The deep cervical fascia neck lift.

The main and more frequent problem in face lift is recurrence of neck bands. To improve face lift stability, a new aging analysis is proposed. The visible sign of face aging is skin excess. Superficial musculo aponeurotic system (SMAS) retraction is a much less visible sign. Nevertheless, botulinum toxin injections elongate muscles of the SMAS and rejuvenate the face. In the Face Recurve Concept, MRI studies prove the mimic muscles retraction that comes with aging. Face lift techniques include SMAS plication, traction or excision, which increases discrepancy between the envelope, the skin and the core, the SMAS. As skin excision is poorly efficient because performed posteriorly, far from the anterior skin excess located at the medial neck, the association to SMAS retraction exacerbates the gradient difference between envelop and core. This analysis shows that it is paramount to preserve the SMAS. (1) The sub-skin dissection has to be executed moving beyond the marionette fold and the paramedian neck bands; (2) no action is performed on the SMAS, only an horizontal section of the platysma at the hyoid height that will avoid platysma band recurrence. A botulinum toxin injection performed herein just after, blocks muscle regeneration; (3) the skin is pulled backward with a clear posterior transposition to the platysma. The skin at the cervico-mental angle and all along the cervico-mental crease is fixed to the deep cervical fascia, in the gap between the edges of the sectioned platysma, blocking muscle recreation. A resorbable barbed thread is used, with a first bite made at the cervico-mental angle through the deep cervical fascia then in the direction of the mastoid, with long bites through the deep cervical fascia versus short subcutaneous bites. Thanks to this strong shift, the cervico-mental crease is definitely recreated with no need of pre-auricular skin tension. Thirty-two patients have been operated with this technique on a one-year period. The results are a lot more stable and swelling is lowered down to the minimum.

Hyo-neck lift evolution: Neck lift with fixation of the platysma to the deep cervical fascia.

The aim of any neck lift obviously includes the restoration of an acute cervicomandibular angle. The hyo neck lift, first published in April 2016, did proposed a new technique of neck lift with a sub-cutaneous neck dissection and suture of the platysma to the hyoid through this sub-cutaneous approach. To enhance results and efficiency, a major change of the hyo neck lift technique is herein proposed with a vertical anterior sub-platysmal and sub-platysmal fat opening and dissection. This anterior dissection ensures a precise and efficient fixation of the platysma to the deep cervical fascia on direct visual control. This permits to create an horizontal and posterior vector of tension on both platysma and skin, which induces flattening of the submental area and consequently creates or recreates an acute cervicomandibular angle. The sub-cutaneous dissection is no more necessary at the hyoid level. In addition, the posterior border of the anterior platysmal flap is suspended to the mastoid fascia. If necessary, the submandibular gland, through this lateral approach, can be partially excised inside it's capsule, after strong bipolar coagulation. A botulinum toxin injection, realized in early post-op, will definitively stabilize the platysma to deep cervical fascia fixation. Fifteen patients underwent the new technique of neck lift with fixation of the platysma to the deep cervical fascia and suspension of the lateral platysma (Platysma Fixation Platysma Suspension: PF PS) and were evaluated at one year post-op and compared to the results obtained with the first preliminary prospective study "hyo neck lift technique" published in April 2016. As now subcutaneous dissection is limited, recovery is faster. No transient nerve damage happened because dissection planes are designed to be far from nerve branches. CONCLUSIONS: The simplest way to obtain an acute cervicomandibular angle is to reattach the platysma to the deep cervical fascia along the platysma cords. The new neck lift with fixation of the anterior platysma to the deep cervical fascia and suspension of the lateral platysma, is faster to perform, induces a faster recovery and is safer and more efficient than the subcutaneous hyo neck lift and other described types of anterior platysma plasties.

[Aging prevention, new surgical techniques and future options for facial rejuvenation]. / Prévention du vieillissement, techniques chirurgicales récentes et voies d'avenir de la chirurgie du rajeunissement facial.

