Optimizing Brazilian Buttock Lift Results Using the BBL Assessment Tool.

The most distinguished feature of the female silhouette is the buttock. As such, the Brazilian Butt Lift (BBL) has become the most popular plastic surgery procedures in recent years. Despite the popularity of this buttock reshaping and augmentation procedure, there remains no prevailing standard for evaluating, planning surgical design, and objectifying buttock size and shape outcomes. In fact, we have observed a wide range of preferred buttock size and shapes among our patients. We have previously published the BBL assessment tool that serves to guide patient communication of their preferred buttock size and shape. In this study, we demonstrate how the BBL assessment tool can serve to optimize Brazilian Buttock Lift results. We present 25 case studies of how the BBL assessment tool can serve to optimize BBL results by providing a guide for evaluation, surgical design, and objectification of outcomes.Level of Evidence IV Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Breast Lift Algorithm for the Treatment of Breast Implant Illness Requiring Implant Removal.

BACKGROUND: The recommendation of breast lift surgery in the setting of patients requiring breast implant removal is twofold. First, a breast lift is indicated for patients who present with breast mound or nipple-areolar complex ptosis. Second, a breast lift is indicated to accommodate the forecasted redundancy in skin and breast ptosis created by implant explantation. The most popular approaches to mastopexy include the inferior and superior pedicled breast lifts. We present a surgical algorithm with diagrams and cases clarifying mastopexy approaches for patients desiring breast implant removal in patients presenting with breast implant illness syndrome. METHODS: An algorithm was developed to explain the process for selecting the ideal pedicle approach for mastopexy and implant removal surgeries. RESULTS: Three cases are presented to illustrate the application of each pedicle under different presentations and goals. CONCLUSIONS: Advantages of an inferior pedicle include the capacity for unlimited lifting of the nipple-areola complex and for preservation of maximal breast mound volume. Its disadvantages include the inability to remove the breast capsule simultaneously and contraindicated if the lower breast pole is contracted. The advantages of a superior pedicle include the ability to remove the entire capsule and to eliminate lower breast pole if it is contracted. Its disadvantages include limitations to how high the nipple-areola complex can be lifted and the inability to preserve maximal breast mound volume. With the current trend for the request of implant removal in patients presenting with breast implant illness syndrome, the algorithm presented may assist surgeons with selecting the ideal breast lift and implant removal approach. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A new technique involving a spherical stainless steel device to optimize positioning of the umbilicus.

BACKGROUND: Creating an aesthetically pleasing umbilicus may be challenging due to various factors that involve the patient limitations and suboptimal techniques available to the surgeon. Although many techniques aim to locate the umbilicus after abdominoplasty, none are ideal. The authors use a new technique involving a stainless steel spherical device for definite location of the new neo-umbilicus site. METHODS: Abdominoplasty with full muscle plication and umbilicoplasty was performed to test the effectiveness of this new technique that involves a stainless steel marble called the Umbilicator. It has a diameter of 1.5 cm and three 2-mm holes drilled 120° apart in an equilateral triangle. The Umbilicator is secured to the inferior and superior dermis of the umbilical stalk to help identify the future location of the umbilicus on the abdominal skin. Once the marble is secured, the superior abdominal flap is redraped and trimmed, the suture is repaired, and the location of the umbilicus is determined by feeling for the smooth spherical surface bump with gentle downward pressure on the overlying abdominal skin located within the proximity of the umbilicus. RESULTS: The result of this technique produced a definitive means of identifying and delivering the umbilical stalk during abdominoplasty. This technique has been performed in 23 consecutive abdominoplasty procedures with no difficulties locating the umbilical stalk and no infections resulting from the procedure. CONCLUSIONS: Accurate identification of the umbilicus provides the ability to create an aesthetically pleasing neo-umbilicus, thus optimizing abdominoplasty results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Cortical thickness parameters for endoscopic browlift fixation.

