Ancillary Procedures to Facelift Surgery: What has Changed?

The facelift remains the gold standard for rejuvenating the aging face. Many surgical techniques exist in the surgeon's armamentarium that vary based on scar burden, extent of skin undermining, and manipulation of the superficial musculoaponeurotic system. Yet, existing strategies predominantly address the mobile face and have limited effect on fixed zones such as perioral, periorbita, and forehead. Multiple ancillary techniques have therefore been developed to address this therapeutic gap in facial rejuvenation. The most popular techniques today include dermabrasion, lasers, chemical peels, and radiofrequency devices. All have demonstrable safety and efficacy and are chosen based on the patient's unique anatomical presentation, comfort level, and tolerability of recovery time. Surgeons are ideally equipped with the tools and skills to offer all modalities and then tailor their treatment to the specific patient's anatomy. Herein, we review the most effective ancillary procedures of the facelift and describe an evolution of their use in our practice.

Taking it on the chin: recognizing and accounting for lower face asymmetry in chin augmentation and genioplasty.

During the course of thousands of preoperative facial analyses, it has become apparent that the chin, in most individuals, appears weaker on the left than on the right. This previously unreported disparity spans age, sex, and ethnicity. To document this finding, frontal and lateral photographs of 20 random patients from the senior author's practice were subjected to a battery of soft-tissue measurements. Analysis of four celebrities further demonstrated the ubiquity of relative left chin weakness. Precedent for asymmetry in human anatomy is abundant (e.g., handedness). Asymmetry, moreover, often is conserved throughout the population (e.g., sidedness of visceral orientation). Left-sided chin weakness appears to be another example of well-preserved anatomical asymmetry. The presence of this asymmetry should be considered in planning chin augmentation and genioplasty.

The percutaneous trampoline platysmaplasty: technique and experience with 105 consecutive patients.

BACKGROUND: Controversy persists regarding the optimal procedure to rejuvenate the aging neck. More invasive procedures carry increased risks of complications, whereas less invasive approaches may deliver marginal results. The challenge is selecting the appropriate procedure for delivering consistent, durable results meeting both the patient's and surgeon's expectations. OBJECTIVES: The authors describe their trampoline platysmaplasty (TPP) approach, a percutaneous suture suspension necklift that constitutes a less invasive approach for neck rejuvenation. METHODS: A retrospective study was conducted of 105 consecutive patients who underwent TPP. Age, sex, procedure(s) performed, complications, and patient satisfaction were recorded. Cadaver studies were conducted to compare the tensile strength of the ligaments that anchor the TPP to the tensile strength of the sutures placed to approximate the medial platysma borders. In addition, the accuracy of light transillumination to determine depth of travel of the light-emitting diode (LED) lighted rod was evaluated. RESULTS: Patients underwent either TPP alone (18 women, 24 men) or TPP with a facelift (35 women, 28 men) between October 2007 and June 2009. The average age of the patients was 52 years, and average length of follow-up was 33 months. Patient satisfaction was high. Three early patients underwent immediate revision to improve results secondary to the suture matrix being too loose. Six additional patients had recurrent banding around one year postoperatively, but correction was achieved in all six by replacing the matrix with the help of the lighted rod. The results of the cadaver study revealed that the tensile strength of the retaining ligaments was statistically identical to the medial platysma borders, and the light transillumination feedback was accurate with regard to the depth of travel of the illuminated rod tip. CONCLUSIONS: The TPP approach for neck rejuvenation is effective and durable in properly-selected patients. It works well as a stand-alone procedure and in conjunction with facelift procedures. It also offers younger patients a less-invasive option to improve neck contours inherited through genetics. After nearly three years of follow-up of the patients in this report, the results appear to be long-lasting.

Face lift.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Identify and describe the anatomy of and changes to the aging face, including changes in bone mass and structure and changes to the skin, tissue, and muscles. 2. Assess each individual's unique anatomy before embarking on face-lift surgery and incorporate various surgical techniques, including fat grafting and other corrective procedures in addition to shifting existing fat to a higher position on the face, into discussions with patients. 3. Identify risk factors and potential complications in prospective patients. 4. Describe the benefits and risks of various techniques. SUMMARY: The ability to surgically rejuvenate the aging face has progressed in parallel with plastic surgeons' understanding of facial anatomy. In turn, a more clear explanation now exists for the visible changes seen in the aging face. This article and its associated video content review the current understanding of facial anatomy as it relates to facial aging. The standard face-lift techniques are explained and their various features, both good and bad, are reviewed. The objective is for surgeons to make a better aesthetic diagnosis before embarking on face-lift surgery, and to have the ability to use the appropriate technique depending on the clinical situation.

The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection.

