The forehead lift: techniques to avoid complications and produce optimal results

This discussion of forehead lifting, based on modifications of Vinas, Caviglia, and Cortinas, shares the authors' methods of patient evaluation, diagnostic details, architectural planning, and surgical concepts for forehead rhytidectomy along with correction of malpositioned and ptosis of the eyebrows and also glabellar frown problems. In addition, the nasal deformities associated with the sagging of the skin and subcutaneous tissue onto the upper fourth of the nose may make the nose look too short for a pleasing balance of the face and the upper fourth may appear disagreeably wide. A contribution to this excessive width is made by a sometimes thick and wide procerus muscle along with bilateral thick depressor supercilii muscles. When this nasal deformity is corrected, glabellar frown problems are also corrected. Attention to the details of the above-mentioned factors results in very long-lasting, sometimes permanent, and almost complication-free results that please the surgeon and the patient. Complications such as adherence of the dermis to the underlying pericranium, lack of motion in a portion of or the entire forehead, hyperactivity around areas of immobility, muscle irregularities, and also surgically produced depressions which require grafting, skin sloughing, permanent nerve injury, persistent sensory nerve loss, and short-term improvement have been avoided by paying attention to diagnosis, surgical planning, and technique, and postoperative care. Most patients can return to work in four or five days with minimal discoloration and swelling if they have not had aspirin or vitamin E one month before surgery, and there is hemostasis and the use of drains when indicated. Minimizing detection of the surgical incisions is accomplished by detailed preoperative planning of their location, architectural design development and drawing at the time of surgery, special surgical techniques, and excision of the skin or scalp. For patients with male pattern baldness use of specially designed V-Y advancement flaps with the browlift procedure improve the appearance of the hair's thickness and distribution.

Lower lid "tarsal fixation" blepharoplasty: a personal technique

The majority of patients seeking lower-lid blepharoplasty find that a muscle roll under their lower-lid ciliary margin is a desired postoperative feature. Very few prefer a flat postoperative lower lid. In addition to the cosmetic advantage obtained by more closely simulating a youthful lower eyelid, preservation of the pretarsal portion of the orbicularis oculi muscle also has a physiologic value in maintaining lower eyelid tone and support. A method to create this fold, which included placement of tarsal fixation sutures, has been previously described. It was accompanied by prolonged postoperative swelling. In hands other than masterful surgeons, it often resulted in irregular shape and asymmetry. Perhaps this is why the technique never became very popular. The technique described here consists of overlapping two layers of orbicularis oculi muscle over the lower lid tarsal plate. The method is simple, quick, requires no additional sutures, and does not complicate or prolong the postoperative course. The result is that of a soft, even, and natural appearing lower eyelid roll and lower eyelid.

Reactions to a bovine collagen implant. Clinical and immunologic study in 705 patients

A small percentage of patients treated with bovine collagen implants have adverse reactions involving both the cellular and humoral types of immune response. We report a clinical follow-up of 705 subjects treated with a new bovine collagen implant, Atelocollagen (Koken Co. Ltd., Tokyo, Japan). Sensitization to the implant was evaluated in all subjects by skin testing, and humoral response was monitored in 166 subjects by measuring the level of circulating antibodies directed against bovine collagen. Twenty-seven patients (3.8%) exhibited a positive response to a skin test, and of the remaining 656 patients, an adverse reaction to the implant developed in 2.3%. We found a strong correlation between the presence of antibodies to collagen and a positive response to skin testing (92%) or an adverse reaction (100%). In the case of a borderline clinical response to bovine collagen implantation, anticollagen serologic tests appeared to be a useful tool for the identification of clinically reactive patients.

