New workplace challenges. One year after September 11.

The political and social response to September 11 has required home health employers to address new and sometimes unfamiliar personnel matters. Home care employers must be mindful of certain legal obligations, some imposed quite recently, designed to protect the rights of employees both on the job and if called away to duty.

A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation.

BACKGROUND: The present study evaluated volumetric changes in the aging midface. Both young and old living subjects were studied using high-resolution magnetic resonance imaging (MRI) to investigate the distribution and volume of the muscle and subcutaneous components of the midface. METHODS: MRI with a customized radiofrequency coil was performed in 20 healthy Caucasian female volunteers equally divided between young (16 to 30 years) and old (>59 years) age groups. Sagittal oblique images were obtained at 1-mm intervals through the midface, perpendicular to the nasolabial fold. Quantitative analyses of the cheek fat pad overlying the levator labii superioris and zygomaticus major muscles were performed separately. RESULTS: For both mimetic muscles, there were no significant differences between young and old subjects in muscle length, thickness, or volume from muscle origin to nasolabial fold. In addition, there were no significant differences between age groups in fatty infiltration of the muscles. The volumes of the medial and lateral aspects of the cheek fat pad were significantly greater in old than in young subjects (p < 0.05). In young subjects the greatest distribution of fat pad volume was found in the middle third of the cheek mass. There was a significant reduction in that portion of the fat pad distributed in the upper third and a further reduction in the lower third (p < 0.01). In old subjects, because of the increased distribution of fat in the upper third of the cheek fat pad, there was no significant difference in volume between the upper and middle thirds of the cheek fat pad. The percentage increase in fat in the upper third relative to the remainder of the midface was significantly greater in old compared with young subjects (p < 0.01). In contrast, the volume of the lower third of the midface was not significantly different between young and old subjects. CONCLUSIONS: The present study indicates that ptosis alone does not account for the changes observed in the aging midface. Selective hypertrophy of the upper portion of the cheek fat pad was also observed. The mimetic muscles, on the other hand, showed no significant differences with aging. To attain maximum precision in facial rejuvenation, these data suggest that after suspension of the ptotic cheek fat pad, each patient should be evaluated for excess bulk in the upper portion of the cheek fat pad. If excess bulk is present, patients may benefit further from selective reduction directed to the upper portion of the cheek fat pad, remaining superficial to the mimetic muscles of the face.