Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

BACKGROUND: Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS. OBJECTIVES: The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS. METHODS: The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold. RESULTS: The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P < 0.0001). Stress relaxation was similar in all vertical regions with measurements of 54% in the lateral, 48% in the mid-cheek, and 59% in the medial SMAS. Creep was found to be similar in the lateral and mid-cheek SMAS with values of 18% and 19%, respectively. The medial SMAS was noted to have a higher creep at 22%. CONCLUSIONS: The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

How Should Results of Nonsurgical Subcutaneous Fat Removal Be Assessed? Accuracy of B-Mode Ultrasound.

BACKGROUND: Nonsurgical fat reduction has become extremely popular among patients; however, a reliable method of measuring its efficacy has not been established. METHODS: Ultrasound measurement of human female abdominal subcutaneous fat thickness was carried out on five volunteers. Forty-seven measurements were performed using a GE Venue 40 diagnostic ultrasound device with a 12-MHz transducer. Transducer pressure measurements were recorded simultaneously according to the protocol described by Toomey et al.. RESULTS: Reproducible measurements of abdomen subcutaneous fat could be consistently achieved with a margin of error (95 percent CI) of ±0.558 mm. CONCLUSIONS: Using a protocol with a transducer pressure less than 1 N (Toomey protocol) allows accurate and reliable measurement of subcutaneous fat. The authors further conclude that such a protocol is practically reproducible in the clinical setting and should be the standard for evaluating the results of nonsurgical fat removal, particularly in the abdomen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Face Lift.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the essential anatomy of the aging face and its relationship to face-lift surgery. 2. Understand the common operative approaches to the aging face and a historical perspective. 3. Understand and describe the common complications following face lifting and treatment options. SUMMARY: Surgical rejuvenation of the aging face remains one of the most commonly performed plastic surgery procedures. This article reviews the anatomy of the face and its impact on surgical correction. In addition, this review discusses the evolution of various face-lift techniques and the current surgical approach to the aging face. Finally, this article discusses potential postoperative complications after rhytidectomy and management solutions.

Comparison of Limited-Undermining Lipoabdominoplasty and Traditional Abdominoplasty Using Laser Fluorescence Imaging.

BACKGROUND: Body contouring that involves abdominoplasty and/or liposuction is a common cosmetic surgery procedure. Although single-staged lipoabdominoplasty has gained popularity, safety concerns remain. OBJECTIVES: The authors compared abdominal flap perfusion and overall complication rates for traditional abdominoplasty and limited-undermining lipoabdominoplasty. METHODS: Eighteen abdominoplasty patients were evaluated in a prospective study. All patients were nonsmokers and lacked major comorbidities. The control group (n = 9) underwent traditional abdominoplasty with wide undermining. The study group (n = 9) underwent abdominoplasty with limited undermining as well as liposuction of the abdominal flap. The groups were similar with respect to age and body mass index. Patients received follow-up for an average of 97 days. Fluorescence imaging was utilized for perfusion studies. Results and complications were documented, and statistical significance was ascertained via the Student t test. RESULTS: Neither group had major complications or revisions. Minor complications included an exposed suture, resulting in delayed wound healing, in the control group. A patient in the study group had a small area of fat necrosis and a small seroma, neither of which required further treatment. No significant difference in abdominal flap perfusion was found between the control (57%) and study (50%) groups based on fluorescence levels relative to a designated baseline reference marker. CONCLUSIONS: Results of the study indicate that no significant differences exist between the 2 operations with respect to the rates of abdominal flap perfusion or complications. LEVEL OF EVIDENCE: 3.

Facelift and patterns of lymphatic drainage.

BACKGROUND: It has commonly been assumed that deeper facelift dissection causes greater and more prolonged swelling. OBJECTIVES: In this preliminary report, the authors compare the lymphatic reconstitution after multiple techniques of rhytidectomy by means of dynamic lymphoscintigraphy. METHODS: Three patients were enrolled in this study. All three were female, were similar in age, and exhibited similar signs and degrees of facial aging. Each woman underwent a facelift with a different technique: (1) subcutaneous dissection with superficial musculoaponeurotic system (SMAS) plication, (2) subcutaneous dissection with SMASectomy, and (3) a "high SMAS" composite facelift. Postoperatively, (99m)Tc-sulfur colloid was injected into a standardized infraorbital location in each patient to compare patterns of lymphatic drainage using lymphoscintigraphy. Postoperative scans at two weeks, six weeks, three months, six months, and one year were compared to the preoperative scans taken seven days prior to surgery. RESULTS: All rhytidectomy techniques appeared to temporarily create a significant and similar degree of interruption in lymphatic drainage. There was a subtotal recovery of lymphatic pathways within three months and complete return to baseline drainage pattern after six months, regardless of surgical technique. CONCLUSIONS: Based on the results of this study, it appears that the extent of facial dissection, rather than the depth, is the most significant factor in postoperative edema.

The viscoelastic properties of the SMAS and its clinical translation: firm support for the high-SMAS rhytidectomy.

