Optimizing Brazilian Buttock Lift Results Using the BBL Assessment Tool.

The most distinguished feature of the female silhouette is the buttock. As such, the Brazilian Butt Lift (BBL) has become the most popular plastic surgery procedures in recent years. Despite the popularity of this buttock reshaping and augmentation procedure, there remains no prevailing standard for evaluating, planning surgical design, and objectifying buttock size and shape outcomes. In fact, we have observed a wide range of preferred buttock size and shapes among our patients. We have previously published the BBL assessment tool that serves to guide patient communication of their preferred buttock size and shape. In this study, we demonstrate how the BBL assessment tool can serve to optimize Brazilian Buttock Lift results. We present 25 case studies of how the BBL assessment tool can serve to optimize BBL results by providing a guide for evaluation, surgical design, and objectification of outcomes.Level of Evidence IV Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Breast Lift Algorithm for the Treatment of Breast Implant Illness Requiring Implant Removal.

BACKGROUND: The recommendation of breast lift surgery in the setting of patients requiring breast implant removal is twofold. First, a breast lift is indicated for patients who present with breast mound or nipple-areolar complex ptosis. Second, a breast lift is indicated to accommodate the forecasted redundancy in skin and breast ptosis created by implant explantation. The most popular approaches to mastopexy include the inferior and superior pedicled breast lifts. We present a surgical algorithm with diagrams and cases clarifying mastopexy approaches for patients desiring breast implant removal in patients presenting with breast implant illness syndrome. METHODS: An algorithm was developed to explain the process for selecting the ideal pedicle approach for mastopexy and implant removal surgeries. RESULTS: Three cases are presented to illustrate the application of each pedicle under different presentations and goals. CONCLUSIONS: Advantages of an inferior pedicle include the capacity for unlimited lifting of the nipple-areola complex and for preservation of maximal breast mound volume. Its disadvantages include the inability to remove the breast capsule simultaneously and contraindicated if the lower breast pole is contracted. The advantages of a superior pedicle include the ability to remove the entire capsule and to eliminate lower breast pole if it is contracted. Its disadvantages include limitations to how high the nipple-areola complex can be lifted and the inability to preserve maximal breast mound volume. With the current trend for the request of implant removal in patients presenting with breast implant illness syndrome, the algorithm presented may assist surgeons with selecting the ideal breast lift and implant removal approach. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objectifying High-Definition Brazilian Buttock Lift Results Using the Buttock Assessment Tool.

BACKGROUND: The buttock is an essential feature of the female silhouette. This has led to the rise of the Brazilian butt lift as one of the most popular plastic surgery procedures in recent years. Despite this popularity, there remains no prevailing standard for the ideal buttock size and shape. In fact, a wide range of preferred sizes and shapes among the authors' patients has been observed. The authors hypothesized that age, religious affinity, and ethnic differences may demonstrate different buttock size and shape preferences. METHODS: The authors designed the buttock assessment tool, which utilizes digitally altered buttock sizes and shapes to determine desired buttock shape (upper, middle, and lower pole maximum fullness) and buttock size (waist-to-hip width ratio) for both the posteroanterior and lateral views. A survey of 422 patients was completed, evaluating variation of desired buttock size and shape based on patient age, cultural, and ethnic differences. RESULTS: There were significant differences in buttock size and buttock shape based on age, ethnicity, and religion. Hispanics and African Americans were twice as likely as Caucasians to request lower pole fullness in the posteroanterior view. Older respondents preferred a smaller buttock in both views. African Americans preferred a larger buttock compared to Caucasians in both views. Hispanics preferred a larger buttock in only the lateral view. Muslim respondents preferred a smaller buttock in the posteroanterior view. CONCLUSION: The Brazilian buttock assessment tool has become critical to understanding and delivering prospective Brazilian butt lift patients' goals by objectifying buttock size and shapes.

Masculinized Male Chest Contouring: Creating the Armor Plate.