Nondestructive investigations on ninety-seven surgically excised mammary prostheses

The information contained in the medical files of 68 patients having undergone surgical excision of a total of 97 internal mammary prostheses allowed us to define a typical patient profile at time of first implantation. Age: 33 years 11 months, height: 1.59 m, weight: 51.5 kg, two children. Twenty-one percent of these patients had the operation done subsequent to a mastectomy, while 79% requested it for cosmetic reasons. The duration of implantation was less than 55 months for 76% of the prostheses received after excision. The most frequent evolutive complications were the formation of a fibrous capsule followed by silicone bleeding, as well as mineralization. Macroscopic examination of the 97 explanted prostheses provided information on their integrity (38.1% of prostheses ruptured), gel differentiation (24.7%), sticky surfaces (26.8%), surface deposits (33%), memory folds (54.6%), and Dacron fixation patches (20.6%). According to the medical files, a fibrous capsule was found in association with 69.8% of the breast implants. We received only 46 capsules. The average thickness was 1.4 mm. Mineralizations were present on 15 capsules (32.6%). Two zinc phosphates were identified, for the first time, in human body: parascholzite and hopeïte. Statistical examination showed that Heyer-Schulte prostheses stayed in place for a longer time. Integrity and gel differentiation depended on the duration of the implantation. Presence of mineralization was model-related (Dow Corning prostheses were associated with deposits) and depended on the presence of fixation patches.

Combination of facial rejuvenation and lipoplasty of the torso

Older women seeking facial rejuvenation often exhibit another sign of middle age--the accumulation of subcutaneous fat in the torso. In the author's practice a total body evaluation approach is used. It is often suggested that the patient combine facial rejuvenation with lipoplasty of the torso if the patient is a good surgical candidate and the procedures can be performed jointly in less than six hours. The advantages are many, including a single convalescent period, decreased costs, and very high patient satisfaction with the degree of makeover in one session.

Dermal implants: safety of products injected for soft tissue augmentation

Soft tissue augmentation is a frequently performed outpatient operation. Products available for soft tissue augmentation vary in chemistry, clinical indications, and toxicity. This review examines safety and efficacy data for collagen implants (Zyderm and Zyplast), gelatin matrix implants (Fibrel), and injectable silicone. Soft tissue augmentation requires excellent technique to achieve excellent clinical efficacy. When used appropriately, the available products for soft tissue augmentation have few complications or adverse reactions.

Collagen/hydroxylapatite implant for augmenting deficient alveolar ridges: a 24-month clinical and histologic summary

A new alveolar ridge augmentation material composed of purified fibrillar collagen (PFC) and particulate hydroxylapatite (HA) (Alveoform Biograft, Collagen Corp., Palo Alto, Calif.) was evaluated in the treatment of 77 edentulous patients in a multicenter study. All patients had mandibular augmentation; 22 also had maxillary implant augmentation. Mean ridge height was 15.4 mm before surgery. Twenty-four-month data showed a mean ridge augmentation of 4.1 mm. Prosthodontists rated the ridge firmness "good" to "excellent" in 96.6% of patients after 2 years. All adverse effects with the exception of some residual paresthesia/dysesthesia resolved spontaneously within 24 months. Bone-graft interface samples were examined histologically in five patients 1 year after mandibular ridge augmentation. No evidence of PFC was found, and the HA particles were surrounded by dense, fibrous, host-connective tissue or trabeculae of woven and lamellar bone. Assessment of PFC/HA-augmented ridges at 24 months showed clinically and histologically significant results.

Stability-time profile of trichloroacetic acid at various concentrations and storage conditions

Trichloroacetic acid (TCA) is a deliquescent chemical widely used for a variety of procedures. Stability of various concentrations of TCA in both amber glass and plastic bottles stored under refrigeration and at room temperature was measured at several time points. Extended stability data suggest that TCA potency is stable for 23 weeks and would best be maintained in glass amber bottles stored under refrigeration.

Lifting of the eyebrows in blepharoplasties

Excessive skin in the upper eyelid may be totally or partially a result of ptosis of the eyebrows. In this case, blepharoplasty corrects this deformity insufficiently and may even increase the sagging of the eyebrows, giving the face a sad expression. A technique for lifting the eyebrows during a blepharoplasty is presented. It consists of affixing the dermis and galea to the aponeurosis of the temporal muscle through a subgalean tunnel in the scalp. We believe that this is an anatomically based procedure, is easy to execute, has few complications, yields lasting results with hidden scars, and is of low cost. Among the 100 cases in which this technique was used, the majority showed highly satisfactory results.

