety for aesthetic procedures in these regions.

The microanatomy of the distal arrector pili: possible role for alpha1beta1 and alpha5beta1 integrins in mediating cell-cell adhesion and anchorage to the extracellular matrix.

The arrector pili (AP) muscle is a small band of smooth muscle that attaches proximally to the bulge area of the pilosebaceous apparatus in the reticular dermis and extends up toward the epidermis. The distal anatomy of the AP and the anchorage mechanism allowing hair erection have not been previously described. Integrins are likely candidates mediating this attachment. Immunohistochemical techniques were used to determine the distribution of the following integrins: alpha1, alpha2, alpha3, alpha4, alpha5, alpha6 and beta1 as well as fibronectin. Frozen human scalp tissue was sectioned in traditional planes, obliquely and horizontally to visualize microanatomy in three dimensions. Histological examination revealed that the distal portions of smooth muscle fibers splay extensively between collagen bundles of the upper dermis. Integrin subunits alpha1, alpha5 and beta1 were expressed by the AP muscle. Analysis of the relative density of immunoreactivity in digitized sections revealed increased alpha5 subunit expression at the extracellular matrix (ECM)-muscle interface. These data suggest that anchorage of the AP muscle to the ECM is via alpha5beta1 integrin and alpha1beta1 integrin functions in muscle cell-cell adhesion. Extensive splaying of smooth muscle fibers may allow increased surface area contact between the ECM and smooth muscle cells expressing peripherally situated alpha5 integrin.

SMAS fixation to the facial skeleton: rationale and results.

The trend in modern facial rejuvenation surgery is to reposition the ptosis of the superficial soft-tissue mass relative to the facial skeleton. The logical method of supporting the superficial tissue is to reattach it to the underlying skeleton, thereby replicating the function of the retaining ligaments. Five hundred consecutive face lifts involving deep fixation of the submucosal aponeurotic system flap to the periosteum of the zygoma were reviewed for complications and side effects. Expected complications, such as irregularities, dimpling, and palpable sutures, occurred in fewer than 1 percent of cases, confirming the safety of this method. The conclusion from this experience is relevant to all methods of deep-layer facial rejuvenation surgery, including the endoscopic approach.

Developmental changes in serotonergic receptor-mediated modulation of embryonic chick motoneurons in vitro.

Intracellular recordings were obtained from antidromically identified motoneurons in an embryonic chick spinal cord slice preparation at two developmental stages (embryonic days 12 and 18, E12 and E18) which bracket a critical period in spinal cord growth. The resting membrane potential of chick motoneurons did not change significantly between E12 and E18, but there was a significant decrease in neuronal input resistance. A small inward rectification was present in cells of both ages, although a lower proportion of E12 motoneurons exhibited inward rectification compared to E18 motoneurons. Injection of depolarizing current pulses revealed that most E12 motoneurons exhibited spike adaptation, while the majority of E18 motoneurons showed high frequency tonic firing. Bath application of serotonin (5-HT) and its agonists 5-carboxamido-tryptamine (5-CT, a 5-HT1 agonist) and alpha-methyl 5-HT (a 5-HT2 agonist) produced hyperpolarizing responses accompanied by decreased input resistance in all E12 motoneurons studied. The same three agonists produced depolarizing responses and increased input resistance in all E18 motoneurons studied. The effects of serotonergic agonists on motoneuronal excitability were tested using depolarizing current pulses. In most cases, serotonergic agonists caused a decrease in firing frequency during the hyperpolarizing response in E12 neurons. At E18, bath application of 5-HT, 5-CT or alpha-methyl 5-HT produced an increase in firing frequency in all motoneurons during the depolarizing response. Our results indicate that both 5-HT1 and 5-HT2 receptor subtypes contribute to modulation of chick motoneuron excitability and appear to reverse the polarity of their effects on membrane potential after a critical period in development of the spinal cord.

Developmental changes in the effects of serotonin and N-methyl-D-aspartate on intrinsic membrane properties of embryonic chick motoneurons.

A spinal cord slice preparation was developed in order to study developmental changes in intrinsic membrane properties and in responses to N-methyl-D-aspartate and serotonin in embryonic chick motoneurons. Transverse spinal cord slices were obtained from chick embryos over a series of developmental stages (embryonic days 12-18). Intracellular recordings were obtained from 87 antidromically identified motoneurons. During the stages examined, the average resting membrane potential did not vary significantly, the voltage threshold of current-evoked action potentials became significantly more negative, there was a non-significant trend towards a decrease in the recorded input resistance, but there were no significant changes observed in the membrane time constant. There were significant developmental changes in the waveform of the current-evoked action potentials. The average amplitude of the action potentials increased over the stages studied, while the action potential duration measured at half-amplitude decreased. All of the motoneurons examined were maximally depolarized by bath application of 50 microM N-methyl-D-aspartate. The depolarization persisted in the presence of tetrodotoxin but was blocked by 100 microM 2-amino-5-phosphonopentanoic acid and, therefore, was at least partially due to a direct action of N-methyl-D-aspartate on motoneuronal receptors. The average amplitude of the N-methyl-D-aspartate-induced depolarizations decreased significantly over the stages examined. In contrast, bath application of 50 microM serotonin produced either depolarizing or hyperpolarizing responses depending on the developmental age of the motoneuron. Serotonin induced a depolarization in about 50% of the motoneurons at embryonic day 12, 69% of the motoneurons at embryonic day 15 and 100% of the motoneurons recorded from at embryonic day 18. These findings reveal important developmental changes in intrinsic membrane responses and action potential properties of chick motoneurons recorded from a slice preparation. We have also documented changes in the motoneuronal responses to serotonin, a neurotransmitter used by a major descending projection, and N-methyl-D-aspartate, which activates glutamate receptors known to contribute to synaptic activity in segmental circuits.