BACKGROUND: Irrigation and débridement is an attractive low morbidity solution for acute periprosthetic knee infection. However, the failure rate in the literature is high, averaging 68% (range, 61%-82%). Patients who fail subsequently undergo two-stage reimplantation after a prolonged period of illness. This leads to higher surgical risk and further delays in rehabilitation and may contribute to failure of subsequent revision surgery. QUESTIONS/PURPOSES: We determined the rerevision rate due to infection after two-stage reimplantation performed for failed irrigation and débridement of infected TKA. METHODS: We performed a multicenter retrospective review of periprosthetic knee infections treated with a two-stage procedure from 1994 to 2008. Selection criteria for the study included initial treatment with irrigation and débridement and subsequent two-stage revision surgery. Failure of two-stage revision was defined as the need for any additional surgery due to infection. RESULTS: Of the 83 knees that had undergone previous irrigation and débridement, 28 (34%) failed subsequent two-stage revision and required reoperation for persistent infection. CONCLUSIONS: The failure rate in this series of two-stage revisions for periprosthetic knee infection in patients treated with previous irrigation and débridement is considerably higher than previously reported failure rates of two-stage revision. Factors affecting the failure rate may include host quality, thoroughness of débridement, and organism virulence. Patients and surgeons must understand that irrigation and débridement, while initially attractive, may lead to high failure rates of subsequent two-stage reimplantation. LEVEL OF EVIDENCE: Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

Intraoperative issues concerning the patellofemoral mechanism during total knee arthroplasty.

The patellofemoral joint historically has been a significant source of poor clinical outcomes in total knee arthroplasty. Patellar maltracking, peeling of the patellar tendon insertion, and difficult exposure are conditions that must be addressed and corrected during surgery. A surgeon with a repertoire of techniques to handle patellofemoral problems intraoperatively can prevent or correct these problems with confidence.

Perioperative management of antidepressants and herbal medications in elective plastic surgery.

BACKGROUND: Patients seeking elective aesthetic surgery often use herbal medications and/or antidepressants. As the popularity of these medications grows, the plastic surgeon must become familiar with these drugs and their potentially harmful effects during the perioperative period. METHODS: The authors performed a PubMed search to identify commonly used herbs and antidepressants and their effects on patients during elective cosmetic surgery. RESULTS: Case series, studies, and reviews for 29 of the most common herbs and antidepressant medications were obtained from this search. On the basis of the existing data, the authors established recommendations for the management of these medications before elective cosmetic surgery. CONCLUSIONS: Most commonly used herbs and antidepressant medications have potentially deleterious effects on the patient during surgery, ranging from increased risk of bleeding to fatal interactions. The plastic surgeon must be familiar with these drugs to manage these patients appropriately.

Lower lid deformity secondary to autogenous fat transfer: a cautionary tale.

Although autogenous fat grafting is performed with increasing frequency, its safety around the periorbital area remains ill defined. This article presents the case of a young woman whose tear troughs were treated using autogenous fat transfer (AFT), with resultant bilateral lower lid deformities. Secondary correction of this aesthetic deformity caused by AFT to the tear trough proved extremely difficult and resulted in a temporary lower lid ectropion. After resolution of her ectropion, the patient was very satisfied with her postoperative appearance. The authors recommend a judicious approach to the correction of this deformity with AFT until objective outcome studies on this technique become more widely available.

Immortalization of epithelial progenitor cells mediated by resveratrol.

Within the hierarchy of epithelial stem cells, normal progenitor cells may express regulated telomerase during renewal cycles of proliferation and differentiation. Discontinuous telomerase activity may promote increased renewal capacity of progenitor cells, while deregulated/continuous telomerase activity may promote immortalization when differentiation and/or senescent pathways are compromised. In the present work, we show that resveratrol activates, while progesterone inactivates, continuous telomerase activity within 24 h in subpopulations of human Li-Fraumeni syndrome-derived breast epithelial cells. Resveratrol results in immortalization of mixed progenitor cells with mutant p53, but not human epithelial cells with wild type p53. Our results demonstrate the potential for renewing progenitor cells with mutant p53 to immortalize after continuous telomerase expression when exposed to certain environmental compounds. Understanding the effects of telomerase modulators on endogenous telomerase activity in progenitor cells is relevant to the role of immortalization in the initiation and progression of cancer subtypes.

Current methods for brow fixation: are they safe?