The surgical management of upper eyelid hooding

A technique is described that aesthetically corrects brow ptosis and upper eyelid hooding in selected patients. This procedure is performed through a standard upper eyelid blepharoplasty incision and addresses the common findings of soft tissue fullness below the brow due to excessive suborbicularis fat and hypertrophied orbicularis oculi muscle.

Inverted nipple: the new method of correction

A new technique for correcting inverted nipples is described. It consists of the sectioning of the only genetic factor--the resistance of the collagen fibers--by undermining, under the control of a palper. The trophicity of the nipple is assured by a circular "umbrella" musculocutaneous flap containing the superficial vascular system. A subdermal cutaneous notch "blocks" the nipple and prevents any recurrence.

Unoccluded Baker-Gordon phenol peels--review and update

Phenol is used to induce peeling of certain superficial skin lesions, for improving eyelid rhytides, and for total facial rejuvenation. Contraindications and complications of the phenol chemical peel are examined. Phenol solution formula and mechanism of action are described along with techniques for sedation, cleansing, application, and postoperative care.

Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction

The distribution of the fat tissue in the subcutaneous layer is described. Since it has specific characteristics in each region of the human body, careful evaluation of the distribution before selecting patients for surgery is necessary. The subcutaneous tissue after an operation frequently demonstrates a thick and hard fibrosis which is evidence that liposuction should be performed in the lamellar layers. This type of fibrotic tissue in the subcutaneous areola layer often brings on irregularities and ungraceful waves on the skin surface.

Variations and comparisons in medium-depth chemical peeling

Two effective methods in chemical peeling, solid carbon dioxide plus trichloroacetic acid and Jessner's solution plus trichloroacetic acid, were compared clinically with photographs and histologically with serial biopsies. Carbon dioxide produced a deeper wound than Jessner's solution, and CO2 + TCA was slightly deeper than Jessner's + TCA but was probably not significantly deeper from a clinical standpoint except in correcting scarring. Triple consecutive applications of TCA can substantially increase wound depth with both combination peels.

Liposuction and the treatment of nasolabial folds

We investigate whether the application of liposuction to the nasolabial region is a useful adjunct to the rhytidectomy procedure. We have devised a system to grade the severity of the depth and the length of the nasolabial folds pre- and postoperatively. This grading system was used to evaluate the nasolabial region in 60 consecutive patients who underwent rhytidectomy. We compared two subgroups: those who underwent rhytidectomy alone (Group I) and those who underwent rhytidectomy augmented by liposuction in the region of the nasolabial folds (Group II). A change in the length of the fold occurred in 2% of Group I and in 30% of Group II. A change in depth of the fold occurred in 12% of Group I and in 70% of Group II. These results suggest that suction-assisted lipectomy consistently improves the results of rhytidectomy in the region of the nasolabial fold.

Liposuction: optimizing factors

Two aspects of liposuction procedures are discussed as ways of improving results. First, to help with the efficiency of fat removal several technical points are considered, especially the freedom and the facility of performing the liposuction procedure with a syringe without the aid of an aspirator. Surgeons are showing a growing interest with this new method. New and practical material that allows a reduced number of necessary manipulations is described. Second, we stress the importance of drainage, especially in relation to the resumption of activity which is much quicker due to the absence of postoperative bruising. When using drainage, the final result can be obtained as early as the second or third day.

The Jessner's + TCA peel: a medium-depth chemical peel

The Jessner's + TCA peel, a method of chemexfoliation, is a combination of two acidic compounds. It has been found to be an effective peeling procedure that produces a medium-depth peel for photoaging skin, actinic keratoses, and rhytides.

Depths of chemexfoliation induced by various concentrations and application techniques of trichloroacetic acid in a porcine model

The depth of wounds created by various concentrations and application techniques of trichloroacetic acid (TCA) in a porcine model is evaluated. The depth of tissue necrosis increased with the concentration of TCA. Tape occlusion did not deepen the wound but rather decreased its depth. An inverse relationship of wound depth to epidermal thickness is described.

Superficial peeling

Superficial peeling involves the topical use of mild exfoliating chemicals to rejuvenate actinically damaged facial skin and to treat acne, pigmentary disturbances, fine wrinkling, and superficial scarring. Some of the chemicals that can be used and the various techniques employed are discussed.