Prevention of aging is mainly obtained through appropriate health practices, modulated by the genetic causes of aging. Causes of facial structural aging include gravity, volume loss, contraction of the mimic muscles and obviously biological aging of tissues. Among the very numerous new surgical technique of facial rejuvenation, we could point out: for the frontal region, obviously we are focus on the endoscopic and non-endoscopic frontal lifts. But also, we should note the transcutaneous Brow Shaping which with a well defined, step by step technique is indeed a simple way to improve a possible difficult situation; concerning the mid-face lift, as the main risk is the secondary eyelid malposition, a high Smas or a temporo-malar lift can be performed. It ensures a good temporal effect but there is nearly no improvement at the mid-pupilla level. A mid-face lift is nevertheless mandatory to achieve an efficient skin removal on the mid-pupilla line. This is performed most of the time with a complete orbicularis oculi muscle opening, and only with a small lateral opening in case of the concentric malar lift, which minimize the risk of eyelid malposition. Based on a new description of the lymphatic draining of the lower lid, a new treatment of the chemosis is proposed with a corticoid injection at infero-lateral part of the malar area, in the preperiosteal plane. For the oval, the DAO section and the suspension of the middle premasseter space beyond the anterior border of the masseter where the Smas overlies the buccal fat pad, stay efficients. Regarding the neck, the suspension of the posterior border of the platysma to the Loré's fascia, the digastric corset with or without a platysma corset are advanced and valuable techniques. Lately, a new option was described using a lateral skin-platysma flap to minimize platysma bands and even more recently a neck lift with fixation of the anterior platysma to the deep cervical fascia and suspension of the lateral platysma flap.

[Botulinum toxin: An important complement for facial rejuvenation surgery]. / Toxine botulique : un complément important à la chirurgie du rajeunissement facial.

The improved understanding of the functional anatomy of the face and of the action of the botulinum toxin A leads us to determine a new injection procedure which consequently decreases the risk of eyebrow and eyelid ptosis and increases the toxin's injection possibilities and efficiencies. With less units of toxin, the technique herein described proposes to be more efficient on more muscles: variable toxin injections concentration adapted to each injected muscle are used. Thanks to a new procedure in the upper face, toxin A injection can be quite close to an endoscopic surgical action. In addition, interesting results are achievable to rejuvenate the lateral canthus with injection on the upper lateral tarsus, to rejuvenate the nose with injection at the alar base, the jawline and the neck region. Lastly, a smoothing effect on the skin (meso botox) is obtained by the anticholinergic action of the toxin A on the dermal receptors.

A new approach to functional anatomy of the lower face: Role of the hyoplatysmal ligament, of the platysma and of the depressor labii lateralis.

BACKGROUND: Although there are numerous techniques for necklift, medium-term instability is frequent with this procedure. A misunderstanding of the functional anatomy of the neck may explain these unsatisfactory surgical outcomes. OBJECTIVES: The author analyzes the functional anatomy of the platysma (PLA) and of the hyoplatysma ligament. The depressor labii lateralis (DLL) is described for the first time. METHODS: The PLA was dissected in 4 fresh adult cadavers to infer its function and to reevaluate current knowledge regarding this anatomic region. In addition, 30 patients who presented to the author's private practice for rejuvenation of the lower face were photographed undergoing specific muscle contractions for functional analysis. RESULTS: The PLA functions as a neck elevator only. Lower lip traction is controlled by independent antagonistic muscles, including the depressor labii inferioris, the anguli oris, and the DLL. The juxtaposition of these antagonistic muscles occurs at the mandibular line, which explains why the aging process is so distinct in this area. The hyoplatysmal ligament is responsible for the creation and stability of the acute cervicomandibular angle. CONCLUSIONS: The aim of neck rejuvenation should be to restore elongation of the PLA posteriorly and to create posterior tension in the submental skin. Vertical platysmaplasty should be replaced with horizontal suturing of the PLA toward the hyoid and then to the skin to recreate the cervicomandibular angle and the submental area of the patient in youth.