BACKGROUND: Techniques for endoscopic browlift include bony fixation over the lateral frontal region and soft tissue fixation over the temporal region. Although bony fixation over the lateral frontal region is advocated universally, limited information exists about bicortical thickness in this area. OBJECTIVES: The authors provide bicortical thickness measurements between the frontal midline and the most inferior temporal region to assist surgeons in identifying appropriate fixation planes. METHODS: Bicortical thickness was measured in the hemicraniums of 13 female cadavers, along the coronal planes that travel through the anterior border of the mandibular condyles and at the junction of the posterior mandibular condyles and the external auditory meatuses. Measurements began at the midline and coursed laterally at 1-cm intervals. RESULTS: Average cranial thickness along the frontal region ranged from 8.9 ± 2.4 mm to 6.4 ± 2.8 mm over the anterior coronal line and 8.8 ± 2.2 mm to 5.6 ± 1.8 mm over the posterior line. Average thickness along the temporal region ranged from 5.6 ± 2.8 mm to 2.8 mm ± 1.4 mm over the anterior coronal line and 5.1 ± 1.8 mm to 3.4 ± 1.4 mm over the posterior line. Minimum thickness was 3.7 mm and 1.3 mm over the frontal and temporal regions, respectively. There was no significant difference between left and right hemicranial thickness. CONCLUSIONS: To avoid violation of the inner cortex during surgery, endoscopic browlift procedures should include measurement of cortical thickness at various fixation points. Bony fixation over the temporal region should be avoided. Minimal bicortical thickness was observed in the lateral frontal region.

Bony anatomic landmarks to avoid injury to the marginal mandibular nerve.

BACKGROUND: Marginal mandibular nerve injuries are more likely to be symptomatic than other facial nerve injuries following facelift procedures. The marginal mandibular nerve courses over the facial artery in the region of the mandible. The nerve is most susceptible to injury in this location because it lies superficial to the anterior facial artery. OBJECTIVES: The authors describe the location of the marginal mandibular nerve based on superficial anatomic landmarks as it crosses the facial artery above the mandibular border, in order to help surgeons avoid injury to this nerve during facelift procedures. METHODS: Eighteen cadaveric facial halves were dissected with the aid of loupe magnification. The distance from the facial artery to the palpable masseteric tuberosity at the angle of the mandible was measured. The distance from the masseteric tuberosity to the mental midline was also measured to determine a ratio of the facial nerve from the masseteric tuberosity to the mental midline. RESULTS: The facial artery was found to be an average of 3.05 ± 0.13 cm anterior to the masseteric tuberosity along the mandible. The marginal mandibular nerve crossed the facial artery along the mandibular border approximately 3 cm anterior to the masseteric tuberosity. The distance from the masseteric tuberosity to the mental midline averaged 11.3 ± 0.54 cm. Therefore, the marginal mandibular nerve courses superficial to the facial artery at approximately one-fourth of the distance from the masseteric tuberosity to the mental midline. CONCLUSIONS: Knowledge of the masseteric tuberosity and mental midline landmarks of the facial artery can provide a reliable and safe approach to surgery of the lower face.

Objectifying High-Definition Brazilian Buttock Lift Results Using the Buttock Assessment Tool.

BACKGROUND: The buttock is an essential feature of the female silhouette. This has led to the rise of the Brazilian butt lift as one of the most popular plastic surgery procedures in recent years. Despite this popularity, there remains no prevailing standard for the ideal buttock size and shape. In fact, a wide range of preferred sizes and shapes among the authors' patients has been observed. The authors hypothesized that age, religious affinity, and ethnic differences may demonstrate different buttock size and shape preferences. METHODS: The authors designed the buttock assessment tool, which utilizes digitally altered buttock sizes and shapes to determine desired buttock shape (upper, middle, and lower pole maximum fullness) and buttock size (waist-to-hip width ratio) for both the posteroanterior and lateral views. A survey of 422 patients was completed, evaluating variation of desired buttock size and shape based on patient age, cultural, and ethnic differences. RESULTS: There were significant differences in buttock size and buttock shape based on age, ethnicity, and religion. Hispanics and African Americans were twice as likely as Caucasians to request lower pole fullness in the posteroanterior view. Older respondents preferred a smaller buttock in both views. African Americans preferred a larger buttock compared to Caucasians in both views. Hispanics preferred a larger buttock in only the lateral view. Muslim respondents preferred a smaller buttock in the posteroanterior view. CONCLUSION: The Brazilian buttock assessment tool has become critical to understanding and delivering prospective Brazilian butt lift patients' goals by objectifying buttock size and shapes.

Eyebrow peak position redefined.

