Facelift With Power-Assisted Dissection: A Preliminary Report

BACKGROUND

Subcutaneous elevation of the skin has remained a key component in all facelift techniques.

OBJECTIVES

The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss.

METHODS

The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck.

RESULTS

Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema.

CONCLUSIONS

The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.

LEVEL OF EVIDENCE: 4

In-Vitro Comparative Examination of the Effect of Stromal Vascular Fraction Isolated by Mechanical and Enzymatic Methods on Wound Healing

BACKGROUND

Enzymatic digestion has been the gold standard for stromal vascular fraction (SVF) isolation but remains expensive and raises practical and legal concerns. Mechanical SVF isolation methods have been known to produce lower cell yields, but may potentially produce a more robust product by preserving the extracellular matrix niche.

OBJECTIVES

The aim of this study was to compare mechanically dissociated SVF (M-SVF) and enzymatically digested SVF (E-SVF) in terms of wound-healing efficacy.

METHODS

Lipoaspirate was partitioned into 2 equal groups and processed by either mechanical or enzymatic isolation methods. After SVF isolation, cell counts and viabilities were determined by flow cytometry and cell proliferation rates were measured by the WST-1 test. A wound-healing scratch assay test, which is commonly used to model in-vitro wound healing, was performed with both cell cocktails. Collagen type 1 (Col1A) gene expression level, which is known for its role in wound healing, was also measured for both groups.

RESULTS

As predicted, E-SVF isolated more cells (mean [standard deviation], 1.74 [3.63] × 106/mL, n = 10, P = 0.015) than M-SVF (0.94 [1.69] × 106/mL, n = 10, P = 0.015), but no significant difference was observed in cell viability. However, M-SVF expressed over 2-fold higher levels of stem cell surface markers and a 10% higher proliferation rate compared with E-SVF. In addition, the migration rate and level of Col1A gene expression of M-SVF were found to be significantly higher than those of E-SVF.

CONCLUSIONS

Although the cell yield of M-SVF was less than that of E-SVF, M-SVF appears to have superior wound-healing properties.

Progressive Improvement in Midfacial Volume 18 to 24 Months After Simultaneous Fat Grafting and Facelift: An Insight to Fat Graft Remodeling

BACKGROUND

Although many facelift techniques incorporate fat grafting with tissue repositioning and removal, the intermediate and long-term changes in facial volume after these techniques is unknown. Whereas fillers for facial volume have predictable life spans, we know little about the facial volume changes following fat grafting with facelift surgery.

OBJECTIVES

The authors sought to track the short-term and long-term effects on midfacial volume change.

METHODS

We evaluated a subset of patients who were followed by 3-dimensional (3D) photometric imaging 18 to 24 months after facelift with fat grafting to the deep midfacial fat compartments and buccal fat pads. Volume changes were measured preoperatively and postoperatively every 1, 3, 6, 12, 18, and 24 months using the 3D photometry.

RESULTS

At the 1- to 2-month follow-up period, average facial volume was 49.60% of the initial fat injected. At the 18- to 24-month follow-up period, average facial volume was 73.64% of the initial fat injected, indicating an increase in midfacial volume. Upon graphing available photometric data, dynamic changes in facial volume were observed. In 5 midfacial zones, facial volume appeared to initially decline (average decline, 49.0% of original fat injection), troughing at 10 months (range, 2-15 months), but later inclined (average increase in volume, 95.9% of original fat injection), peaking around 16 months (range, 4-24 months).

CONCLUSIONS

Progressive improvement in midfacial volume in part may be explained by the graft replacement theory of Suga and Yoshimura, which suggests that grafted adipose tissue immediately dies after transplantation and is replaced by adipose-derived stem or progenitor cells.

LEVEL OF EVIDENCE: 4

Identifying Medical Diagnoses and Treatable Diseases by Image-Based Deep Learning

The implementation of clinical-decision support algorithms for medical imaging faces challenges with reliability and interpretability. Here, we establish a diagnostic tool based on a deep-learning framework for the screening of patients with common treatable blinding retinal diseases. Our framework utilizes transfer learning, which trains a neural network with a fraction of the data of conventional approaches. Applying this approach to a dataset of optical coherence tomography images, we demonstrate performance comparable to that of human experts in classifying age-related macular degeneration and diabetic macular edema. We also provide a more transparent and interpretable diagnosis by highlighting the regions recognized by the neural network. We further demonstrate the general applicability of our AI system for diagnosis of pediatric pneumonia using chest X-ray images. This tool may ultimately aid in expediting the diagnosis and referral of these treatable conditions, thereby facilitating earlier treatment, resulting in improved clinical outcomes. VIDEO ABSTRACT.