Male patients are routinely consulted regarding dislike of their chest appearance. To date, majority of patients have desired elimination of their feminine-appearing breast, termed gynecomastia. These patients have associated their overweight body image, with the femininity of their breasts as presented by fullness and roundedness of their breasts and subsequently have desired maximal flattening of their breast. We present a new set of patients who desire a more muscular-appearing chest than a gynecomastia repair that is interposed on a chiseled abdominal contour. In contrast to the former set of patients, these patients desire bulking of their breasts with a bolder-appearing armor plate look. We present an alternative to traditional gynecomastia repair which involves a novel approach to chest contouring creating a flat, yet bold, pentagonal-shaped breast with linear borders utilizing both fat and gland removal as well as strategic fat grafting back into the chest. We present a novel protocol to create an armor plate male chest appearance as an alternative to traditional gynecomastia contouring. All patients treated to date demonstrate a muscular-appearing chest that is harmonious on an interposed masculine-appearing abdomen.

Successful Back Contouring With Elimination of Back Rolls Using Ultrasound-Assisted Liposuction and Helium-Activated Radiofrequency.

BACKGROUND: Patients are routinely consulted regarding dislike of their upper and middle back contour and associated back rolls that stick out of their bras. Although patients only associate this fullness with excess fat, on examination it becomes evident that back rolls are due to a combination of excess fat as well as skin redundancy. To date, treatment of both excess skin and fat in back rolls has required consideration of excisional surgery such as an upper body lift. OBJECTIVES: We present 14 consecutive back contouring cases that were treated with an alternative protocol involving simultaneous ultrasound assisted liposuction and helium activated radiofrequency. METHODS: Patients underwent ultrasound assisted liposuction to remove superficial fat over the upper and middle back as well as helium activated radiofrequency to tighten the skin using subdermal coagulation. RESULTS: All 14 patients visually demonstrated elimination of back rolls and improvement in upper and middle back contour. All 14 patients also reported overall satisfaction in their postoperative follow-ups at 3, 6, and 12-months. CONCLUSION: In summary, simultaneous ultrasound assisted liposuction and helium activated radiofrequency provide an effective treatment for patients desiring improvements in upper and middle back contour and elimination of back rolls while avoiding more invasive excisional surgeries.

Understanding Why Lateral Osteotomy During Rhinoplasty Can Be Performed Safely.

Background: Lateral osteotomy is a mainstay of rhinoplasty surgery and involves fracture of the nasal and maxillary bones to narrow or widen the nasal dorsal bridge and base. To avoid nasal midvault collapse following rhinoplasty, the accepted "high-low-high" lateral osteotomy technique advocates for the preservation of a triangular strut of maxillary bone when initiating the osteotomy. Objective: We evaluated the risk of starting a lateral osteotomy in the "high" position to leave the aforementioned triangular maxillary strut without risk of falling into the nasomaxillary suture line, which can result in an aberrant and uncontrolled fracture. Methods: We utilized high-definition computed tomographic scans to reconstruct layered 3-dimensional images of 20 patient skulls and measured the distance from the rhinion (most inferior point of the central nasal bone junction) to the nasomaxillary suture line and from the rhinion to the maxillary groove. Results: We found that the nasomaxillary suture line was reliably only halfway down the bony nasal pyramid and not in proximity to the maxillary groove. Conclusions: Our findings provide reassurance that a generous triangular strut can be preserved along the maxillary component of the piriform aperture without concern of falling into the nasomaxillary suture line. Thus, controlled lateral osteotomies can be performed safely to achieve aesthetic gains without fear of compromising midvault stability.

Upper Vault Septal Anatomy and Short Nasal Bone Syndrome: Implications for Rhinoplasty.

Introduction: This is a diagnostic study that investigates the clinical significance between patients with short and long nasal bones and the variation in upper septal composition that would delineate propensity for middle vault collapse. Methods: Computed tomographic scans of 16 female patients undergoing evaluation with sinus films were analyzed. Two measurements were taken from each scout image: nasal bone length and total nasal length. Patient scans were separated into 2 groups; patients whose nasal bone length was less than one-half their total nasal length were defined as patients with "short nasal bone" (n = 8), and those with nasal bones longer than one-half the length of their noses were defined as patients with "long nasal bone" (n = 8). Results: Key differences were identified between patients with short and long nasal bones. Total septal area in the upper vault was decreased in the short nasal bone group relative to that of the long nasal bone group (5.7 ± 0.6 cm2 vs 8.1 ± 1.0 cm2, P = .002). This was mainly the result of the decreased ethmoid bone component in the short nasal bone group when compared with the long nasal bone group (1.6 ± 0.6 cm2 vs 3.2 ± 0.8 cm2, P = .007).