BACKGROUND: The aesthetically appealing eyebrow shape has been defined by its arch, located near the junction between the medial two-thirds and lateral one-third. The position of this arch has been historically described by arbitrary anatomical landmarks that have no logical structural relationship. Moreover, selection of endoscopic brow lift incision sites that define vector of pull and fixation points have been variably described. OBJECTIVES: The authors examine the position of the deep temporal fusion line to determine whether it can act as a more accurate and functional landmark than prior anatomical landmarks for the eyebrow peak position. METHODS: Eyebrows were measured in 50 subjects from the medial aspect of the eyebrow to the a) deep temporal fusion line (ridge), b) eyebrow peak (arch), c) lateral aspect of the brow, and d) lateral limbus. Pearson's correlation, descriptive statistics, and student's t test results were obtained. RESULTS: Eyebrow measurements demonstrated that the deep temporal fusion line is the most precise indicator of brow peak position among all examined landmarks. The Pearson correlation value was strongest between brow peak and deep temporal fusion line (P = .860) and a t test confirmed this observation with no significant difference between brow peak and deep temporal fusion line. The lateral limbus and medial two-thirds lateral one-third junction more accurately predict brow peak in females, but the deep temporal fusion line is an equally reliable predictor of brow peak for males and females. CONCLUSIONS: These findings suggest that placement of endoscopic brow lift incisions and subsequent fixation points may be best defined along the deep temporal fusion line.

Anatomical characteristics of the conchal cartilage with suggested clinical applications in rhinoplasty surgery.

BACKGROUND: Numerous cartilage grafts from a number of donor sites have been described, each with a different shape and size. These donor sites include the nasal septum, costal chondral cartilage, and the conchal bowl. Although harvests from the conchal bowl are commonly-employed, the techniques have been minimally-described in the literature, particularly as it applies to rhinoplasty. OBJECTIVES: The authors identify differences in the conchal bowl cartilage parameters that could aid in the planning and harvesting of conchal grafts during augmentation rhinoplasty. METHODS: The authors dissected ears from fourteen cadavers (eight females and six males), ranging between 59 and 77 years of age. The conchal bowls were isolated, after which a reference point or was marked at the junction of the helical root and the conchal extension of the helical root. A cartilage grid was mapped out at 3-mm interval divisions with a horizontal limb axis parallel to the helical root extension and a vertical limb axis perpendicular to the latter. Conchal cartilage width, height, and thickness were then measured. Axial tissue slices were harvested and histologic preparations completed with hemotoxylin and eosin (H&E) staining to delineate microscopic characteristics of the cartilage. RESULTS: Maximum conchal bowl width ranged from 1.9 to 2.9 cm and was widest on average over the cymba (2.4 ± 0.3 cm). Maximum conchal bowl height ranged from 1.7 to 3.1 cm and was greatest on average over the region posterior to the junction of the helical root and conchal bowl (2.4 ± 0.5 cm). Conchal bowl thickness ranged from 1.9 to 4.4 mm and was observed thickest over both the conchal extension of the helical root (3.5 ± 0.4 mm) as well as over a distinct region in the inferior-anterior aspect of the cavum (3.7 ± 0.9 mm). No difference in thickness was observed between the conchal extension of the helical root (3.5 ± 0.4 mm) and the distinct region in the inferioranterior aspect of the cavum (3.7 ± 0.9 mm; P > .05). Naturally-occurring cartilaginous divisions were appreciated on histologic specimens located at the junction of the cavum and external auditory meatus and at the junction of the helical root and conchal extension of the helical root. CONCLUSIONS: The results, examination, and outline of conchal bowl parameters from cadaver cartilage demonstrated in this article will aid the surgeon in effectively obtaining the appropriate cartilage grafts for placement during rhinoplasty.

Masculinized Male Chest Contouring: Creating the Armor Plate.

Male patients are routinely consulted regarding dislike of their chest appearance. To date, majority of patients have desired elimination of their feminine-appearing breast, termed gynecomastia. These patients have associated their overweight body image, with the femininity of their breasts as presented by fullness and roundedness of their breasts and subsequently have desired maximal flattening of their breast. We present a new set of patients who desire a more muscular-appearing chest than a gynecomastia repair that is interposed on a chiseled abdominal contour. In contrast to the former set of patients, these patients desire bulking of their breasts with a bolder-appearing armor plate look. We present an alternative to traditional gynecomastia repair which involves a novel approach to chest contouring creating a flat, yet bold, pentagonal-shaped breast with linear borders utilizing both fat and gland removal as well as strategic fat grafting back into the chest. We present a novel protocol to create an armor plate male chest appearance as an alternative to traditional gynecomastia contouring. All patients treated to date demonstrate a muscular-appearing chest that is harmonious on an interposed masculine-appearing abdomen.