Hyo neck lift: Preliminary report.

BACKGROUND: The aim of neck lift is to recreate an acute cervicomandibular angle. Surgical neck rejuvenation typically is associated with posterosuperior traction on the platysma (PLA) with an anterior vertical PLA corset or a digastric corset. Medium-term instability can exist with these procedures. OBJECTIVES: A novel platysmaplasty technique called the hyo neck lift is described and its surgical efficacy is compared with those of previously described techniques. METHODS: Ten patients underwent hyo neck lift and were evaluated in a preliminary prospective study. Hyo neck lift involved horizontal suturing of the PLA towards the hyoid and then to the skin to recreate a youthful cervicomandibular angle and to place tension on the submental area. RESULTS: Six months postoperatively, all patients showed improvement in the definition and flattening of the submental area and in ptosis of the submandibular gland. Hyo neck lift is less invasive, without any specific dissection, like in the digastric corset. CONCLUSIONS: The simplest way to achieve an acute cervicomandibular angle is to reattach the PLA and skin to the hyoid. Hyo neck lift is logical and efficient and produced satisfactory aesthetic and functional outcomes in this preliminary study.

Specificity of facelift surgery, including mid facelift, in case of facial palsy.

The asymmetry created by the facial palsy is of course a cause of demand for facelift surgery. As this lifting action is specific and different from the standard procedures, 3 zones of analysis are proposed: first the frontal and temporal areas with the direct eyebrow lift, second the neck and jawline with action on the depressor anguli oris for the non-paralyzed side and the anterior sub SMAS dissection and third the midface. A new and more simple technique of concentric malar lift is proposed. The first publication on concentric malar lift was made 11years ago. Midface rejuvenation stays very challenging. As a proof of that, many authors prefer a partial rejuvenation of mid face with fat reinjection, with no effect on skin excess, even if all the MRI studies demonstrated no fat loss with time but only fat transfer. This proves that midface lift did not acquire enough simplicity, reliability to become a standard procedure. Six hundred concentric malar lift later, a technical simplification validated with 110 patients and 2years of follow-up is proposed. The improvement is due to a new way to pass the threads deeply on the bone, using permanent barbed sutures. This surgery becomes easier and more efficient.

[Facial palsy sequel and botulinum toxin]. / Séquelles de paralysie faciale et toxine botulique.

Medical treatment of facial paralysis sequel is an essential part of the overall management of this pathology. The use of botulinum toxin has revolutionized results in greatly improving facial symmetry. The toxin can be used either the healthy side of the face by treating the compensatory hyperactivity of non-paralyzed side of the face or the paralyzed side (in the spastic forms) to treat synkinesis and spasms of the face on the pathologic side. This treatment course will be complemented by the rest of the therapeutic, i.e. rehabilitation and surgical treatment.

[First applications of matrix therapy in plastic and aesthetic surgery]. / Premières applications de la thérapie matricielle en chirurgie plastique et esthétique.

