Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty.

Anchor or lid invagination blepharoplasty is an operation giving neat, crisp, and youthful lids of a permanency unobtainable by traditional techniques. It allows the surgeon to preserve precious lid skin and give optimal results. Although there is more postoperative edema, long-term results verify the efficacy of the technique. This article represents the author's 25 years' experience with thousands of patients, both Caucasians and Orientals, undergoing invagination-technique lid blepharoplasty procedures.

Canthopexy as a routine blepharoplasty component.

Canthopexy should be a routine companion or alternative to lower lid blepharoplasty. It restores tone and youthful contour to the deteriorating eye, and it reduces or eliminates the need to resect skin that in truth is not excessive, but appears so owing to dropped lid posture from lid atonicity. Canthopexy with fat reduction and enhancement of the deficient suborbital portion of the malar complex should be the principal thrust of lower lid surgery. Skin removal accompanies this only when there is true excess and redundancy. Transconjunctival or stab wound fat removal are preferred procedures when there is no excess skin to remove. Canthopexies are possible through lower lid incisions, through upper lid incisions, or via coronal type access. They are an essential companion to aesthetic blepharoplasty if the surgeon wishes to prevent deformity.

Tear trough implants for correction of tear trough deformity.

This essay describes the tear trough deformity and its extension into the cheek. It is an extremely common and consistently deforming characteristic of the lower orbital region. The article focuses on cause and correction. A suborbital malar implant designed to alleviate the deformity is now available from an implant manufacturer in a variety of sizes. The procedure provides in most instances a definitive correction of a significant disfigurement.

Periorbital aesthetic surgery for men. Eyelids and related structures.

This article has provided an overview of recent advances and contemporary philosophy in male blepharoplasty and aesthetic periorbital surgery. It has emphasized the importance of proper brow positioning, invagination procedures on the upper lid with minimal skin excision, restoration of tone in the lower lid without deforming the aperture, designing skin and muscle excisions to prevent deformity, and repair of the deforming tear trough or nasal-jugal ditch through an extremely helpful new tear trough implant.

Alloplastic augmentation of the anterior mandible.

Alloplastic implantation of the anterior mandible--and when indicated, the posterior mandible--is not only a surgical technique but also a carefully and meticulously learned art form. The day of stuffing preformed and poorly thought out commercial implants into a chin without consideration of host contour is hopefully behind us. During the decade of the 1990s and in subsequent years, the demand will continue to be for a carefully conceived, carefully prepared, and exactly executed repair of mandibular contour defects. The availability of new implant designs makes this actualization a simpler task. Familiarity with osteoplastic techniques and orthodontic possibilities, constraints, and processes allows the aesthetic surgeon to select properly those cases for which alloplastic implantation offers the best solution to the existing problem.

Optimal procedure in secondary blepharoplasty.

Secondary repair is a common necessity after blepharoplasty. The need stems from faulty methodology in primary aesthetic periorbital repair. Rethinking initial procedures with careful attention to diagnosis, planning, and execution in the light of contemporary knowledge should eliminate the need for most secondary repair. The procedures that have been traditional over the last 50 years are obsolete today, as we have come to a better understanding of blepharoplasty. It is appropriate that conceptualization and technique change to eliminate the massive and growing volume of secondary deformity. Redirecting the focus in secondary repair, both in the upper and lower orbital regions, gives reoperation a greater chance of success, while avoiding ill conceived solutions that accentuate deformity.

The art of eyelid and orbital aesthetics: multiracial surgical considerations.

Contemporary philosophy on eyelid surgery mandates a totally new approach to orbital aesthetics and aesthetic surgery of the orbital region. This demands, first of all, that the aesthetics be defined and that the surgeon understand its ingredients, the potential for repair, and the close relationship between optimal function and optimal aesthetics. This revised approach results in enhancement of the quality of the operative repair and of patient satisfaction.

The surgical correction of the non-Caucasian nose.

Repairing the non-Caucasian nose can be satisfying to both patient and surgeon. Goals should be directed towards restoring balance and accent--not the elimination of racial characteristics. Careful technique, adhering to a group of principles, leads to exciting results with minimal morbidity and complications.

Precision planning in blepharoplasty. The importance of preoperative mapping.

Routine standardized periorbital planning prior to blepharoplasty and brow lifting facilitates optimal outcome and minimizes the need for reoperation. It should be an essential companion to blepharoplasty in all instances.

Diagnosing photographic distortion. Decoding true postoperative contour after eyelid surgery.

A method of "decoding" deceptive blepharoplasty photographs resulting from head postural changes (or changes in camera planes) between pre- and postoperative photographs is now available. One need only measure changes in the intercanthal axis relative to the horizontal plane of the face. Each degree of alteration of the axis represents 1 mm of true postural change in the margin of the lower lid--disguised by head tilt or downward gaze. This new "tool" can expose and help eliminate undesirable techniques that consistently deform the eye through lowered lid posture and increased scleral show, saddening the appearance of the orbital region and the entire face.

The biomechanics of brow and frontalis function and its effect on blepharoplasty.

Understanding the biomechanics and dynamics of eyebrow and frontalis function is essential to controlling the outcome of blepharoplasty. Ignoring the forehead in the pursuit of blepharoplasty excellence dooms to failure any eventual outcome. If, however, the principles laid out in this article become the basis for planning and execution, the final result, measured in the quality of aesthetic repair, will surely improve immensely.

Fishhooks for forehead harnessing.

Coronal lifting can be simplified and dissection enhanced with a system of hooks attached to elastic bands harnessing the forehead and providing steady and symmetrical retraction.