Successful Back Contouring With Elimination of Back Rolls Using Ultrasound-Assisted Liposuction and Helium-Activated Radiofrequency.

BACKGROUND: Patients are routinely consulted regarding dislike of their upper and middle back contour and associated back rolls that stick out of their bras. Although patients only associate this fullness with excess fat, on examination it becomes evident that back rolls are due to a combination of excess fat as well as skin redundancy. To date, treatment of both excess skin and fat in back rolls has required consideration of excisional surgery such as an upper body lift. OBJECTIVES: We present 14 consecutive back contouring cases that were treated with an alternative protocol involving simultaneous ultrasound assisted liposuction and helium activated radiofrequency. METHODS: Patients underwent ultrasound assisted liposuction to remove superficial fat over the upper and middle back as well as helium activated radiofrequency to tighten the skin using subdermal coagulation. RESULTS: All 14 patients visually demonstrated elimination of back rolls and improvement in upper and middle back contour. All 14 patients also reported overall satisfaction in their postoperative follow-ups at 3, 6, and 12-months. CONCLUSION: In summary, simultaneous ultrasound assisted liposuction and helium activated radiofrequency provide an effective treatment for patients desiring improvements in upper and middle back contour and elimination of back rolls while avoiding more invasive excisional surgeries.

Understanding Why Lateral Osteotomy During Rhinoplasty Can Be Performed Safely.

Background: Lateral osteotomy is a mainstay of rhinoplasty surgery and involves fracture of the nasal and maxillary bones to narrow or widen the nasal dorsal bridge and base. To avoid nasal midvault collapse following rhinoplasty, the accepted "high-low-high" lateral osteotomy technique advocates for the preservation of a triangular strut of maxillary bone when initiating the osteotomy. Objective: We evaluated the risk of starting a lateral osteotomy in the "high" position to leave the aforementioned triangular maxillary strut without risk of falling into the nasomaxillary suture line, which can result in an aberrant and uncontrolled fracture. Methods: We utilized high-definition computed tomographic scans to reconstruct layered 3-dimensional images of 20 patient skulls and measured the distance from the rhinion (most inferior point of the central nasal bone junction) to the nasomaxillary suture line and from the rhinion to the maxillary groove. Results: We found that the nasomaxillary suture line was reliably only halfway down the bony nasal pyramid and not in proximity to the maxillary groove. Conclusions: Our findings provide reassurance that a generous triangular strut can be preserved along the maxillary component of the piriform aperture without concern of falling into the nasomaxillary suture line. Thus, controlled lateral osteotomies can be performed safely to achieve aesthetic gains without fear of compromising midvault stability.

Upper Vault Septal Anatomy and Short Nasal Bone Syndrome: Implications for Rhinoplasty.

Introduction: This is a diagnostic study that investigates the clinical significance between patients with short and long nasal bones and the variation in upper septal composition that would delineate propensity for middle vault collapse. Methods: Computed tomographic scans of 16 female patients undergoing evaluation with sinus films were analyzed. Two measurements were taken from each scout image: nasal bone length and total nasal length. Patient scans were separated into 2 groups; patients whose nasal bone length was less than one-half their total nasal length were defined as patients with "short nasal bone" (n = 8), and those with nasal bones longer than one-half the length of their noses were defined as patients with "long nasal bone" (n = 8). Results: Key differences were identified between patients with short and long nasal bones. Total septal area in the upper vault was decreased in the short nasal bone group relative to that of the long nasal bone group (5.7 ± 0.6 cm2 vs 8.1 ± 1.0 cm2, P = .002). This was mainly the result of the decreased ethmoid bone component in the short nasal bone group when compared with the long nasal bone group (1.6 ± 0.6 cm2 vs 3.2 ± 0.8 cm2, P = .007).

The Danger Zone in the Anterior Neck: Anatomical Landmarks to Avoid Injury to Anterior Jugular Vein During Face-Lift and Neck-Lift.

