Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids.

Inactivation of the orbicularis oculi muscle by chemodenervation with botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) as a sole procedure or in conjunction with blepharoplasty has proved to be a reliable method to improve the appearance of the periocular area. Botox has the unique and ideal characteristic in that, with repeated use, there is potential for a prolonged clinical effect with smaller dosages. In addition, if a complication does arise--while not aesthetically acceptable and potentially untoward--it is time-limited, and the anatomical area will eventually return to its pretreatment baseline status. In this study, in three cases [in more than 1000 crow's feet treatment sessions (2000 sides)] over the course of 1 year, partial lip ptosis resulting from weakening of the zygomaticus major muscle after the injection of Botox into the periocular region are reported. This article reviews suggested treatment guidelines and anatomic considerations for the periocular region to maintain injection standardization and improve the safety profile of Botox as the aesthetic indications for its use expand and the number of individuals who inject it increases.

Liposuction of the chest and back.

Subcutaneous fat deposition on the chest and back is notoriously diet and exercise resistant. The "top heavy" appearance is a source of frustration for patients as well as surgeons. Fortunately, with advent of tumescent liposuction surgery the disparity between the upper and lower torso can now be reconciled.

Botulinum A exotoxin for the management of platysma bands.

Injections of botulinum A exotoxin are successfully used to treat neuromuscular disorders and to improve hyperkinetic muscles and dynamic rhytids of the upper face. Using these principles, we extended its use to the treatment of the aging neck (hypertrophic platysma muscle bands). A classification system (I to IV) based on horizontal neck rhytids, platysma bands, and skin laxity was devised to categorize the degree of deformity and serve as a guideline for suggested dosages of botulinum. The results correlated with the degree of age-related neck degeneration. Type II (mild horizontal neck rhytids; thin, mild platysma muscle flaccidity; and mild skin laxity) and III (moderate horizontal neck rhytids; thick, moderate platysma muscle flaccidity; and moderate skin laxity) patients were the most satisfied, followed closely by types I and IV. A total of 1500 patients were treated by three independent practices. The majority of them achieved good-to-excellent results, as evaluated by both the physician and patient. The degree of muscle flaccidity and hypertrophy were the factors that most influenced success rates, not the anatomic variations in muscle configuration.

Complications of botulinum A exotoxin for hyperfunctional lines.

Clostridium botulinum type A exotoxin is one of the recent advances for treatment of the aging face. Due to the sudden and exponential surge in popularity, there is little precise consensus regarding its safety and efficacy. Many of the reported complications associated with its aesthetic use are few and anecdotal. As we gain more experience and long-term follow-up with this procedure, complications and their treatment can be better documented. As most of the salutary effects of Botulinum toxin are temporary, fortunately, so too are the complications associated with this form of therapy.

Cutaneous resurfacing.

Cutaneous resurfacing can be accomplished with application of acids, abrasive modalities, or the new generation of carbon dioxide lasers. Ultimately, the universal goal is removal and replacement of the epidermis and dermal collagen remodeling. The indications range from therapeutic and reconstruction to the treatment of the stigmata associated with senescence. The indications are not technique-specific, and the art of cutaneous resurfacing is identifying the cutaneous defect and selecting the appropriate tool or tools to realize the optimal clinical results.

When does your liposuction patient require an abdominoplasty?

BACKGROUND: Abdominal surgery has evolved from one operation applied to all patients requesting contouring, to a group of procedures based on individual variations in anatomy. Currently, the authors favor four (Types I-IV) different procedures. Liposuction alone (Type I) is performed in the majority of patients. In the remainder (procedures Type II-IV) liposuction combined with modifications of open, traditional abdominoplasty are utilized. These additional methods are appropriate in patients that necessitate rectus muscle reinforcement or skin reduction procedures in order to adequately contour the abdomen. OBJECTIVE: This report describes the indications for abdominal contour surgery, beyond just liposuction. METHODS: A consecutive series of over 300 abdominal contour patients were reviewed and analyzed, with recommendations based on individual variations in their soft tissue anatomy. RESULTS: We demonstrate that the majority of patients benefit from a "closed" procedure (liposuction or ultrasonic assisted liposuction) but that patients with muscle flaccidity or laxity in their skin may require an open procedure. CONCLUSION: Abdominal contour surgery should be considered a group of operations (abdominolipoplasty system of classification and treatment) based on individual varieties in anatomy.

Deep chemical peeling.