The "Diamond Head" graft for paralytic ectropion of the lower eyelid.

Traditional methods of paralytic ectropion repair fail to elevate the medial lower lid and inferior punctum into the proper position. That deficiency does not exist with relatively simple, time-proven technique we have described. A lazy trapezoidal-shaped cartilage graft attached to a fascial sling restored the lost tone and medial lid posture, thrusting the punctum back into its normal and properly functioning position. The operation takes its name from Diamond Head crater in Waikiki, Hawaii, whose silhouette resembles the required cartilage graft responsible for the correction.

The "pluck and sew" technique of individual hair follicle placement.

A novel and simple approach to single hair follicle transplantation for alopecia is a hair threaded on a curved needle with the follicle attached. It is the best aesthetically acceptable procedure in certain areas, namely the eyebrow, the sideburn, the hair margin, areas requiring precise grafting following face lift procedures, and the eyelash. The presented technique simplifies the precise, oriented placement of single hair grafts and has been time-tested by the senior author for the last 20 years.

Occult chin abscess associated with an autologous chin implant.

The case of an occult abscess associated with an autologous nasal hump cartilage chin graft is presented. The graft was placed 30 years prior to secondary aesthetic surgery performed on December 22, 1992. In the course of the removal of the autologous tissue, an abscess pocket was discovered which subsequently cultured positive for Staphylococcus epidermidis. The area was thoroughly debrided and irrigated, and a preoperatively custom-fabricated silicone elastomer implant was placed. A 2-week course of appropriate antibiotic therapy was administered following receipt of the culture and sensitivity data. The patient suffered no postoperative complications. The bacteriology of implant colonization and infection in the light of host defenses would predict such a course, although, if known preoperatively, the more prudent course of abstinence from alloplastic implantation would likely be dictated in the aesthetic surgery patient.

Comparative and multilaboratory studies of two immunodiffusion method enrichment protocols and the AOAC/Bacteriological Analytical Manual culture method for detection of Salmonella in all foods.

The single enrichment immunodiffusion (1-step), the preenrichment and selective enrichment immunodiffusion (2-step), and the AOAC/Bacteriological Analytical Manual culture methods for Salmonella were evaluated for equivalence in 2 separate studies, a comparative evaluation and a multilaboratory dilution study. In the comparative study, all 3 methods were performed on 10 food types. For 550 samples, analyses resulted in 99.3 and 99.6% agreement between the culture method and the 1-step and 2-step methods, respectively. False negative rates were 0.9 and 0.3% for 1-step and culture, and 0.0% and 0.6% for the 2-step and culture, respectively. Subsequently, 6 food types were included in a multilaboratory dilution-to-extinction study. A sequential dilution series of Salmonella in foods was analyzed by the 3 methods to determine their lower limits of detection for Salmonella. A total of 1185 samples analyzed resulted in 98.9% agreement between 1-step and culture, and 99.7% agreement between 2-step and culture. False negative rates were 1.8 and 0.1% for 1-step and culture, and 0.4 and 0.1% for 2-step and culture, respectively. During these evaluations, 1735 samples and controls representing 10 different naturally contaminated and inoculated foods were tested. The data indicate statistical equivalence of all 3 methods when analyzing all food types.

Elevated-temperature, colorimetric, monoclonal, enzyme-linked immunosorbent assay for rapid screening of Salmonella in foods: collaborative study.

A collaborative study was performed by 30 laboratories in 3 sets of trials to validate a modified colorimetric monoclonal enzyme-linked immunosorbent assay (ELISA) method for Salmonella detection. The modifications to the current methodology included incubation of enrichments and post-enrichments at an elevated temperature, addition of novobiocin to the M-broth post-enrichment, and elimination of the centrifugation and agitation steps. Five artificially contaminated foods (nonfat dry milk, milk chocolate, dried egg, ground black pepper, and soy flour) and 1 naturally contaminated food (raw ground turkey) were analyzed. The artificially contaminated foods were inoculated with individual Salmonella serotypes at a high (10-50 cells/25 g) and low (1-5 cells/25 g) contamination level. Results from the modified ELISA method were compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method. In 2 of the food products, milk chocolate and pepper, a number of laboratories isolated Salmonella from un-inoculated control samples, thus invalidating their data. As a result, there were too few laboratories remaining with valid data, and these foods were repeated. In the completed study, there were 11 false negative results obtained by the modified ELISA method, while there were 28 false negatives produced by the BAM/AOAC procedure. There were 11 ELISA positive assays which could not be confirmed by culture methods. Statistically, there were no differences between the modified, colorimetric, monoclonal ELISA and the reference culture method in all foods except raw turkey, where the ELISA method was more productive. The colorimetric monoclonal enzyme immunoassay (Salmonella-Tek) method for detecting Salmonella in all foods has been adopted first action by AOAC INTERNATIONAL.

Computer imaging: true or false.

Technologic advancements in the field of computer imaging are providing plastic surgeons with the ability to give patients a visual forecast of postsurgical outcome and serve as a platform for improved doctor-patient communication. This same technology allows the convenient and stable storage, cataloguing and rapid retrieval of massive numbers of photographs in minimal space. Along with these positive aspects, negative ones are becoming apparent. Poor prediction of outcomes by the physician, whether conscious or not, could result in patient dissatisfaction with what might be an optimal operative result. The hard copy evidence of the predicted outcome may then serve as evidence in our very unyielding legal system. Our inability to discern altered from unaltered photographs, negatives and slides presents our profession with ethical challenges in the presentation of data to our peers. Some partial solutions are discussed but the advent of this new technology calls us to a unique and absolute commitment to professional honesty.