The Danger Zone in the Anterior Neck: Anatomical Landmarks to Avoid Injury to Anterior Jugular Vein During Face-Lift and Neck-Lift.

Background: An estimated 125,711 face-lifts and 54,281 neck-lifts were performed in 2015. Regardless of the technique employed, facial and neck flap elevation carries with it anatomical risk of which any surgeon performing these procedures should be aware of. Statistics related to anterior jugular vein injury during these procedures have not been published. Objective: To define a "danger zone" that will contain both of the anterior jugular veins on the basis of anatomical landmarks to aid surgeons with planning their surgical approach during rhytidectomy in the anterior neck region. Methods: Ten fresh tissue heminecks were dissected. All specimens were dissected under loupe magnification in a 45° (face-lift) position in which a midline incision was used for exposure. Measurements from the anterior jugular vein to the hyoid, thyroid cartilage, and cricoid cartilage bilaterally were taken. The transverse distance between the anterior jugular veins at the level of the hyoid, thyroid cartilage, and cricoid cartilage was also measured. Results: The anterior jugular veins remain in an anatomical danger zone while they travel in the anterior neck. Regardless of anatomical variation of the vessels between bodies, they generally reside in this danger zone from their inferior emergence behind the sternocleidomastoid muscle until they branch in the suprahyoid region. Conclusions: Knowledge of the anatomy, course, and location of the anterior jugular veins through the anterior neck based on anatomical landmarks and distance ratios can facilitate a safer dissection during rhytidectomy procedures.

A new technique involving a spherical stainless steel device to optimize positioning of the umbilicus.

BACKGROUND: Creating an aesthetically pleasing umbilicus may be challenging due to various factors that involve the patient limitations and suboptimal techniques available to the surgeon. Although many techniques aim to locate the umbilicus after abdominoplasty, none are ideal. The authors use a new technique involving a stainless steel spherical device for definite location of the new neo-umbilicus site. METHODS: Abdominoplasty with full muscle plication and umbilicoplasty was performed to test the effectiveness of this new technique that involves a stainless steel marble called the Umbilicator. It has a diameter of 1.5 cm and three 2-mm holes drilled 120° apart in an equilateral triangle. The Umbilicator is secured to the inferior and superior dermis of the umbilical stalk to help identify the future location of the umbilicus on the abdominal skin. Once the marble is secured, the superior abdominal flap is redraped and trimmed, the suture is repaired, and the location of the umbilicus is determined by feeling for the smooth spherical surface bump with gentle downward pressure on the overlying abdominal skin located within the proximity of the umbilicus. RESULTS: The result of this technique produced a definitive means of identifying and delivering the umbilical stalk during abdominoplasty. This technique has been performed in 23 consecutive abdominoplasty procedures with no difficulties locating the umbilical stalk and no infections resulting from the procedure. CONCLUSIONS: Accurate identification of the umbilicus provides the ability to create an aesthetically pleasing neo-umbilicus, thus optimizing abdominoplasty results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Cortical thickness parameters for endoscopic browlift fixation.

BACKGROUND: Techniques for endoscopic browlift include bony fixation over the lateral frontal region and soft tissue fixation over the temporal region. Although bony fixation over the lateral frontal region is advocated universally, limited information exists about bicortical thickness in this area. OBJECTIVES: The authors provide bicortical thickness measurements between the frontal midline and the most inferior temporal region to assist surgeons in identifying appropriate fixation planes. METHODS: Bicortical thickness was measured in the hemicraniums of 13 female cadavers, along the coronal planes that travel through the anterior border of the mandibular condyles and at the junction of the posterior mandibular condyles and the external auditory meatuses. Measurements began at the midline and coursed laterally at 1-cm intervals. RESULTS: Average cranial thickness along the frontal region ranged from 8.9 ± 2.4 mm to 6.4 ± 2.8 mm over the anterior coronal line and 8.8 ± 2.2 mm to 5.6 ± 1.8 mm over the posterior line. Average thickness along the temporal region ranged from 5.6 ± 2.8 mm to 2.8 mm ± 1.4 mm over the anterior coronal line and 5.1 ± 1.8 mm to 3.4 ± 1.4 mm over the posterior line. Minimum thickness was 3.7 mm and 1.3 mm over the frontal and temporal regions, respectively. There was no significant difference between left and right hemicranial thickness. CONCLUSIONS: To avoid violation of the inner cortex during surgery, endoscopic browlift procedures should include measurement of cortical thickness at various fixation points. Bony fixation over the temporal region should be avoided. Minimal bicortical thickness was observed in the lateral frontal region.

