Nerve allografting represents a unique situation

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Asian Face Lift with the Composite Face Lift Technique

BACKGROUND

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

METHODS

Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

RESULTS

Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

CONCLUSION

The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Review of the Nomenclature of the Retaining Ligaments of the Cheek: Frequently Confused Terminology

Since the time of its inception within facial anatomy, wide variability in the terminology as well as the location and extent of retaining ligaments has resulted in confusion over nomenclature. Confusion over nomenclature also arises with regard to the subcutaneous ligamentous attachments, and in the anatomic location and extent described, particularly for zygomatic and masseteric ligaments. Certain historical terms—McGregor’s patch, the platysma auricular ligament, parotid cutaneous ligament, platysma auricular fascia, temporoparotid fasica (Lore’s fascia), anterior platysma-cutaneous ligament, and platysma cutaneous ligament—delineate retaining ligaments of related anatomic structures that have been conceptualized in various ways. Confusion around the masseteric cutaneous ligaments arises from inconsistencies in their reported locations in the literature because the size and location of the parotid gland varies so much, and this affects the relationship between the parotid gland and the fascia of the masseter muscle. For the zygomatic ligaments, there is disagreement over how far they extend, with descriptions varying over whether they extend medially beyond the zygomaticus minor muscle. Even the ‘main’ zygomatic ligament’s denotation may vary depending on which subcutaneous plane is used as a reference for naming it. Recent popularity in procedures using threads or injectables has required not only an accurate understanding of the nomenclature of retaining ligaments, but also of their location and extent. The authors have here summarized each retaining ligament with a survey of the different nomenclature that has been introduced by different authors within the most commonly cited published papers.

Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold

The anatomic basis for the jowl has not been fully described. A formal analysis was performed of the sub-superficial musculoaponeurotic system (SMAS) areolar tissue layer, which overlies the lower part of the masseter. For this research, facial dissections were performed on 16 fresh cadavers ages 12 to 89 years, and detailed anatomic observations were made during the course of several hundred rhytidectomy procedures. Tissue samples from varying age groups were examined histologically. The areolar cleavage plane overlying the lower masseter has specific boundaries and is a true space named the "premasseter space." This space is rhomboidal in shape, lined by membrane, and reinforced by retaining ligaments. The masseter fascia lines the floor, and branches of the facial nerve pass under its deep surface. Histologically, the floor is formed by a thin layer of dense connective tissue, which undergoes minor deterioration in architectural arrangement with age. The roof, lined by a thin transparent and adherent membrane on the underside of the platysma, has a less dense collagen network and contains more elastin. With age, there is a significant reduction in the collagen density of the roof. Expansion of the space with aging, secondary to weakness of the anterior and inferior boundaries, results in formation of the jowl. Medial to the premasseter space is the buccal fat in the masticator space, which descends with aging and contributes to the labiomandibular fold and jowl. Application of the premasseter space in surgery provides significant benefits. The SMAS incision should be forward of the traditional preauricular location to be over the space, not behind. Because the space is a naturally occurring cleavage plane, dissection is bloodless and safe, as all facial nerve branches are outside. The premasseter space should be considered as the preferred dissection plane for lower (cervicofacial) facelifts.

Histologic and ultrastructural evaluation of sutures used for surgical fixation of the SMAS

In extensive SMAS face-lift surgery, retaining ligaments are released, and the SMAS is resutured to the deep fascia to maintain the advanced position. The suture used to reattach the SMAS should replicate the quality of support provided by the original ligaments. Nonabsorbable sutures (monofilament and braided) retrieved intraoperatively from 22 patients undergoing secondary face-lift procedures were examined by light microscopy and transmission electronmicroscopy. A distinctive enclosure of dense collagen and elastin formed around both types of suture. Based on the presence of inflammatory cells, fibroblasts, collagen, and elastin, the tissue reaction to monofilament suture was less than with the braided suture. The collagen and elastin were thicker around the braided suture, and, additionally the collagen matrix infiltrated between the individual filaments. Ultrastructural analysis of the braided suture showed significant collagen binding around each individual filament. The greater quantity of connective tissue around the thread which continued into the interstices of the braided suture has the characteristics of a ligament. This suggests a stronger and more lasting tissue fixation.

Designing a Virtual Reality Model for Aesthetic Surgery

BACKGROUND

Aesthetic surgery deals in large part with the manipulation of soft-tissue structures that are not amenable to visualization by standard technologies. As a result, accurate three-dimensional depictions of relevant surgical anatomy have yet to be developed. This study presents a method for the creation of detailed virtual reality models of anatomy relevant to aesthetic surgery.

METHODS

Two-dimensional histologic sections of a cadaver from the National Library of Medicine's Visible Human Project were imported into Alias's Maya, a computer modeling and animation software package. These two-dimensional data were then "stacked" as a series of vertical planes. Relevant anatomy was outlined in cross-section on each two-dimensional section, and the resulting outlines were used to generate three-dimensional representations of the structures in Maya.

RESULTS

A detailed and accurate three-dimensional model of the soft tissues germane to aesthetic surgery was created. This model is optimized for use in surgical animation and can be modified for use in surgical simulators currently being developed.

CONCLUSIONS

A model of facial anatomy viewable from any angle in three-dimensional space was developed. The model has applications in medical education and, with future work, could play a role in surgical planning. This study emphasizes the role of three-dimensionalization of the soft tissues of the face in the evolution of aesthetic surgery.

Composite tissue allotransplantation--a new era in plastic surgery?

Composite tissue allotransplantation (CTA) holds great potential for reconstructive surgery. The recent hand transplants have made this a clinical reality. However, concerns about CTA have divided the medical community. The current transplants require life-long immunosuppression, which could place the recipients at risk of serious complications. In addition despite potent immunosuppression, chronic rejection may still negate any early favourable results. This article will outline the clinical experience of CTA, the major problems of the technique and the potential solutions to these problems.