The Role of Sclerotherapy in Abnormal Varicose Hand Veins:

Cervicofacial rhytidoplasty: more does not mean better

BACKGROUND

Aesthetic correction of cervicofacial flaccidity has undergone numerous modifications over time, including extent and depth of dissection. We present our experience with this type of surgery, passing through different stages and procedures to achieve optimal and highly satisfactory results.

METHODS

From January 1995 to December 2009, 576 patients (498 females and 78 males, age range = 34-78 years, mean = 47) underwent cervicofacial rhytidoplasty. During the first 6 years of the study period, cervicofacial tissue was managed with six different types of plications, according to the needs of each patient, requiring extensive supra-SMAS undermining. During the last 9 years, undermining was significantly limited and only three of the six plications were used, adding different surgical procedures to achieve the surgical objectives.

RESULTS

During the first period, 220 patients were operated on and 164 patients required additional procedures (74%). Seventy-nine patients (36%) needed 6 plications, 90 patients (41%) required 5 plications, and 51 patients (23%) only 4 plications. During the second period, 356 patients were operated on, needing only 3 plications, but 336 (94%) required additional procedures. The percentage of complications during the first period was 2.2% hematomas, 2.7% superficial necrosis, and 0.45% deep necrosis compared with 0.84, 0.56, and 0%, respectively, in the second period. A greater disability rate than expected from edema and/or prolonged ecchymosis occurred in 25 and 12% of the patients in the first and second periods, respectively. A similar degree of patient satisfaction was obtained in both periods, 93 and 92%, respectively.

CONCLUSION

Our approach to cervicofacial rhytidoplasty has varied substantially by limiting undermining, which has produced a lower complication rate and has accelerated the recovery process. However, to acquire similar results, we have had to implement additional procedures, with which we have obtained the same degree of satisfaction but with a lower rate of postsurgical morbidity.

Achieving aesthetic balance in the brow, eyelids, and midface

An approach to the brow, eyelids, and midface emphasizing release and advancement of the orbicularis oculi muscle, conservative removal of orbital fat, preservation of the nerve supply to the orbicularis oculi muscle, and avoidance of canthal division was evaluated in 100 consecutive patients. The technique describes the selected release of three key retaining ligaments to the forehead, brow, and upper eyelid; mobilization of the lateral retinaculum and division of the lower lid retaining ligament; and division of the midface malar retaining ligament (zygomatic-cutaneous ligament). Preservation of motor branches to the lower lid orbicularis is stressed. Of significance to this series of patients is the inclusion of 50 patients with morphologically prone lower eyelids defined as atonic lower lids, exorbitism, and/or negative vector orbits. Three sites had failure of brow fixation, two patients had midface asymmetry requiring revision, and three patients failed to have complete correction of their preoperative lower lid retraction. There was zero incidence of scleral show or lower lid retraction that was not present preoperatively. No patients required division of the lateral commissure with canthoplasty, taping or suture suspension, massage, or steroid injections. Only two patients required division of the deep head of the lateral canthus, and these patients were noted to have had lateral canthal malposition preoperatively.

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.