Bony anatomic landmarks to avoid injury to the marginal mandibular nerve.

BACKGROUND: Marginal mandibular nerve injuries are more likely to be symptomatic than other facial nerve injuries following facelift procedures. The marginal mandibular nerve courses over the facial artery in the region of the mandible. The nerve is most susceptible to injury in this location because it lies superficial to the anterior facial artery. OBJECTIVES: The authors describe the location of the marginal mandibular nerve based on superficial anatomic landmarks as it crosses the facial artery above the mandibular border, in order to help surgeons avoid injury to this nerve during facelift procedures. METHODS: Eighteen cadaveric facial halves were dissected with the aid of loupe magnification. The distance from the facial artery to the palpable masseteric tuberosity at the angle of the mandible was measured. The distance from the masseteric tuberosity to the mental midline was also measured to determine a ratio of the facial nerve from the masseteric tuberosity to the mental midline. RESULTS: The facial artery was found to be an average of 3.05 ± 0.13 cm anterior to the masseteric tuberosity along the mandible. The marginal mandibular nerve crossed the facial artery along the mandibular border approximately 3 cm anterior to the masseteric tuberosity. The distance from the masseteric tuberosity to the mental midline averaged 11.3 ± 0.54 cm. Therefore, the marginal mandibular nerve courses superficial to the facial artery at approximately one-fourth of the distance from the masseteric tuberosity to the mental midline. CONCLUSIONS: Knowledge of the masseteric tuberosity and mental midline landmarks of the facial artery can provide a reliable and safe approach to surgery of the lower face.

Anatomical characteristics of the conchal cartilage with suggested clinical applications in rhinoplasty surgery.

BACKGROUND: Numerous cartilage grafts from a number of donor sites have been described, each with a different shape and size. These donor sites include the nasal septum, costal chondral cartilage, and the conchal bowl. Although harvests from the conchal bowl are commonly-employed, the techniques have been minimally-described in the literature, particularly as it applies to rhinoplasty. OBJECTIVES: The authors identify differences in the conchal bowl cartilage parameters that could aid in the planning and harvesting of conchal grafts during augmentation rhinoplasty. METHODS: The authors dissected ears from fourteen cadavers (eight females and six males), ranging between 59 and 77 years of age. The conchal bowls were isolated, after which a reference point or was marked at the junction of the helical root and the conchal extension of the helical root. A cartilage grid was mapped out at 3-mm interval divisions with a horizontal limb axis parallel to the helical root extension and a vertical limb axis perpendicular to the latter. Conchal cartilage width, height, and thickness were then measured. Axial tissue slices were harvested and histologic preparations completed with hemotoxylin and eosin (H&E) staining to delineate microscopic characteristics of the cartilage. RESULTS: Maximum conchal bowl width ranged from 1.9 to 2.9 cm and was widest on average over the cymba (2.4 ± 0.3 cm). Maximum conchal bowl height ranged from 1.7 to 3.1 cm and was greatest on average over the region posterior to the junction of the helical root and conchal bowl (2.4 ± 0.5 cm). Conchal bowl thickness ranged from 1.9 to 4.4 mm and was observed thickest over both the conchal extension of the helical root (3.5 ± 0.4 mm) as well as over a distinct region in the inferior-anterior aspect of the cavum (3.7 ± 0.9 mm). No difference in thickness was observed between the conchal extension of the helical root (3.5 ± 0.4 mm) and the distinct region in the inferioranterior aspect of the cavum (3.7 ± 0.9 mm; P > .05). Naturally-occurring cartilaginous divisions were appreciated on histologic specimens located at the junction of the cavum and external auditory meatus and at the junction of the helical root and conchal extension of the helical root. CONCLUSIONS: The results, examination, and outline of conchal bowl parameters from cadaver cartilage demonstrated in this article will aid the surgeon in effectively obtaining the appropriate cartilage grafts for placement during rhinoplasty.