Ethanol exposure alters the development of serotonergic neurons in chick spinal cord.

Exposure to ethanol is known to alter the development of the serotonergic system. However, previous studies have examined large populations of cells and have not determined the effects of ethanol on individual serotonergic neurons. In the present study, the effects of various concentrations of ethanol on the development of single serotonergic neurons in the chick embryo spinal cord were determined using immunohistochemical techniques. Between embryonic day 7 (E7) and E14, ethanol administrations produced in ovo alcohol concentrations of: a) low dose, 30-60 mg/dl, b) medium dose, 150-200 mg/dl or c) high dose, 240-300 mg/dl. In animals exposed to the medium and high ethanol doses, the normal developmental increase in cross-sectional area of the somata was not observed. At all stages examined, the numbers of primary and nonprimary processes were significantly lower in ethanol-treated groups compared to controls. These data indicate that ethanol exposure induces dose-dependent alterations in the development of identified spinal cord neurons. The ethanol-induced changes may be involved in the motor dysfunction observed after embryonic ethanol exposure.

Overexpression of nerve growth factor in epidermis of transgenic mice preserves excess sensory neurons but does not alter the somatotopic organization of cutaneous nerve projections.

To determine how target-derived nerve growth factor (NGF) affects sensory neuronal survival and the development of topographic nerve projections in the spinal cord, anatomical studies were performed on transgenic mice that overexpress NGF in skin and other keratinized epithelial structures. Transgenic animals showed a 100% increase in the number of sensory neurons in specific dorsal root ganglia and exhibited significantly more fibers immunoreactive for calcitonin gene-related peptide in the dorsal horn compared to control animals. This confirms earlier studies which suggested that naturally occurring sensory neuronal death is decreased, or eliminated, in the transgenic mice. Nerve labeling studies showed that the somatotopic organization of cutaneous nerve projections was not altered in the transgenic animals. These data suggest that neuronal death does not act to remove sensory neurons that project to inappropriate regions of the spinal cord.

Anatomy of the midface.

Surgical procedures for the midface and nasolabial fold demand that the surgeon possess a magnified knowledge of the facial anatomy and its structural relationships. With this knowledge, the surgeon limits complications while achieving better results. This article reviews the anatomy of the midfacial subcutaneous soft tissues.

Extended sub-SMAS dissection and cheek elevation.

The extended SMAS facelift techniques gave plastic surgeons the ability to correct the nasolabial fold and medial cheek. Retensioning the SMAS transmits the benefit through the multilinked fibrous support system of the facial soft tissues. The effect is to provide a recontouring of the ptotic soft tissues, which fills out the cheeks as it reduces nasolabial fullness. Indirectly, dermal tightening occurs to a lesser but more natural degree than with traditional facelift surgery. Although details of current techniques may be superseded, the emerging surgical principles are becoming more clearly defined. This article presents these principles and describes the author's current surgical technique.

Children's global self-esteem predicted by body-esteem but not by weight.

Three factors of a body-esteem scale, Appearance, Weight, and Attribution, were inversely related to relative weight in youngster between 8 and 16 years old (243 girls and 168 boys). Global self-esteem, however, was generally not related to relative weight. Nonetheless, self-esteem covaried with Appearance and Attribution.

Adolescents' weight, sex, and family functioning.

The study explored family functioning with adolescents of varying weight. The participants were 572 adolescents (286 boys and 286 girls) (M = 15.7 years, SD = 1.04) who comprised four weight groups: underweight (less than 90% expected weight), normal weight (90 to 110%), overweight (111 to 125%), and obese (over 125%). They completed 9 of the 15 subscales of the Self-Report Measure of Family Functioning pertaining to family styles (e.g., Authoritarian) and relationships (e.g., Conflict, Enmeshment). Obese girls rated their families lower on Cohesion, Expressiveness, and Democratic Family Style. Obese and moderately overweight girls seem to perceive their families differently. Obese and overweight boys did not differ from normal weight boys on any of the measures. There was a tendency for underweight boys to report lower Cohesion, Expressiveness, and Democratic Family Style. The need to consider family environment, particularly the family's differing expectations for obese daughters and underweight sons, is discussed with reference to treatment.

