Endoscopic forehead lifting and contouring.

The concept of endoscopic foreheadplasty is based upon a sub- or supraperiosteal dissection of the parietal, occipital and frontal scalp, incision and release of the superior and lateral orbital periosteum, selective myotomies of the brow depressor muscles, and brow elevation into a desired position with fixation and healing. A significant limitation of this procedure appears to be the ability to predict the long-term forehead and brow elevation. We review the anatomy relevant to forehead rejuvenation surgery and present our surgical technique for permanent fixation endoscopic forehead lifting. We discuss the scientific rationale for permanent fixation to ensure long-term forehead and brow position and draw our conclusions based upon the results of animal and clinical studies that have been completed.

The multivectorial subperiosteal midface lift.

Traditional rejuvenation on the midface has been predicated on extension of laterally based rhytidectomy techniques. Recently, attempts to improve this area have been performed through brow access points and are directed superolaterally. Transblepharoplasty approaches have in the past focused on limited rejuvenation of the immediate periocular area. The technique described in this article is a method by which the multiple directions of midfacial aging can be reversed and corrected with greater safety and better visualization than previously described.

Augmentation of the cheeks, chin and pre-jowl sulcus, and nasolabial folds.

The demand for augmentation of central and lower facial features continues to increase. There are several safe and effective materials available for this purpose, and techniques have become highly refined. The relative strengths and weaknesses of silicone, expanded polytetrafluoroethylene (ePTFE), high-density polyethylene (HDPE), and merseline mesh are discussed for augmentation of the chin/pre-jowl sulcus and cheek. Materials for augmentation of the nasolabial folds (NLF) are also discussed. There are various forms of solid ePTFE that have been developed for soft tissue augmentation. These are particularly well suited for the NLF. Techniques for facial skeletal and soft tissue augmentation are presented.

Collagen, human collagen, and fat: the search for a three-dimensional soft tissue filler.

As the body ages, not only are the soft tissues of the face subject to gravity but they also may undergo progressive atrophy. Suspensory procedures may return the tissues to a more youthful position, but the atrophic changes are left uncorrected and produce an aged appearance. Three-dimensional (3-D) soft tissue fillers ideally would replace the bulk that was lost. Safety, persistence, and verisimilitude to the native tissues should be optimal in useful 3-D fillers. To date, no such material has been described, but there has been a resurgence in natural materials for this purpose. This article serves as an update on human-derived soft tissue fillers.

Evaluation of acellular dermal graft (AlloDerm) sheet for soft tissue augmentation: a 1-year follow-up of clinical observations and histological findings.

OBJECTIVES: To evaluate and compare the long-term clinical persistence and histological appearance of subdermally implanted acellular dermal graft (AlloDerm) sheets and intradermal type I bovine collagen cross-linked with glutaraldehyde (Zyplast). PATIENTS: Ten adult patients (5 men and 5 women; average age, 46 years; age range, 37-59 years) not allergic to bovine collagen. METHODS: AlloDerm sheets were implanted surgically in a subdermal plane in one postauricular crease, and Zyplast was injected intradermally on the opposite side. AlloDerm and Zyplast implants were digitally photographed and their apparent volumes calculated at 1, 3, 6, 9, and 12 months after implantation. A specimen was removed at 3 and 12 months and examined histologically for collagen persistence, host tissue invasion, and inflammatory reaction. RESULTS: The apparent implant volume of the AlloDerm sheets decreased during the first 6 months and then stabilized over the next 6 months. By contrast, Zyplast was progressively absorbed, with complete loss of clinical effect by 6 months. Histological analysis of implanted AlloDerm sheets demonstrated progressive repopulation of the graft with minimal inflammation. CONCLUSIONS: AlloDerm sheets seem to provide stable soft tissue augmentation after an early period of resorption and are clearly superior to Zyplast injections for long-term, large-volume, soft tissue correction. Recommendations for clinical use include routine overcorrection, with subsequent augmentation delayed by at least 6 months.

Preoperative identification of psychiatric illness in aesthetic facial surgery patients.

The purpose of this study was to evaluate the preoperative use of a two-part standardized assessment program (Prime-MD, Biometrics Research Department, New York State Psychiatric Institute) to objectively detect psychiatric disorders in facial plastic surgery patients, and to compare its use to findings identified by the facial plastic surgeon. Seventy-five new patients requesting aesthetic facial surgery at two academic centers and two private practice locations were evaluated.

Autologous collagen dispersion (Autologen) as a dermal filler: clinical observations and histologic findings.