Eyebrow peak position redefined.

BACKGROUND: The aesthetically appealing eyebrow shape has been defined by its arch, located near the junction between the medial two-thirds and lateral one-third. The position of this arch has been historically described by arbitrary anatomical landmarks that have no logical structural relationship. Moreover, selection of endoscopic brow lift incision sites that define vector of pull and fixation points have been variably described. OBJECTIVES: The authors examine the position of the deep temporal fusion line to determine whether it can act as a more accurate and functional landmark than prior anatomical landmarks for the eyebrow peak position. METHODS: Eyebrows were measured in 50 subjects from the medial aspect of the eyebrow to the a) deep temporal fusion line (ridge), b) eyebrow peak (arch), c) lateral aspect of the brow, and d) lateral limbus. Pearson's correlation, descriptive statistics, and student's t test results were obtained. RESULTS: Eyebrow measurements demonstrated that the deep temporal fusion line is the most precise indicator of brow peak position among all examined landmarks. The Pearson correlation value was strongest between brow peak and deep temporal fusion line (P = .860) and a t test confirmed this observation with no significant difference between brow peak and deep temporal fusion line. The lateral limbus and medial two-thirds lateral one-third junction more accurately predict brow peak in females, but the deep temporal fusion line is an equally reliable predictor of brow peak for males and females. CONCLUSIONS: These findings suggest that placement of endoscopic brow lift incisions and subsequent fixation points may be best defined along the deep temporal fusion line.

Local cooling provides muscle flaps protection from ischemia-reperfusion injury in the event of venous occlusion during the early reperfusion period.

Clinicians often place patients in heated rooms following muscle flap transfers. We hypothesize that exposure of flaps to heated room temperatures could result in an unnecessary hyperthermic ischemic insult if the flaps were to be compromised by venous outflow obstruction, while exposure of elective flaps to local cooling during early perfusion may provide protection in the event of venous occlusion. The rat rectus femoris muscle flap was elevated and clamped for 1 h. The muscle was then exposed to various temperatures for 1 h of perfusion followed by complete venous occlusion for 3 h. Occlusion clamps were removed and flaps were allowed to reperfuse for 24 h. Flaps were assessed for muscle necrosis and edema. Venous occluded muscles demonstrated decreased muscle necrosis and edema in the locally cooled group (8.5 +/- 6.7%, 3.06 +/- 0.14; P < 0.001) compared to the room temperature group (76.2 +/- 23.0%, 3.73 +/- 0.13), and the local warming group (97.3 +/- 1.4%, 3.84 +/- 0.29) respectively. No difference was noted in muscle necrosis nor edema amongst non-ischemic muscles irrespective of temperature exposure. These results suggest a beneficial role for exposure of elective flaps to local cooling during the early perfusion period in order to provide protection from ischemia reperfusion injury in the event of a venous occlusion insult. The prophylactic exposure of flaps to local cooling is further supported by the lack of a harmful effect when flaps were not compromised by venous occlusion.

Variations in the anatomy of the third common digital nerve and landmarks to avoid injury to the third common digital nerve with carpal tunnel release.