Chronic embryonic MK-801 exposure disrupts the somatotopic organization of cutaneous nerve projections in the chick spinal cord.

The effect of altering neural activity on the development of the central projections of cutaneous and muscle sensory neurons was studied in the embryonic chick spinal cord. Animals were treated chronically with MK-801, a non-competitive N-methyl-D-aspartate receptor antagonist, during the period when both cutaneous and muscle sensory afferents form connections in the spinal cord. Daily applications of MK-801 began on embryonic day 5, 1 day before sensory collaterals penetrate the spinal cord gray matter, and continued until the animals were analyzed (at embryonic day 14). The patterns of cutaneous and muscle sensory nerve projections were determined by applying fluorescent tracers to individual, identified peripheral nerves. MK-801 treatment did not overtly alter the pattern of muscle afferent projections. However, in the MK-801-treated embryos, the somatotopic organization of cutaneous afferent projections was dramatically altered. Normally, the projections formed by the lateral femoral cutaneous and the medial femoral cutaneous nerves are located immediately adjacent to one another in the lumbar dorsal horn, with little overlap. In the MK-801-treated embryos, the projections from these two cutaneous nerves both expanded significantly within dorsal horn laminae to become almost completely superimposed. These data suggest that MK-801 disrupts the development of the somatotopic organization of cutaneous afferent projections in the spinal cord.

Ontogeny and effect of activity on proenkephalin mRNA expression during development of the chick spinal cord.

Numerous studies have shown in the adult nervous system that mRNA expression can be regulated by neuronal activity. To examine the effect of activity during embryogenesis, the ontogeny of proenkephalin mRNA expression and expression following activity blockade was investigated during development of chick spinal cord. A cDNA fragment (ca. 0.5 kb) coding for chick proenkephalin was cloned and sequenced. With this cDNA, a cRNA probe was made to examine proenkephalin mRNA expression in the spinal cord during embryogenesis. Proenkephalin mRNA was expressed in spinal cord in clusters of cells located in the developing dorsal horn and intermediate lamina at the earliest stages examined (stage 22; E4). Proenkephalin-positive cells in the intermediate lamina were located immediately adjacent to the ventricular zone. At stage 28 (E6) an additional cluster of proenkephalin mRNA-positive cells was seen at the lateral border of the developing intermediate lamina. At stage 33 (E7.5-5-8) the pattern of hybridization positive cells was similar to earlier stages, but individual cells could be identified. At stage 39 (E13) densely labeled cells were seen throughout the dorsal horn and intermediate laminae including the column of Terni. To determine whether neural activity affects proenkephalin mRNA expression, d-tubocurarine (an inhibitor of neural activity) was injected into developing embryos. Following administration of d-tubocurarine a dramatic decrease was seen in proenkephalin mRNA hybridization in the dorsal horn and intermediate lamina of the spinal cord. This study demonstrates in vivo that changes in the level of neural activity can alter gene expression during embryogenesis and suggests that activity is required for expression of nervous system-specific genes.

Herniated fat and the orbital septum of the lower lid.

The bulging fat of aging eyelids has always been described as a hernia; yet, the treatment has not been that of a true hernia. Rather, the contents (orbital fat) have been excised and the hernia wall left unrepaired. It is possible to treat bulging lower eyelids as a hernia by replacing both the fat and the sac into the original location within the orbital cavity, and then repairing the retaining wall.

Cosmetic surgery for the ageing face.

Cosmetic surgery is unique in that the results are qualitative. Recent technical advances now allow the skilled and artistic surgeon to achieve the degree of change requested by most patients, without the obvious operated look. General practitioners should extend their professional relationship with cosmetic surgery patients. Preliminary counselling can reduce patient's anxiety by clarifying their objectives and by providing relevant information and support. The relationship of trust so engendered is helpful for post operative support and allows the practitioner to share in the satisfaction experienced by the patient as a result of surgery.

Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation.

The nasolabial fold has defied satisfactory correction with the face lift operation. This is despite variations of the SMAS technique over the last 20 years. In this study, the nasolabial fold is shown to be part of the overall aging deformity that affects the cheek and perioral region. The key to surgical correction, not previously appreciated, is the complete release of the anterior SMAS from the zygoma and zygomaticus major muscle. This allows a dramatic mobilization of the nasolabial fold without tension. The advanced SMAS is then reattached to the zygomatic periosteum by a series of permanent sutures. Each suture, by its location and direction of lift, corrects one of the four nasolabial regions including the jowl. The relevant anatomy is reviewed and the safety of the procedure is assessed in a personal series of 135 patients. It is concluded that the two principles of this technique, i.e., complete SMAS release and reattachment to the zygoma, safely and effectively achieve a natural-appearing rejuvenation of the cheek and nasolabial fold.