INTRODUCTION: A new medical device based on a concept of the reconstruction of the extracellular matrix by a molecule belonging to the family of the ReGeneraTing Agents (RGTA(®)) has just been available to treat skin lesions. RGTA(®) are biodegradable polymers engineered to mimic heparan-sulfate in the extracellular matrix of damaged tissue. RGTA(®) improves tissue healing in several animal models, by stabilizing and protecting heparin-binding growth factors (HBGFs) and matrix proteins. We have evaluated the effects of this device containing RGTA(®) on cutaneous cicatrisation in a group of patients treated by reduction mammoplasty and in a group operated by a centrofacial lifting. PATIENTS AND METHODS: Seventeen patients who underwent mammoplasty for breast hypertrophy received cutaneous application of the device at D1, D4, D8 and D11 on one breast. Quality, color, inflammation of the scar and eventual complications have been evaluated by photography and at the third postoperative month by the Vancouver Scar Scale. Another group of 50 patients that underwent a centrofacial lifting received a bilateral deposition of drops of RGTA(®) in the operating plane at the end of the surgical procedure. Discomfort, oedema, ecchymosis and inflammation of the scars have been evaluated at 1-month postoperative and compared with an identical group of 50 other patients, operated by the same surgeon without RGTA(®). RESULTS: In the group of mammoplasties, inflammation, prurit and hypertrophic scars were less frequent for the breast treated by RGTA(®). The mean Vancouver Scar Scale has been lower in the treated group than in the control group. In some patients the pain, related probably to the local inflammation, has been less important for the treated breast. In the sequence of centrofacial lift at 1-month postoperative, scar inflammation, oedema and bruises were much less frequent in the treated group (10 %) than in the non-treated group (90 %). CONCLUSION: Topical application of RGTA(®) seems to improve cutaneous healing in a group of patients operated for breast reduction and to reduce discomfort, ecchymosis and oedema in the group of centrofacial lifting. These results are concordant to the experimental results obtained and pilot studies results.

[The surgical innovation: From the legal framework through the veritable ethics innovation - Technical aspects and practical applications]. / L'innovation chirurgicale : du cadre légal à une véritable éthique de l'innovation. Aspects théoriques et applications pratiques.

Grace to the creativity of surgeons and the introduction of new technologies, second half of the XXth century opened the era of innovations and decisive progress. At the same time, however, is born the feeling of distrust and claiming which has come with the graving and threatening juridiciarisation. The evolution of complex structures of our society joined the ingenuity researchers unlimited makes formal law and the legal framework constantly to adapt oneself to circumstances. In the field of surgery, it's necessary to make work in integrity the innovation and protection at the patient's and their dignity. The legal framework that governs today innovation in surgery must still to go further and will precise. Dignity, compelling paradigm for all those who seek to better understand and better protect human starred as impassable limit any search and any experimentation. To make this chapter more alive, we have supplemented it and illustrated by the testimony some of the most fruitful French last years innovative in order to enrich our thinking of the fruit of their large and brilliant experience.

[Muscular aging and its involvement in facial aging: the Face Recurve concept]. / Vieillissement musculaire et son implication dans le viellissement facial : le concept du Face Recurve.

Cutaneous ageing is responsible for the increasingly creased appearance of the skin, pores opening, skin dyschromia, while the ageing of the structures of the face is attributed primarily to the effect of gravity on the tissues. The theory expounded below sets out to prove that the main and initial cause of this ageing is the repeated contractions of the mimic muscles. This concept attributes only a secondary role to gravity in the ageing process, which is initially brought about by muscular contractions. An MRI study recently made it possible to demonstrate the anterior convexity curve of the mimic muscles in the young subject. This curve is due to the existence of a deep fat pad at the back of these muscles. While this mass of fat is effectively a mechanical sliding plane, its convexity constitutes the founding principle behind this new ageing theory. In the young subject, the extent of its convexity and its location give a specific, youthful character to the movements, in terms of direction and amplitude, of the facial muscles. With age, the muscle gradually straightens and shortens, due to the repeated contractions that expel the underlying fat and increase the tonus at rest. The structural ageing becomes visible and with time, the expression of the subject is consequently more rigid.

[Can the botulinum toxin prevent aging?]. / La toxine peut-elle prévenir le vieillissement ?

This study wants to prouve that the resting tone is increasing with age. On the behalf of the Face Recurve concept, the deep fat is expelled superficially because of mimic muscle shortening. Botulinum toxin is proposed for a new indication: resting tone decrease in order to slow down muscle shortening and consequently structural aging. Injections can be performed very early in the ageing process, before the appearance at rest of wrinkle, only when it becomes visible in contraction. Precision of the injection is related to the recent determination of motor end plate location in every mimic muscle. Two classical uses, the maximum strength of contraction and the dermal injection, are associated to the action on the resting tone for more evolved cases. Finally, a new possibility for botulinum toxin injection is the blockage of muscular regeneration to stabilize the section of the age marker fascicules performed in the Face Recurve concept. This new indication is also useful in reconstructive surgery for treatment of the marginal mandibular lip deformity in patients with chronic unilateral facial palsies.