Occluded Baker-Gordon chemical peel: review and update

The Baker-Gordon phenol chemical peel is a safe and effective method to improve fine and moderate depth wrinkles as well as actinically damaged skin. Indications, applications of the chemical, taping, and pre- and postoperative care are reviewed.

Injectable cross-linked collagen with improved flow properties

Aqueous suspensions of glutaraldehyde cross-linked fibrillar collagen and non-cross-linked fibrillar collagen were examined by rheometry, particle size analysis, and microscopic techniques. Although cross-linked collagen suspensions were similar to non-cross-linked suspensions by microscopic and size analyses, they differed in rheometric properties. Concentric cylinder Couette flow, shear creep, uniaxial creep, and porous bed flow all revealed that cross-linked collagen was more resistant to deformation and flow than non-cross-linked collagen. These results were in agreement with in vivo dermal implantation studies, both in pig and human; i.e., compared to non-cross-linked collagen, the cross-linked formulation was more difficult to inject into tissue and did not spread uniformly, sometimes giving rise to palpable lumps or large masses evident in histological sections. When hyaluronic acid was blended with cross-linked collagen to achieve a final hyaluronate concentration of 5 mg/mL, there was a significant improvement in ease of injection into tissue. Rheometry on blends of hyaluronate and cross-linked collagen demonstrated that the blend required lower forces to achieve deformation and flow, compared to cross-linked collagen alone. Particle size analysis on the blend showed a reduction in fiber aggregate dimensions, compared to cross-linked collagen alone.

Harvesting auricular cartilage

Auricular cartilage has many uses in ophthalmic plastic and reconstructive surgery. We present a simple method to harvest auricular cartilage with minimal complications, allowing the surgeon to avoid bulky pressure dressings and providing adequate examination of the wound in the immediate postoperative phase.

The safety of fentanyl use in the emergency department

Fentanyl citrate is a synthetic narcotic 1,000 times as potent as meperidine. It produces minimal hemodynamic effects and is characterized by a rapid onset of sedation and analgesia, a relatively short duration of action (approximately 30 to 40 minutes), and rapid reversal with opiate antagonists. These properties make fentanyl an ideal drug for emergency department use. The safety of fentanyl use in an adult ED population has not previously been studied. We retrospectively reviewed the charts of 841 patients who received fentanyl at the University of Cincinnati Center for Emergency Care between January 1985 and June 1988. The study population included 497 (59%) men and 344 (41%) women, with an average age of 33 years. The average dose of fentanyl was 180 micrograms (range, 25 to 1,400 micrograms). Six patients (1%) experienced mild side effects including nausea (one), emesis (two), urticaria (one), and pruritus (two). Nine patients (1%) developed more serious complications including six cases (0.7%) of respiratory depression and three cases (0.4%) of hypotension. Two of 183 patients (1%) who received midazolam and two of nine patients (22%) who received haloperidol developed respiratory depression. Four of the six patients with respiratory depression and two of the three patients with hypotension were intoxicated. All of the complications were transient, and none resulted in hospitalization. We conclude that fentanyl is a safe drug for use in the ED. To maximize safety, we recommend careful dosing and titration, close patient monitoring, and the availability of naloxone hydrochloride and resuscitation equipment.(ABSTRACT TRUNCATED AT 250 WORDS)

Medial thighplasty, prevention of scar migration, and labial flattening

As more people seek body contour surgery spurred on by the media's great interest in suction lipectomy and the seemingly increasing numbers of satisfied patients, we should re-examine an area where results of body contour surgery have been less satisfying, the inner thigh. In those patients whose problem remains skin flabbiness rather than excessive fat, either alone or after successful or partially successful suction lipectomy, an inner-thigh procedure is indicated.

The Regnault "B" technique in mastopexy and breast reduction: a 12-year review

The "B" technique for mastopexy and reduction with and without prosthesis has been used by the author over the last 12 years for all forms of breast ptosis and hypertrophy. It has been used consistently and uniquely in over 1000 cases. Its cosmetic advantages are the short length of the scar, avoidance of a median projection of the scar, and a beautiful roundness in the best cases. The technique proved to be very adaptable to various deformities and is easy to use. The percent of complications is thought to be no greater than that of other techniques.