Background: An estimated 125,711 face-lifts and 54,281 neck-lifts were performed in 2015. Regardless of the technique employed, facial and neck flap elevation carries with it anatomical risk of which any surgeon performing these procedures should be aware of. Statistics related to anterior jugular vein injury during these procedures have not been published. Objective: To define a "danger zone" that will contain both of the anterior jugular veins on the basis of anatomical landmarks to aid surgeons with planning their surgical approach during rhytidectomy in the anterior neck region. Methods: Ten fresh tissue heminecks were dissected. All specimens were dissected under loupe magnification in a 45° (face-lift) position in which a midline incision was used for exposure. Measurements from the anterior jugular vein to the hyoid, thyroid cartilage, and cricoid cartilage bilaterally were taken. The transverse distance between the anterior jugular veins at the level of the hyoid, thyroid cartilage, and cricoid cartilage was also measured. Results: The anterior jugular veins remain in an anatomical danger zone while they travel in the anterior neck. Regardless of anatomical variation of the vessels between bodies, they generally reside in this danger zone from their inferior emergence behind the sternocleidomastoid muscle until they branch in the suprahyoid region. Conclusions: Knowledge of the anatomy, course, and location of the anterior jugular veins through the anterior neck based on anatomical landmarks and distance ratios can facilitate a safer dissection during rhytidectomy procedures.

Avoiding the "pixie-ear" deformity following face lift surgery by differential insetting and secondary intention healing.

BACKGROUND: The "pixie-ear" deformity has been described by its "stuck-on" or "pulled" appearance, due to the extrinsic pull of the cheek and jawline skin flaps on the earlobe attachment point (O), the otobasion inferius. The tension results in migration of the earlobe attachment point from a posterior cephalad position to an anterior caudal position. Recently, the 2 components of the earlobe, the attached cephalic segment (I to O distance) and the free caudal segment (O to S distance), have been defined. OBJECTIVE: We describe a novel technique involving differential insetting of the cheek and jawline skin flaps to the earlobe and secondary intention healing to create an aesthetically pleasing cephalic attached segment. METHODS: Rhytidectomy was performed using an extended superficial muscular aponeurotic system (SMAS) technique along with jawline undermining. The earlobe soft-tissue-retaining ligaments to the mastoid were released to the level of the new otobasion inferius to creat a cephalic attached segment less than 1.5 cm, which allowed the caudal free segment to approximate 0.5 cm. Whereas the cephalic segment was directly repaired, the free caudal segment anterior and posterior skin flaps were not reapproximated and were to heal by secondary intention. RESULTS: In a series of 20 consecutive patients, excellent aesthetic results were obtained using this approach without healing complications, hypertrophic scarring, or "pixie-ear" deformity. CONCLUSIONS: Our approach for cheek and jawline skin flap fixation to the earlobe eliminates any vector of pull on the free caudal segment of the earlobe and, consequently, any potential for "pixie-ear" formation. We advocate allowing the free caudal segment to heal by secondary intention, which results in the medial edge of the free caudal earlobe attaining a curved and blunt-edged appearance that is aesthetically superior to primary repair.

Vitamin E inhibits melanoma growth in mice.

BACKGROUND: Previous work has demonstrated that vitamin E succinate (VES), an ester analogue of vitamin E, inhibits the growth of melanoma in vitro. However, there is no information about the effect of VES on melanoma in vivo. We investigated the effect of VES on melanoma in vitro and in vivo. METHODS: The effect of VES on the proliferation and apoptosis of the B16F10 murine melanoma cell line was determined by a modified Cell Titer 96 AQ assay and a cell death detection enzyme-linked immunosorbent assay, respectively. The in vivo effect of VES on B16F10 melanoma cells allografted in athymic nude mice was investigated. The mechanism of the in vivo antitumor effect of VES was determined by immunohistochemical detection of proliferation and apoptosis. RESULTS: VES decreased cell proliferation (P =.0001) and increased cell apoptosis (P =.0001) in a dose-dependent manner in vitro. Also, VES significantly inhibited melanoma growth in mice (P =.0013). The VES antitumor effect in vivo was associated with a significant increase in the melanoma apoptosis rate (P =.0256). CONCLUSIONS: This is the first report of the antimelanoma effect of VES in vivo. The mechanism of the antimelanoma effect of VES in vivo involves the promotion of tumor cell apoptosis. These findings support future investigations of VES as a therapeutic micronutrient against melanoma.