[Midface region: functional anatomy, ageing process, indications and concentric malar lift]. / La région médiofaciale : anatomie fonctionnelle, vieillissement, indications thérapeutiques et lifting malaire concentrique.

Functional anatomy indicates the specificities of the most mobile zone of the face. Ageing process analysis, with the help of CT scan and MRI, confirm the validity of the Face recurve concept: the repetition of the contraction of certain fascicles of the mimic muscles is responsible for the deep fat diminution. For the first time, two fascicles of the orbicularis oculi muscle, malar part, are demonstrated to cause the recession of the inferior orbital rim and of the mid part of the malar bone. Medical and surgical indications are differenciated, depending on the palpebral and midface skin excess. In case of noticeable skin excess, the concentric malar lift can remove vertically the major part of it, reposition the deep and superficial fat at it's original location and weaken the age marker fascicles. Restoration of the periorbital bone volume could be a challenge in the future.

[Z-plasty low tension]. / Plasties en Z basse tension.

Performing a conventional Z-plasty on postburn scar tissue frequently leads to varying degrees of necrosis of the tips of the transposed flaps. In the conventional technique, the flaps are transposed first by anchoring the tips and then by performing the other sutures. In this order, the tips are subjected to a high degree of tension. Again, according to the conventional technique, perpendicular incisions are performed along the tips, which do not ensure the effective vascularisation of the tips in this context of postburn scarring tissue with loss of dermal blood flow. Two technical modifications are proposed: a different approach to the tension by first of all anchoring the base of the flaps and not by classical first suturing of the tips and the performance of oblique incisions away from the tips to ensure a maximum vascularisation of the subdermal fatty tissue. These two elements have allowed us to improve the results of our plasties.

[Use the hyaluronic acid according to the concept Face Recurve: vacuum technical and interpores technical]. / Emploi de l'acide hyaluronique selon le concept du Face Recurve: vacuum technique et interpores technique.

Two new applications of the Face Recurve concept to hyaluronic acid injections are: --the vacuum technique, for deep and for retro muscular injections, which is performed to avoid diffusion and increase precision; --the interpore technique for superficial injections, which is performed in the epidermis to macroscopically erase the interpore wrinkle and to decrease the pore diameter.

Timing optimizes sustained-release indomethacin treatment of osteoarthritis.

Chronopharmacologic studies of indomethacin have indicated that time of dosing influences tolerance and effectiveness. A double-blind, crossover chronotherapeutic trial was undertaken in 66 subjects with osteoarthritis of the hip or knee who were treated with an indomethacin sustained-release (ISR) oral preparation once a day. Varying the ISR dosing time resulted in a quadrupling of tolerance and a doubling of analgesic effectiveness. Three dosing times (8 a.m., noon, and 8 p.m.), each tested during 1-wk spans and randomized for sequencing, were compared in each subject. Subjects self-rated pain intensity every other hour before (1 to 2 days) and during each week of treatment. Morning dosing was associated with a 32% incidence of undesirable effects, whereas the comparable rate was 7% for evening dosing. Ninety-five percent of the subjects reported increased drug effectiveness with a change in ISR ingestion time. The time of dosing that resulted in optimal effectiveness differed among subjects. This was explainable by large interindividual differences in the circadian variation of self-rated pain intensity. Evening dosing was most effective in subjects with predominantly nocturnal or morning pain; conversely, morning or noon dosing was most effective in subjects with greater afternoon or evening pain. The differences that resulted from varying the timing of the identical ISR dose in the same subject greatly exceeded those reported for other nonsteroidal anti-inflammatory drugs.