BACKGROUND: No single technique for fixation of the scalp after forehead-lift is universally accepted. Complications such as alopecia, loss of elevation, implant palpability, paresthesia, and dural injury are possible with the variety of techniques used currently. This anatomic study was designed to evaluate the thickness of the calvarium at selected points used in brow fixation. The depth of cranial penetration necessary for currently used techniques is measured and compared. METHODS: In a study of 14 fresh adult cadavers, calvarial thickness was measured at selected points (A-F) used in various brow-lifting procedures. This was accomplished by drilling holes in selected points and using a depth gauge to measure thickness. Immediately adjacent to selected points, the cranium is prepared for brow fixation using the following techniques: cortical tunnels, 2.0-mm screw fixation (10, 12, and 14 mm), the Mitek 2.0-mm Quickanchor screw, and the Endotine 3.5 Forehead Device. The depths required for adequate fixation and the potential for cranial penetration through the inner table with all the standard techniques are compared. RESULTS: Depth analysis by mean values showed that sites posterior to the coronal suture (points C-F) were thickest. Depth analysis of sites stratified by gender showed that mean values for the thickness of female skulls were greater than those for males. A review of fixation methods found that cortical tunnels at 45 degrees angles never penetrated the inner table in any of the 14 skulls. Mitek screws never penetrated the inner table, and one Endotine post penetrated the inner table on the left side of one cadaver skull. After placement of 10-, 12-, and 14-mm miniscrews at each of the sites, it was found that three penetrated the inner table. The penetrations all were at far lateral sites, posterior to the coronal suture. CONCLUSION: Variation in skull thickness exists among cadaver specimens at different sites on the skull. In this study, thickness increased medially and posteriorly. Women tended to have thicker skulls than men, and age was not a major variable. This is consistent with findings in previous work. Given the unpublished reports of inner table penetration, with cerebrospinal fluid leak after invasive brow fixation, it behooves the surgeon to keep in mind the anatomy of the calvarium and its nuances.

An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection.

BACKGROUND: Approaches for exposure of the muscles of brow depression include transpalpebral, endoscopically assisted, and open coronal techniques. The purpose of this anatomical study was to compare the capacity for visualization and amount of brow depressor muscle resection with each technique. METHODS: The corrugator supercilii, depressor supercilii, medial orbicularis oculi, and procerus muscles were studied by gross anatomical dissection carried out on 24 sides of 12 cadaver heads. First, all visible corrugator and depressor supercilii muscles were resected by means of an upper blepharoplasty incision. Subsequently, a subgaleal endoscopic approach was used to evaluate the extent of resection performed and remove the remaining muscle after transpalpebral corrugator resection. This was followed by coronal exposure to assess the anatomical location and extent of muscle resection accomplished by the two previously mentioned techniques. RESULTS: In all dissections, endoscopy demonstrated that up to one-third of the lateral aspect of the transverse heads of the corrugator supercilii remained following transpalpebral resection. Oblique corrugator head resections were complete, without significant residual muscle following transpalpebral corrugator resection. The procerus muscle was able to be blindly transected by means of the transpalpebral incision but exposed and ablated in all 12 specimens using endoscopy. Coronal exposure demonstrated that no significant amount of corrugator, depressor supercilii, or procerus muscle remained in any of the 12 heads following endoscopically assisted exposure and resection. The medial head of the orbital portion of the orbicularis oculi was visualized and accessible regardless of the technique used. CONCLUSIONS: In 24 anatomical dissections, transpalpebral corrugator resection failed to remove up to one-third of the transverse head of the corrugator muscle. Removal of the brow depressor muscles was accomplished with the endoscopic approach, as confirmed by coronal exposure.

Designing a virtual reality model for aesthetic surgery.

BACKGROUND: Aesthetic surgery deals in large part with the manipulation of soft-tissue structures that are not amenable to visualization by standard technologies. As a result, accurate three-dimensional depictions of relevant surgical anatomy have yet to be developed. This study presents a method for the creation of detailed virtual reality models of anatomy relevant to aesthetic surgery. METHODS: Two-dimensional histologic sections of a cadaver from the National Library of Medicine's Visible Human Project were imported into Alias's Maya, a computer modeling and animation software package. These two-dimensional data were then "stacked" as a series of vertical planes. Relevant anatomy was outlined in cross-section on each two-dimensional section, and the resulting outlines were used to generate three-dimensional representations of the structures in Maya. RESULTS: A detailed and accurate three-dimensional model of the soft tissues germane to aesthetic surgery was created. This model is optimized for use in surgical animation and can be modified for use in surgical simulators currently being developed. CONCLUSIONS: A model of facial anatomy viewable from any angle in three-dimensional space was developed. The model has applications in medical education and, with future work, could play a role in surgical planning. This study emphasizes the role of three-dimensionalization of the soft tissues of the face in the evolution of aesthetic surgery.

Applications of virtual reality in aesthetic surgery.

BACKGROUND: Virtual reality has a long history in plastic and reconstructive surgery, with uses ranging from anatomical demonstration to craniofacial surgical planning. The purpose of this article is to add to the literature a computer graphics-based resource for aesthetic surgery. METHODS: Deformation tools, virtual cameras, and other components of Alias's Maya 4.0 were used to perform virtual surgical procedures on a detailed model of superficial facial anatomy. This three-dimensional model of superficial facial anatomy, derived from the National Library of Medicine's Visible Human Project, was also "aged" in Maya at key depths of anatomical dissection. Adobe's After Effects 5.5 was used for animation postproduction work for all animations. RESULTS: Three-dimensional computer animations were developed to illustrate techniques in aesthetic surgery. Another animation was created that simulates facial aging at various levels of anatomical dissection. CONCLUSIONS: Computer modeling and animation have the potential to play an important role in education, surgical planning, development, and other aspects of aesthetic surgery.