Volume analysis of preadipocyte injection for vocal cord medialization.

OBJECTIVE: To compare the volume retention of injected preadipocytes with that of standard fat injection in a paralyzed rabbit true vocal cord. STUDY DESIGN: Prospective analysis with blinded data collection. METHODS: Thirteen New Zealand white rabbits were divided into two groups. Group 1 consisted of seven animals undergoing left-side vocal cord paralysis by resection of a 1-cm segment of the left-side recurrent laryngeal nerve and abdominal fat harvest for isolation of preadipocytes. Preadipocytes were cultured under sterile conditions in cell culture media. Animals in group 2 also underwent left-side vocal cord paralysis without fat harvest. After 10 to 14 days, in a second procedure, group 1 underwent injection of 0.1 mL cultured autologous preadipocytes, and group 2 underwent routine injection of 0.1 mL abdominal fat harvested during the same procedure. At 6 and 12 months, volumetric analysis was performed. RESULTS: Volume analysis at 6 months showed a mean volume of 0.029 mL retained fat in group 2 representing a retention of approximately 29% (SD = 0.023) of the original injected volume. Retention in group 1 animals approximated 0.002 mL (SD = 0.0024) or 2% of the injected volume. Analysis at 12 months showed a mean volume of 0.008 mL (SD = 0.0078) in group 2 and of 0.002 mL (SD = 0.0015) in group 1. Group 2 showed significantly higher volumes of the injected fat at 6 and 12 months (P <.033). CONCLUSION: Volumes obtained with standard fat injection were superior to those obtained with preadipocyte injection at both 6 and 12 months.

A tissue-engineering technique for vascularized laryngotracheal reconstruction.

OBJECTIVE: To perform laryngotracheal reconstruction (LTR) using a vascularized neotracheal segment. DESIGN: A neotracheal segment was created within the sternocleidomastoid muscle. An anterior cricoid split procedure was performed using a pedicled, vascularized neotracheal segment. Results were compared with a control group that underwent anterior cricoid split using standard (avascular) autografted cartilage. Cross-sectional area, cartilage viability, extrusion, mucosalization, and wound healing were compared between groups. SUBJECTS: Sixteen female New Zealand white rabbits. INTERVENTIONS: Eight animals underwent placement of a cartilage-wrapped silicone implant into the sternocleidomastoid muscle. After 2 weeks, the silicone implant was removed, leaving a fibrovascular "foreign body" capsule and the interwoven autografted cartilage. The neotracheal segment was trimmed to create an anterior graft for LTR. The remaining animals underwent standard anterior graft LTR using autografted auricular cartilage. The reconstructed segments were harvested for comparison at 2 and 4 weeks. RESULTS: All reconstructed animals survived the postoperative period. No significant differences in stenosis rates or mucosalization were noted between groups. Two animals in the standard LTR group had microabscess formation, and no graft extrusions were encountered. CONCLUSION: A pedicled neotracheal graft can be used for anterior cricoid split procedures in rabbits.

The safe face lift with bony anatomic landmarks to elevate the SMAS.

The risk for facial nerve injury has been reported to be increased with the inclusion of superficial musculoaponeurotic system (SMAS) elevation as compared with a skin-only face lift. The facial nerve courses through the parotid gland. The SMAS is elevated superficial to the parotid gland. However, in elevating the SMAS anterior to the parotid gland, the facial nerve is at risk of injury where its branches emerge from the anterior edge of the parotid gland. The purpose of this study was to identify bony anatomic landmarks to predict the location of the anterior edge of the parotid gland to avoid injury to the facial nerve branches as they exit the parotid gland. The authors dissected 20 cadaver face halves to determine bony landmarks-the masseteric tuberosity and the inferior lateral orbital rim-to predict the location of the anterior parotid edge. Then they measured the anterior edge of the parotid gland in relation to the vector formed between these two bony landmarks. They identified and measured the most anterior portion of the parotid gland in relation to this vector. Then the most posterior aspect of the parotid gland in relation to this vector was measured. In the 20 dissections, the authors found the most anterior portion of the parotid gland to be 2.7 +/- 1.0 mm anterior to the vector from the inferior lateral orbital rim to the masseteric tuberosity. The most posterior part of the anterior edge of the parotid gland in relation to this vector was found to be 1.0 +/- 1.5 mm posterior to this vector. The parotid gland measured an average of 38.8 +/- 3.5 mm in width from the tragus to the anterior parotid edge. In elevating the SMAS with a face lift, the facial nerve branches can be predicted to exit the anterior edge of the parotid gland, which can be located 38.8 mm anterior to the tragus and near the vector from the inferior lateral orbital wall to the masseteric tuberosity.