Facial skin wrinkling and sagging are concerns that often compel patients to seek counsel on rejuvenative procedures. Facial plasty procedures will alleviate many of these concerns. However, deep chemical peels, in conjunction with surgery or alone, can often significantly improve both the ravages of excess sun exposure and the stigmata of aging.

Endoscopic surgical correction of glabellar creases.

BACKGROUND: A number of alternatives exist for the temporary correction of glabellar creases and frown lines. The traditional "open" operative procedure has often involved a large incision to gain access to the depressor muscles that are responsible for the deformity. While useful for patients with multiple or more significant deformities, patients with isolated glabellar creases and frown lines have been reluctant to consider an extensive surgical procedure, with its attendant morbidity, for an isolated problem. OBJECTIVE: The purpose of this report is to describe a new technique of endoscopic corrugator muscle resection, without the need for the traditional lengthy scalp incision. METHODS: Traditional criteria for patient selection was employed. A series of 10 consecutive patients with vertical mid-forehead glabellar-eyebrow frown lines were treated by endoscopic corrugator muscle resection and evaluated. RESULTS: The procedure was efficacious in reducing the frown-muscle complex prominence and rhytids in the mid-forehead area. Circumstances of heavy folds, hyperactive muscle function, or premature furrows in patients with good skin tone appear to be most suitable for this technique. CONCLUSION: With the introduction of a more acceptable, less problematic surgical solution, deformities in the forehead-eyebrow area can be readily addressed surgically. The procedure is a cost-effective alternative to temporary techniques improving aesthetic problems in the forehead-eyebrow area.

Chemical peels. Trichloroacetic acid and phenol.

Chemical peeling is the most widely used modality for treating photoaged skin. The classification, indications, techniques, complications, and histology of two of the most widely used peeling agents, trichloroacetic acid and phenol, are presented.

Wood's lamp for superficial chemical peels.

BACKGROUND: Superficial chemical peels are being used with increasing frequency in the treatment of photoaging. OBJECTIVE: Our purpose was to develop a marker to indicate when all areas of skin have been treated and avoid reliance on a map or operator recall. METHODS: With a Wood's lamp (maximum output 365 nm) and addition of salicylic acid and fluorescein sodium, solutions that are readily available, the progress of the superficial chemical peel can be visualized. RESULTS: Wood's lamp accentuates epidermal pigment and therefore highlights dyschromia that will respond to a superficial chemical peel. Similarly, salicylic acid and fluorescein sodium fluoresce when viewed under Wood's lamp examination. CONCLUSION: When fluorescent compounds are incorporated into a superficial chemical peel, then fluorescence can accurately locate skip areas, minimize inadvertent overlayering, and thereby avoid deeper penetration.

Introduction to cosmetic surgery.

Patients seeking information on improving their appearance is becoming increasingly popular, and dermatologists are often the first to be consulted. It is therefore important for the dermatologist to acknowledge the patient's concerns and if they are not willing or capable of addressing these needs, one should refer them to an appropriate health care provider. However, if the dermatologist does elect to provide a service, it is crucial not only to obtain the knowledge and technical skill but the mechanism to select and recognize who is an acceptable candidate from both anatomic and psychological perspectives.

Comparison of skin hooks and Foley catheters for immediate tissue expansion.

BACKGROUND: Immediate tissue expansion has been reported to expand skin sufficiently to permit primary closure of large facial defects up to 5 cm in diameter. OBJECTIVE: We wished to evaluate and compare skin hooks with foley catheters in producing tissue expansion. METHODS: Seven patients with post-Mohs surgery defects measuring 3.0 to 5.5 cm in diameter and located on scalp, temple, or forehead skin were treated with immediate tissue expansion. RESULTS: Immediate tissue expansion provided a 16 to 36% increase in the tissue available for closure, over and above what was achieved by undermining alone. In each case, adequate stretching of skin was achieved to permit primary closure relatively easily, which was not possible with undermining alone. Skin hooks were found to be equivalent to foley catheters in their ability to produce tissue expansion. At the one year follow-up visit, some spreading of the scar was noted, ranging from 1 to 7 mm, which appears in part to be related to the degree to which the skin was expanded. CONCLUSION: These findings support the concept that immediate tissue expansion is a separate and distinct process from undermining, which provides additional tissue for reconstructive surgery.

Ichthyosiform sarcoidosis: report of a case.

Sarcoidosis is a systemic granulomatous disease of undetermined cause, with cutaneous manifestations occurring in up to 35 percent of patients. We report a case of the rare form of ichthyosiform sarcoidosis occurring in a young black woman.