Anesthesia for outpatient dermatologic cosmetic surgery: midazolam--low-dosage ketamine anesthesia

Cardiovascular, respiratory, CNS, and postoperative effects of using low-dose ketamine and midazolam combined with local anesthesia during 40 outpatient cosmetic procedures are reviewed. This method of anesthesia is safe, effective, and well-tolerated by patients.

Motor point blocks in children. A technique to relieve spasticity using phenol injections

The careful attention that the day-surgery staff provides to the child who undergoes a motor point block procedure can reduce the anxiety of the parents and child and significantly contribute to the overall interdisciplinary care of the patient. The experience should be a positive one for the family and for the surgical staff.

Micro and mini hair grafting using the standard hair implantation procedure

The method described here for micro and mini hair grafting is simpler, faster, and as reliable as the standard implantation procedures that are currently employed.

Donor island harvesting for micro- and minigrafting

Donor island harvesting, a method of obtaining micro- and minigrafts from the hair-bearing strip between donor rows, is described.

The role of skin testing in the use of collagen injectable materials

The experience of 400 consecutive patients evaluated for soft tissue augmentation for a variety of contour defects is reviewed here. The first 200 patients were evaluated with only a single skin test prior to treatment, whereas the second group were skin tested twice. The rate of hypersensitivity to the first skin test was the same in both groups, 5 out of 200 (2.5%). In the 195 patients receiving treatment after a single negative skin test, 6 (3.1%) developed hypersensitivity reaction at treatment sites. In the second group, where double skin testing was employed, an additional 7 patients had a positive second skin test (3.5%). There were no allergic reactions in the 171 patients who received treatment after two negative skin tests.

Correction of established capsular contractures with polyurethane implants

Twelve patients with severe and recurrent capsular contractures following breast augmentation and reconstruction were improved with polyurethane-covered implants. It still has not been established whether these implants prevent or merely delay the onset of contractures, but some of these patients have been followed for over three years and all 12 were improved.

The use and abuse of external incisions in rhinoplasties

The author emphasizes his basic opposition to the use of external incisions in surgical rhinoplasty with only a few minor exceptions. External incisions are justifiable in only a limited number of cases, and when they are published these cases should be exceptional indeed and not suggested as an alternative technique or as an innovation to be used on a routine basis. The endonasal approach should be used in the vast majority of aesthetic rhinoplasties with only a few exceptions mentioned here.

Immediate reconstruction after subcutaneous mastectomy

We describe an improved technique for subcutaneous mastectomy using two surgical approaches, one through a short axillary incision and the other through an inframmary incision. Pathological breast tissue is removed from the prepectoral space through the lower incision and a silicone implant is placed in the retropectoral space through the axillary approach. A further modification is described using a laterally rotated inframmary dermis flap to reinforce the lateral margin of the retropectoral space containing the prosthesis.

Subcutaneous mastectomy data: a final statistical analysis of 1500 patients

A statistical analysis of 1500 patients who underwent subcutaneous mastectomy is presented. Their data suggest that most patients who were treated by subcutaneous mastectomy had proliferative fibrocystic disease or macrocystic disease, among other high risk factors. The data also suggest that a thoroughly performed subcutaneous mastectomy is an effective means of providing prophylaxis in women who are at high risk for breast cancer. Conclusions were confirmed by many unsolicited comments of patients who underwent the procedure and were grateful to their doctors who performed it.

Suggested nomenclature for aesthetic and reconstructive surgery of the breasts. IV: Congenital anomalies of the breast

A nomenclature for the definition, diagnosis, and surgical management of the congenital anomalies of the breast is suggested. The International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) code numbers pertaining to these anomalies have been tabulated.

Mammoplasty using liposuction and the periareolar incision

The major dilemma of reduction mammoplasty and mastopexy has been the difficult choice between a procedure that yields an ideal shape of the breast versus the size of the scar. With our technique, selected breasts can now be reduced through liposuction and the mastopexy performed through a periareolar incision, resulting in virtually imperceptible scarring.