The treatment of alkaline burns of the skin by neutralization.

Literature reports dating as far back as 1927 have lured clinicians into the belief that alkaline skin burns are best treated by water dilution and that neutralization attempts should be avoided. Although this belief has never been substantiated, neutralization of an alkaline burn of the skin with acid was thought to increase tissue damage secondary to the exothermic nature of acid-base reactions. The authors proposed that topical treatment of alkaline burns with a weak acid such as 5% acetic acid (i.e., household vinegar) would result in rapid tissue neutralization and reduction of injury in comparison to water irrigation alone. In a rat skin burn model, animals were exposed to an alkaline injury when filter paper (2 cm in diameter) saturated with 2N sodium hydroxide was placed over the volar aspect of the animal for a period of 1 minute. Treatment was initiated 1 minute after injury and included either neutralization with a 5% acetic acid solution (n = 8) or irrigation (n = 8) with water. Skin temperature and pH were monitored using subdermal needle probes until the pH of the skin returned to physiologic values. Punch-biopsy specimens were obtained from the wound edges 24 hours after injury to assess burn depth and leukocyte infiltration, and biopsies were repeated 10 days later to assess wound healing. The authors proposed that neutralization of an alkaline substance with household vinegar (i.e., 5% acetic acid solution) would result in rapid neutralization and thus reduce extent of tissue injury. Animals treated with acetic acid demonstrated a more rapid return to physiologic pH (14.69 +/- 4.06 minutes versus 31.62 +/- 2.83 minutes; p < 0.001), increased depth of dermal retention (0.412 +/- 0.136 mm versus 0.214 +/- 0.044 mm; p = 0.015), decreased leukocyte infiltrate (31.0 +/- 5.1 cells/high-power field versus 51.8 +/- 6.8 cells/high-power field; p < 0.001), and improved epithelial regeneration (4.0 +/- 0.6 cell layers versus 1.7 +/- 0.5 cell layers; p < 0.001) when compared with animals treated with water irrigation. No difference was detected in peak pH (10.35 +/- 0.28 pH versus 10.36 +/- 0.25 pH; p = 0.47) nor in rise of skin temperature (maximum temperature, 32.8 degrees C versus 32.9 degrees C; p = 0.33) between acetic acid-neutralized and water-irrigated burn wounds. The observed benefits of treating alkaline burns with 5% acetic acid in the rat model are significant and require clinical testing.

Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle.

In the resection of redundant orbital fat during lower blepharoplasty, selective excision is performed from the medial, central, and lateral compartments. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments. When performing a transconjunctival approach, the inferior oblique muscle is even more susceptible to injury because it lies in the direct path of dissection for fat pad exposure. Injury to the inferior oblique muscle can result in symptoms ranging from transient diplopia to a more debilitating permanent strabismus. Fresh cadaver heads were used to identify bony anatomical landmarks that would help to more accurately define the origin and body of the inferior oblique muscle. The orbital rim, infraorbital foramen, and supraorbital notch were chosen as guideline landmarks. The origin of the inferior oblique muscle was designated with respect to the above structures, and the muscle course was delineated. The inferior oblique muscle originates on the orbital floor, 5.14 +/- 1.21 mm posterior to the inferior orbital rim, on a line extending from the infraorbital foramen to 10 +/- 0.9 mm inferior to the supraorbital notch along the supramedial orbital rim. The muscle belly extends from this origin to its insertion into the posterolateral globe in an oblique direction toward the lateral canthal area. Identification of the orbital rim, infraorbital foramen, and supraorbital notch more accurately localizes the origin and course of the inferior oblique muscle, which may facilitate fat resection during lower blepharoplasty by preventing morbidity associated with inferior oblique muscle injury.