BACKGROUND: The superficial musculoaponeurotic system (SMAS) has inherent viscoelastic properties, although the optimal tension levels to minimize tissue relaxation have not been defined. This study evaluated the viscoelastic properties of the SMAS within the biomechanical parameters of the high-SMAS rhytidectomy. METHODS: Patients (n = 30) underwent a high-SMAS face lift performed by the senior author (F.E.B.) with intraoperative tension at the superior (preauricular) and inferior (mastoid) points of SMAS fixation sequentially measured with a tensiometer. Fresh samples of lateral, preparotid SMAS were then harvested and evaluated ex vivo for bursting strength, stress relaxation, and creep. RESULTS: The force applied to the superior, preauricular SMAS intraoperatively (7.21 ± 0.87 N) was significantly lower than that of the inferior mastoid point of fixation (9.59 ± 1.8 N) (p < 0.001). The bursting force of the SMAS was 55.7 N, with the average bursting pressure of 224.97 PSI. The in vivo force applied to the SMAS was found to be only 15 percent of its total bursting strength. The deformational load of the high-SMAS face lift caused only a 14 percent creep in the tissue ex vivo. CONCLUSIONS: The in vivo tension in a high-SMAS face lift is predictable, with the force applied to the mastoid point being significantly greater than that of the superior preauricular point. This intraoperative force is only a fraction of the tissue's inherent bursting strength, contributing to the minimal stress relaxation and creep observed in this study. These biomechanical properties likely contribute to the effective and long-lasting correction of facial aging with the high-SMAS technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

TUNEL assay to characterize acute histopathological injury following treatment with the active and deep FX fractional short-pulse CO2 devices.

BACKGROUND: This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. METHODS: The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. RESULTS: The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. CONCLUSIONS: The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.

The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique.

BACKGROUND: The frontal branch has a defined course along the Pitanguy line from tragus to lateral brow, although its depth along this line is controversial. The high-superficial musculoaponeurotic system (SMAS) face-lift technique divides the SMAS above the arch, which conflicts with previous descriptions of the frontal nerve depth. This anatomical study defines the depth and fascial boundaries of the frontal branch of the facial nerve over the zygomatic arch. METHODS: Eight fresh cadaver heads were included in the study, with bilateral facial nerves studied (n = 16). The proximal frontal branches were isolated and then sectioned in full-thickness tissue blocks over a 5-cm distance over the zygomatic arch. The tissue blocks were evaluated histologically for the depth and fascial planes surrounding the frontal nerve. A dissection video accompanies this article. RESULTS: The frontal branch of the facial nerve was identified in each tissue section and its fascial boundaries were easily identified using epidermis and periosteum as reference points. The frontal branch coursed under a separate fascial plane, the parotid-temporal fascia, which was deep to the SMAS as it coursed to the zygomatic arch and remained within this deep fascia over the arch. The frontal branch was intact and protected by the parotid-temporal fascia after a high-SMAS face lift. CONCLUSIONS: The frontal branch of the facial nerve is protected by a deep layer of fascia, termed the parotid-temporal fascia, which is separate from the SMAS as it travels over the zygomatic arch. Division of the SMAS above the arch in a high-SMAS face lift is safe using the technique described in this study.

Aesthetic surgery of the face and neck.

LEARNING OBJECTIVES: The reader is presumed to have a basic understanding of facial anatomy and facial rejuvenation procedures. After reading this article, the reader should also be able to: 1. Identify the essential anatomy of the face as it relates to facelift surgery. 2. Describe the common types of facelift procedures, including their strengths and weaknesses. 3. Apply appropriate preoperative and postoperative management for facelift patients. 4. Describe common adjunctive procedures. Physicians may earn 1.0 AMA PRA Category 1 Credit by successfully completing the examination based on material covered in this article. This activity should take one hour to complete. The examination begins on page 464. As a measure of the success of the education we hope you will receive from this article, we encourage you to log on to the Aesthetic Society website and take the preexamination before reading this article. Once you have completed the article, you may then take the examination again for CME credit. The Aesthetic Society will be able to compare your answers and use these data for future reference as we attempt to continually improve the CME articles we offer. ASAPS members can complete this CME examination online by logging on to the ASAPS members-only website (http://www.surgery.org/members) and clicking on "Clinical Education" in the menu bar. Modern aesthetic surgery of the face began in the first part of the 20th century in the United States and Europe. Initial limited excisions gradually progressed to skin undermining and eventually to a variety of methods for contouring the subcutaneous facial tissue. This particular review focuses on the cheek and neck. While the lid-cheek junction, eyelids, and brow must also be considered to obtain a harmonious appearance, those elements are outside the scope of this article. Overall patient management, including patient selection, preoperative preparation, postoperative care, and potential complications are discussed.

Fat extrusion and septal reset in patients with the tear trough triad: a critical appraisal.

Arcus marginalis release, fat extrusion, and septal reset were applied to 71 selected patients with a constellation of orbital deformities the authors term a "tear trough triad." Of the initial 71 patients, 59 had complete follow-up records. Evaluated by means of a proportional topographic scale, 95 percent of patients achieved significant improvement. Equally important, no incidence of middle lamella contracture occurred in the entire series. The authors conclude that the procedure is safe and effective in selected patients.

The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update.

The medical charts of 267 patients who had primary high-superficial musculoaponeurotic system (SMAS) rhytidectomies were reviewed. The depth of the nasolabial fold was used as an indicator of the degree of descent of the subcutaneous cheek mass, as a guide in procedure selection, and as a method of judging the operative results. Fold depth was assigned a score of 0 to 3, with 3 being most severe. According to their preoperative fold depth, patients were operated on using one of three variants of the high-SMAS technique: sub-SMAS dissection up to the nasolabial fold, sub-SMAS dissection up to the nasolabial fold plus transnasal SMAS graft, or sub-SMAS dissection across the nasolabial fold. An independent trained observer rated the postoperative fold depth in each case from photographs taken at the 6-month follow-up visit. Of patients with fold scores of 2 or 3, 97 percent (183 of 189 patients) showed visible improvement in nasolabial crease depth after the operation.

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

The "high SMAS" face lift technique.

The "high SMAS" face lift technique suspends the cheek mass securely, leaving the skin and subcutaneous mass attached to the SMAS without placing the skin under greater than normal tension. The author provides the surgical steps. (Aesthetic Surg J 2002;22:481-486.).