Regenerative Cells For Facial Surgery: Biofilling and Biocontouring

Zuk et al in 2001 identified stem and regenerative cells within the stromal vascular fraction of fat. In preclinical studies, these cells appeared to stimulate angiogenesis and reduce inflammation, and soon thereafter, clinical use of stromal vascular fraction (SVF) evolved as researchers such as Rigotti, Coleman, Mojallal, our group, and others demonstrated that fat can be used for both therapeutic and aesthetic indications. The regenerative effects of fat and its contents on facial aesthetics have been shown at the histologic and cellular level. Regeneration of elastin and collagen fibers as well as improvement in capillary density and reduction of inflammation have been reported. We review our current approach to the use of regenerative cells and different types of fat grafts in facial surgery. The fat graft is classified, both from a regenerative point of view as well as a tissue product that can be modified into different tissue characteristics, depending on the area and condition treated. Clinical use of SVF enriched fat, millifat, microfat, and nanofat grafts as well as composite fat grafts are reviewed. Based on clinical experience and evidence to date, it appears that the regenerative effects seen with the use of SVF in aesthetic surgery are modest, but there appear to be definite histologic findings of regeneration. These improvements may not be clinically apparent to a patient when cell enriched fat grafts are compared to fat grafts alone. However, the subtle changes seen in histology may be cumulative over time. Three types of fat grafts are defined: millifat (parcel size 2.4<), microfat (1.2<), and nanofat (400-600 μm). Each are characterized by their injectability ratings and emulsification parcel size as well as amount of sSVF cells. Newer concepts of periosteal fat grafting, buccal fat pad grafting, pyriform aperture fat grafting, intraorbital fat grafting, and nanofat grafting are discussed. Composite fat grafts are presented as a new concept as is biofilling and biocontouring. The use of regenerative cells in facial surgery is evolving rapidly. Our understanding of the anatomic changes that occur with aging has become more precise and our ability to target histologic changes seen with aging has become more effective. Deep fat compartment grafting, superficial fat grafting, nanofat, and SVF are becoming important components of contemporary facial rejuvenation. The use of regenerative approaches in facial rejuvenation is a logical step in changing the paradigm from surgical treatment of aging to a more proactive prevention and maintenance approach that keeps up with changes in the tissues as they age.

Inducible nitric oxide synthase expression in cultures enriched for mature oligodendrocytes is due to microglia

Hewett JA, Hewett SJ, Winkler S, Pfeiffer SE. 1999. Inducible nitric oxide synthase expression in cultures enriched for mature oligodendrocytes is due to microglia. J Neurosci Res 56:189-198. In the article referenced above, the LPS concentration employed in all studies was 1 &mgr;g/ml, not 1 mg/ml as published. This correction appears: in the Materials and Methods section on page 190, column 1, line 47; in the Results section on page 191, column 2, legend to Figure 1, line 3; on page 192, column 2, legend to Figure 2, line 3; on page 194, column 2, legend to Figure 5, line 4; on page 195, column 1, legend to Figure 6, line 3; and in the Discussion section on page 196, column 1, line 9. The publisher regrets this error.

Isoform patterns of apolipoprotein E in diabetes mellitus

Apolipoproteins in delipidated VLDL preparations from normal, diabetic, and non-diabetic hyperlipidaemic subjects were analysed by SDS-polyacrylamide gel electrophoresis, and by isoelectric focusing. On electrophoresis, diabetic VLDL contained more apolipoprotein E (17.3 +/- 7.3 (+/- SD) %, n = 54) than did VLDL from hyperlipidaemic (13.4 +/- 4.2%, n = 52; p less than 0.005) or normal (12.4 +/- 2.6%, n = 29; p less than 0.001) subjects. Apolipoprotein E excess was also seen when subgroups were characterized by apolipoprotein E phenotype. In diabetic patients of E3/E3 phenotype, apolipoprotein E was 16.4 +/- 6.0% (n = 25), compared with 12.9 +/- 2.5% in control subjects (n = 14; p = 0.008). Acidic isoforms were more common in 44 diabetic patients with E3/E3 phenotype; E3, E2, E1, and E1' as percentage of total E apolipoprotein were 58.3 +/- 7.6, 24.5 +/- 4.4, 13.7 +/- 4.5, and 3.8 +/- 4.3% respectively, compared with 63.5 +/- 10.4 (p = 0.034), 19.1 +/- 5.3 (p less than 0.001), 13.7 +/- 6.5 (NS), and 3.7 +/- 2.1% (NS) in 21 normal subjects. In 31 diabetic patients, of apolipoprotein E3/E3 phenotype, E3, E2, E1 and E1' were 60.2 +/- 7.3, 23.4 +/- 9.4, 11.1 +/- 4.1, and 5.4 +/- 3.7%, respectively, compared with 68.0 +/- 7.1 (p less than 0.001), 21.9 +/- 6.4 (NS), 6.3 +/- 3.9 (p less than 0.001), and 3.7 +/- 2.5 (p less than 0.05) % in 32 hyperlipidaemic patients. Diabetic patients of E3/E2 phenotype showed less apolipoprotein E3 than normal or hyperlipidaemic subjects, with a similar trend for apolipoprotein E4 in those of E4/E3 phenotype.(ABSTRACT TRUNCATED AT 250 WORDS)