BACKGROUND: The third common digital nerve (TCDN) has been described as the most commonly injured digital nerve during carpal tunnel release (CTR). Anatomic variations of the origin and course of the TCDN from the median nerve may place this structure at risk. Anatomic landmarks may be useful to predict the location of the TCDN to minimize the risk for injury to this structure during CTR. METHODS: Twenty cadaveric hands were used to determine the origin and course of the TCDN. The origin of the TCDN from the median nerve was identified in relation to the transverse carpal ligament (TCL), cardinal line, and superficial palmar arch. The course of the TCDN was inspected in relation to the scaphoid tubercle and ring finger. RESULTS: Three specific anatomic variations for the origin of the TCDN were identified: type 1 originating proximal to the distal edge of the TCL (3 of 20 patients), type 2 originating distal to the TCL but proximal to the superficial palmar arch (14 of 20 patients), and type 3 originating distal to the TCL and at or distal to the superficial palmar arch (3 of 20 patients). The origin of the TCDN was measured as an average of 5.0 +/- 1.2 mm distal to the cardinal line. The TCDN coursed along an oblique vector from the scaphoid tubercle to the midpoint of the palmar digital crease of the ring finger for type 2 or type 3 variations. Near the cardinal line, the oblique course of the TCDN traverses the vector of the longitudinal incision used for CTR. CONCLUSION: The TCDN is one of the most frequently damaged neurological structures during CTR. Iatrogenic injury to this structure can be disabling and even devastating to patients. A detailed knowledge of the carpal tunnel and its underlying structures can prevent inadvertent injury to the TCDN. Anatomic landmarks to predict the origin and the course of the TCDN allow the surgeon to preoperatively predict the possible locations and paths of this important structure. This information can prove to be useful in avoiding injury to the TCDN by clinicians performing CTR in their practice, whether via the open or via endoscopic technique.

Anatomic landmarks for the radial tunnel.

BACKGROUND: The posterior interosseous nerve (PIN) can be difficult to locate within the radial tunnel. The deep branch of the radial nerve (DBRN) enters the supinator muscle after passing under the arcade of Fröhse. It courses through the superficial portion of the supinator muscle to exit distally as the PIN. Anatomic landmarks could facilitate diagnosis and treatment of radial tunnel syndrome and aid in the injection and decompression of the radial nerve. METHODS: Eighteen cadaveric arms were used to identify anatomic landmarks to facilitate location of the PIN. The landmarks used include the palpable proximal radial edge of the radial head, proximally, and the mid-width of the wrist, distally. The skin was incised along this longitudinal line through the fascia. Deep within this plane the PIN was identified exiting the distal edge of the superficial portion of the supinator muscle. The proximal and distal edges of the supinator muscle were measured from the proximal radial aspect of the radial head. In addition, the course of the DBRN was appreciated proximal and distal to the superficial part of the supinator muscle. RESULTS: The PIN was identified to exit the superficial part of the supinator muscle at an average distance of 7.4 +/- 0.4 cm distal to the proximal radial aspect of the radial head. Distal to the distal edge of the supinator muscle, the PIN passed along a longitudinal vector from the radial head to the mid-width point of the wrist. From within the supinator muscle the DBRN courses retrograde in an oblique direction toward the lateral edge of the distal most part of the biceps tendon. CONCLUSION: The anatomic landmarks of the radial head and the mid-width of the dorsal wrist can be used to predict the course and location of the PIN. The DBRN can be predicted to enter the superficial part of the supinator muscle approximately 3.5 cm distal to the radial head, and the PIN is predicted to exit the supinator at 7.5 cm distal to the radial head.

Follicular anatomy of the anterior temporal hairline and implications for rhytidectomy.

BACKGROUND: Incisions made perpendicular to the hair follicles during anterior frontal hairline brow lifts or forehead shortening procedures help produce an inconspicuous forehead scar. The success of this "hidden" incision relies on the anteriorly directed frontal hairline follicles and their growth vector. The authors hypothesized that a similar incision could be made perpendicular to the hair follicles in the temple region during rhytidectomy. A well-designed anterior hairline beveled incision over the temple would allow for improved leverage during soft-tissue repositioning and a concealed hairline incision in the temple region. METHODS: Anterior temporal hairline strips 4 cm in length at the level of the lateral canthus were excised from 16 fresh cadavers. Hairline follicles (n = 227) were assessed for direction and angle of growth after appropriate tissue preparation and staining (hematoxylin and eosin). The hair follicle angle was analyzed microscopically as it approached the epidermis. RESULTS: The anterior temporal hairline follicles were oriented at a mean angle with the epidermis of 16 +/- 3 degrees anteriorly and inferiorly. CONCLUSIONS: The anterior temporal hairline follicles of the scalp are oriented anteriorly and inferiorly with the epidermis, providing the surgical rational for using a beveled hairline incision angled 30 to 45 degrees to the external skin surface to undercut the distal flap. This incision is perpendicular to and transects the temporal hair follicles during rhytidectomy, permitting hair growth through and anterior to the scar. This modified anterior temporal hairline incision reduces visibility of the scar at the hairline for patients in whom scar show and hairstyle versatility are important concerns.