Immediate breast reconstruction with subpectoral implantation after transaxillary subcutaneous mastectomy for siliconoma

Immediate breast reconstruction on 14 patients suffering from breast hardening after augmentation mammaplasty by injection of silicone gel was performed. Transaxillary subcutaneous mastectomy was done followed by insertion of a double-lumen prosthesis into the subpectoralis plane. The result was greatly influenced by the amount of injected silicone gel. The patient was carefully observed after surgery, and the prosthesis was immediately removed when abnormal skin changes became apparent. Seven cases had no hardening on either side and 1 case had hardening on one side, 3 cases had hardening on both sides and 1 case on one side, 2 cases had the prosthesis removed from both sides and 2 cases from one side. All other cases with hardening or prosthesis removal, except one with removal from both sides, were subsequently reconstructed after more than three months.

Submental-submandibular suction lipectomy: indications and surgical technique

The submental and submandibular regions play an essential role in the overall harmony of facial aesthetics. The appearance of the cervicomental area may be the result of many factors, including mandibular hypoplasia, localized lipodystrophy, a low-positioned hyoid bone, platysmal deformity, soft tissue laxity, or a combination of any of these. Although much attention has been directed toward correction of bony contour deformities of the mandible and chin, minimal emphasis has been placed on evaluation and correction of soft tissue disharmonies in the submental-submandibular areas. This article discusses the indications and contraindications, patient examination, surgical technique, and potential complications of suction-assisted lipectomy of the cervicomental region. Select cases are presented to illustrate the concepts and techniques discussed herein.

Constant compression caliper for objective measurement of breast capsular contracture

The main problem with silicone implants in augmentation mammaplasty and breast reconstruction is the development of capsular contracture. The universal method for evaluating the degree of firmness of the breast is the subjective palpation technique and the classification according to Baker. Many objective methods using calipers for measurements of compression, different devices for indentation and discs for applanation tonometry have been described, but none of these have been widely accepted. In this paper a new measuring instrument is presented based on the principle of a constant compression force between two caliper jaws applied to the breast. The inverse value of the compressibility of the breast is read on a scale on the device. This objective method correlates acceptably with the palpation technique according to the Breast Augmentation Classification (BAC) (12), which is a modification of Baker's classification (1978), except for the first follow-up.

Immunohistochemical study of the biological fate of a subcutaneous bovine collagen implant in rat

The biological fate of a bovine collagen implant (Zyderm Collagen Implant ZCI), injected subcutaneously into rats, was studied by the immunoperoxidase technique using specific antibodies against the bovine implant and against types I, III, IV, V collagens, fibronectin and elastin. The implant remained in the animals until the end of the experiment (90 days), with no visible modification, as demonstrated by immunoperoxidase labelling and scanning electron microscopy. A slight inflammatory reaction was visible around the implant 24 h after injection and within the implant 3 days after injection. Fibroblast invasion began 7 days after injection. The chronology of the deposition in the implant of the host (rat) extracellular matrix components was as follows: by 24 h after injection, fibronectin was observed throughout the implant; types I and V collagens appeared on the 7th day, and, in contrast to surrounding connective tissue, type V collagen labelling was obtained without acid pretreatment of the section. Types III and IV collagens were detected inside the implant only 30 days after injection. At the end of the experiment (90 days), there was abundant types I and IV collagens after fibroblast migration, and abundant type IV collagen demonstrating an important vascularization. No elastic fibres could be detected inside the implant but they appeared as a dense network around the implant in host connective tissue.

Results of subglandular breast augmentation using a new classification method--18-year follow-up

The main problem after augmentation mammaplasty is the formation of capsular contractures. The frequency of this complication varies in different reports. In this study the results in 60 women 15-21 years after subglandular breast augmentation are presented. The patients completed a questionnaire and the breasts were judged according to a new Breast Augmentation Classification (BAC) scale. Of all breasts examined 79% had grade III or IV, but 77% of the patients were satisfied with the final result. However, 84% thought that their breasts were too hard. Breast cancer had not developed in any patient. Rheumatoid arthritis developed in one patient 4 years after the operation. Capsular contracture and unacceptable results after subglandular breast augmentation were found in the major portion of the patients in this study.