Dermal Shift Umbilical Reconstruction: An Innovative and Simple Technique.

SUMMARY: Umbilical reconstruction is a procedure with widespread indications in the setting of congenital or postsurgical loss. Reconstruction of the umbilicus when no remnant of the natural umbilicus is present is also called neoumbilicoplasty. Numerous neoumbilicoplasty techniques have been published, including cartilage grafts, full-thickness skin grafts, and multiflap reconstruction. No consensus has been reached regarding an optimal technique, and many procedures involve complicated designs with small flaps that are difficult to reproduce or explain. The authors divide patients into three types depending on the thickness of the adipose layer of the abdomen. With appropriate patient selection and minor variations depending on patient type, the technique can be applied to all patients. The umbilicus is marked in the appropriate position. Local anesthesia is infiltrated, and the area beneath the skin is defatted. The dermis is then applied to the underlying fascia with a superior shift. The authors describe the technique and its variations and present one illustrative case with additional supplemental digital content. The authors have gone through a progression of techniques to find a simple surgical method yielding consistently reproducible results with minimal complexity, limited morbidity, and an aesthetic final outcome. The authors believe that the technique described here achieves those goals. It can be performed under local anesthetic and with a simple occlusive dressing so that the patient can go on with most of his or her daily activities. There is no scar to suggest a surgical procedure, and patients are extremely happy with the aesthetic outcomes.

Hyoid Suspension Neck Lift.

BACKGROUND: The shape of the deep cervical structures is the shape of an aesthetic neck. With age, changes can obstruct visualization of that shape. Achieving a youthful contour requires removal of excess skin and fat but also control of the platysma to allow skin to redrape like a blanket over an underlying framework. The authors' technique makes the platysma part of the deep cervical structures whose shape underlies an attractive neck and allows the skin to redrape to that contour. METHODS: To make the platysma conform closely to the deep cervical structures and allow the skin to show that new form, the authors developed a procedure that includes removal of excess fat, attaching the platysma to the hyoid fascia, approximating the edges of the platysma above and below that suture, and wide undermining of skin to allow it to re-drape naturally over those deeper structures. RESULTS: Over 7 years, 110 patients underwent aesthetic facial surgery that included hyoid suspension of the platysma. One patient had recurrence of platysmal bands after failure of the key suture. Complications included hematoma in three patients and submental seromas in three patients, but no permanent nerve injury, no skin loss from vascular compromise, no reported changes in vocal resonance, and no complaints of difficulty swallowing. CONCLUSIONS: This method allows the skin to redrape over a youthful framework and produces reliable aesthetic and long lasting results. It is a simple, reproducible, teachable technique that enables surgeons to achieve results previously difficult to obtain in a single operation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Transverse rectus sheath plication in abdominoplasty.

The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. This reduces the contribution of the rectus sheath to the anterior abdominal wall from more than 50 percent to 25 percent or less and creates an unnaturally flat appearance. No amount of exercise can restore the native form of the rectus sheath. For the past 3 years, the authors have performed a transverse plication of the rectus sheath, to address vertical laxity, complemented by a bilateral crescent-shaped plication of the external oblique fascia, to address waistline contour. Six consecutive patients who underwent the transverse rectus plication technique were compared with a similar group of patients who underwent vertical rectus plication. Comparison was made via preoperative and postoperative photographic analysis by two impartial judges. Although the overall result was excellent in both groups, the global score was significantly higher in the transverse plication group (4.5 versus 3.9, p = 0.044). Scores for anterior abdominal contour (4.7 versus 4.2, p = 0.029) and definition of the linea semilunaris (4.6 versus 3.7, p = 0.008) were also significantly higher for the transverse plication group. The difference for waistline contour (4.5 versus 3.8, p = 0.067), definition of the linea alba (4.4 versus 3.9, p = 0.067), and hip-waist transition (4.4 versus 3.7, p = 0.067) did not reach statistical significance. The outline of the rectus sheath is a significant portion of what is perceived as an aesthetic abdomen. Transverse plication of the rectus sheath with bilateral crescent-shaped plications of the external oblique fascia retains this native form. The result is improved anterior abdominal contour and definition of the rectus sheath with a comparable or better improvement in waistline contour and transition from the hips to the waist when compared with wide, vertical rectus plication.

Irrigation pressure and vessel injury during microsurgery: a qualitative study.

Irrigation solution is routinely used in microsurgery. While the anticoagulation solution may aid in anastomotic patency, the direct effect of pressure irrigation can have a detrimental effect on the vessel. An experimental study was performed to determine the effect of irrigation pressure on the vessel wall. Histological evaluation with hematoxylin and eosin (H&E) stain and scanning electron microscopy (SEM) was performed on the arteries of New Zealand white rabbits irrigated with lactated Ringer's solution at pressures of 80 mmHg, 100 mmHg, and 500 mmHg. H&E staining and SEM microscopy demonstrated injury to the endothelial cells and internal elastic lamina at pressures of 100 mmHg or greater. Controlling microsurgical irrigation pressure to less than 100 mmHg may help to avoid vessel injury.

The midface sling: a new technique to rejuvenate the midface.

In the early 1990s, the midface became the focus of facial rejuvenation, and various techniques effected elevation by plicating, or on, the midface. Recent analyses of facial aging demonstrate that selective ptosis of the midfacial tissues lateral to the nasolabial fold results in an infraorbital hollow and deepening of the nasolabial fold. Therefore, the authors propose that the midface, from the lower portion of the cheek mass, will result in superior midface positioning. Since 1996, the authors have elevated the midface in select patients by placing a sling of prosthetic (Gore-Tex) or autogenous (tendon or fascia) material through the cheek mass. The sling is secured medially to the infraorbital rim using a nonabsorbable periosteal suture or a mechanical anchor. As variable tension is applied laterally toward the superficial temporal fascia, the sling functions as a fulcrum to return the cheek mass to a more youthful anatomical position. Elevating the cheek mass in this fashion fills the infraorbital hollow and results in amelioration of deep nasolabial folds and jowling. With a mean follow-up of 18 months, 50 patients treated with the midface sling report satisfaction with the procedure. There have been no instances of nerve damage, infection, or hematoma in the midface. None of the slings have required removal and ectropion has not occurred. Because of postoperative asymmetry in one patient, additional elevation of the ipsilateral cheek mass was performed by increasing the tension on the lateral cheek portion of the midface sling. Mathematical models demonstrate the biomechanical superiority of lift through the use of multiple vectors as compared with linear pull techniques. In this fashion, the midface sling supports the cheek mass, providing rapid, simple, and secure elevation. Because of the limited subcutaneous dissection, there is a reduced risk of facial nerve damage and cutaneous vascular compromise. Unlike with other techniques, the lateral portion of the sling may be easily identified through a small incision in the temporal scalp, facilitating subsequent postoperative adjustment of the midface suspension. Furthermore, because the entire cheek mass is permanently supported with an inelastic sling, the results may last longer than those with techniques that rely on sutures to plicate or lift portions of the superficial musculoaponeurotic system.