Septal cartilage defined: implications for nasal dynamics and rhinoplasty.

BACKGROUND: Although the septal cartilage is integral to structural nasal stability, it is routinely violated during septorhinoplasty. This occurs during dorsal hump reduction, caudal septal reduction, submucoperichondrial resection of a deviated septum, or harvesting of cartilage graft material. Despite such routine alteration and/or use, the characteristics of septal cartilage have not been adequately defined. METHODS: By measuring septal length, height, and cartilage thickness mapped out at 5-mm intervals over the entire nasal septum in 11 fresh cadaver specimens, the characteristics of septal cartilage were determined. RESULTS: Septal thickness measurements demonstrated significant differences along the nasal septum, with the greatest thickness along the septal base (2.7 +/- 0.1 mm), followed by intermediate thickness along the septal dorsum (2.0 +/- 0.2 mm) and the least thickness along the central portion (1.3 +/- 0.2 mm) and at the anterior septal angle (1.2 +/- 0.1 mm) (p < 0.001). CONCLUSIONS: These observations clarify several nuances regarding septal structural stability, septal deformities, and the effects of septal alteration during rhinoplasty. The findings of this study reinforce several principles, including recognition of factors contributing to the high propensity of acquired central septal perforations; preservation of a generous L-strut width, especially at the anterior septal angle, or if planning dorsal hump reduction, prudent allocation of harvested septal cartilage; and clarifying the proclivity for supratip deformity following rhinoplasty.

Increased cutaneous nerve fibers in female specimens.

BACKGROUND: The control of pain is critical to performing surgery. All surgical procedures cause some degree of pain, and the ability to minimize pain often affects a patient's perception of surgical outcome. Although the development of surgery was boosted by the advent of anesthesia, inadequate pain control continues to plague modern medicine. The mechanism of pain induction is an important area of research in the health care industry. To date, few studies have demonstrated increased perception of pain and lower tolerance for pain in female patients when compared with male patients. The authors hypothesized about whether these differences were related to increased density of nerve fibers in female as compared with male patients. METHODS: The density of nerve fibers at a specific location (the skin directly overlying the infraorbital nerve foramen) was measured to test this hypothesis. Twenty cadaver skin specimens (1 cm2) were harvested, prepared using immunohistochemistry (S-100 polyclonal antibody), and counted using 45x high-powered microscopy. RESULTS: Female specimens (n = 10) demonstrated increased nerve fiber density (34 +/- 19 fibers/cm skin) when compared with male specimens (n = 10; 17 +/- 8 fibers/cm skin; p = 0.038). CONCLUSION: Although preliminary and limited in scope, these findings favor a physical (organic) rather than a psychosocial explanation for more pronounced pain perception in female patients.

The "pixie" ear deformity following face lift surgery revisited.

BACKGROUND: The "pixie" ear deformity can be recognized by its "stuck on" or "pulled" appearance, which is caused by the extrinsic pull of the medial cheek and jawline skin flaps at the earlobe attachment point, the otobasion inferius. The tension results in migration of the otobasion inferius from a posterior cephalad position to an anterior caudal position. Although this deformity has been described clinically, it has yet to be objectively defined. METHODS: Recently, the two components of the earlobe, the attached cephalic segment (intertragal to otobasion inferius distance) and the free caudal segment (otobasion inferius to subaurale distance), were shown to be essential in evaluating for earlobe ptosis and pseudoptosis. These two components can be used to designate an objective criterion for the pixie ear deformity. The deformity, as defined by the authors' parameters, was assessed in 44 patients who had undergone rhytidectomy. A simple and accurate surgical treatment is demonstrated by a cadaver dissection and a clinical case. RESULTS: The deformity can be defined as an increase in the attached cephalic segment (intertragal to otobasion inferius distance) and a decrease in the free caudal segment (otobasion inferius to subaurale distance) to 0 mm following rhytidectomy. The incidence of pixie ear deformity was 5.7 percent in the authors' series of patients. CONCLUSIONS: A medially based triangular excision over the attached cephalic segment is presented as a simple and accurate surgical treatment of pixie ear deformity. A more accurate and objective designation may allow for improved detection, avoidance, and treatment of this deformity.