OBJECTIVE: To assess the histologic behavior and clinical efficacy of autologous collagen dispersion (Autologen) in augmenting human dermis. SUBJECTS: Adult patients of the Facial Plastic Surgery Clinic at The New York Eye and Ear Infirmary who were undergoing facial aesthetic surgery with skin excision. METHODS: Five patients were injected intradermally with Autologen in one postauricular area and bovine cross-linked collagen (Zyplast) on the contralateral side. Patients were examined clinically for signs of infection, skin necrosis, or implant rejection/allergy 2, 4, and 12 weeks postinjection. Impressions and photographs of all implant sites were taken at all follow-up visits. Biopsy specimens of each implant were taken 4 and 12 weeks after injection and examined histologically for signs of integration, rejection, and resorption. RESULTS: All implants were well tolerated. No identifiable differences were noted in the clinical persistence of Zyplast vs Autologen. Histologically, there was more variability in the degree of fibroblast infiltration of Autologen vs Zyplast deposits. CONCLUSIONS: Our trial suggests that autologous collagen dispersion may represent a viable alternative to bovine collagen. Clinical persistence and histologic behavior of Autologen appear to be at least as favorable as those of Zyplast, and Autologen obviates the need for allergy testing and eliminates the possibility of disease transmission. Arch Facial Plast Surg. 2000;2:48-52

Modulation of tissue ingrowth into porous high-density polyethylene implants with basic fibroblast growth factor and autologous blood clot.

OBJECTIVE: To investigate the effect of direct application of biologic materials normally present in wounds (basic fibroblast growth factor [bFGF] and autologous blood clot [ABC]) to accelerate the bony and soft tissue ingrowth into porous high-density polyethylene implants. METHODS: We conducted a prospective, blinded animal histological study. Disks made of porous high-density polyethylene impregnated with bFGF or ABC were implanted into adult Sprague-Dawley rats in both subcutaneous and subperiosteal locations. Animals were killed and implants were harvested at 2, 4, and 10 weeks postimplantation and examined histologically for fibroblast invasion, collagen deposition, and inflammatory reaction.The results were compared with control (untreated) implants. RESULTS: As a group, the histological results showed significantly more fibroblasts within the ABC-treated implants than control implants or bFGF-treated implants. This difference in the number of fibroblasts between ABC-treated implants and bFGF-treated and control implants was also statistically significant 2 weeks after implantation. CONCLUSIONS: At the concentration of bFGF of 1 microg/10 microL, no acceleration of tissue ingrowth into porous high-density polyethylene implants was noted. However, when porous high-density polyethylene implants were treated with ABC, the implants were invaded to a greater degree by soft tissue, particularly in the early postoperative period (first 2 weeks). Bioactive substances associated with the coagulation and platelet cascades present in the ABC may be responsible for this accelerated incorporation of the porous implant and may have clinical implications. Arch Facial Plast Surg. 2000;2:27-33

Evaluation of acellular dermal graft in sheet (AlloDerm) and injectable (micronized AlloDerm) forms for soft tissue augmentation. Clinical observations and histological analysis.

OBJECTIVES: To evaluate the histological and clinical properties of (1) subdermally implanted acellular dermal graft (AlloDerm) sheets vs intradermal bovine collagen and (2) subdermally or intradermally injected micronized AlloDerm vs type I bovine collagen cross-linked with glutaraldehyde (Zyplast). PATIENTS: Twenty-five adult patients testing nonallergic to bovine collagen. METHODS: (1) Stacked disks of AlloDerm were implanted subdermally behind one ear, and bovine collagen was injected intradermally behind the other. The soft tissue augmentation caused by the implants was measured by digital photography at 1, 4, and 12 weeks, and biopsy specimens of each implant type were examined at 3 months after implantation. (2) Micronized AlloDerm was injected intradermally and subdermally in 2 different locations behind one ear, and bovine collagen was injected in the same manner behind the other. The soft tissue augmentation caused by the implants was measured by digital photography at the time of implantation and at 1 and 4 weeks after implantation. All implants were examined 1 month after implantation. RESULTS: All patients tolerated both implants well. (1) AlloDerm implants retained a higher percentage of the original implant volume than Zyplast at 1 and 3 months after implantation. Histologically, AlloDerm implants were extensively invaded by host fibroblasts without any foreign body reaction. (2) Intradermally injected micronized AlloDerm implants retained a higher percentage of the original implant volume at 1 month after implantation than intradermal Zyplast. Histologically, micronized AlloDerm implants were extensively invaded by host fibroblasts without any foreign body reaction. No significant differences were noted between subdermally injected micronized AlloDerm and Zyplast. CONCLUSIONS: The macroscopic and microscopic behavior of subdermally implanted AlloDerm sheets and subdermally and intradermally injected micronized AlloDerm was compared with intradermally injected Zyplast. AlloDerm sheet volume persisted to a significantly (P < .001) greater degree than bovine collagen during the first 3 months after placement. Clinically, intradermally injected micronized AlloDerm volume persisted to a significantly (P = .01, .04, and .01, respectively) greater degree than intradermal Zyplast or subdermal micronized AlloDerm or Zyplast. Histologically, micronized AlloDerm and AlloDerm are well tolerated at 1 and 3 months, respectively. Host tissue incorporation with fibroblast in-growth and collagen deposition is seen in both materials. AlloDerm and micronized AlloDerm hold promise for use in facial soft tissue augmentation.

Endoscopic foreheadplasty: a histologic comparison of periosteal refixation after endoscopic versus bicoronal lift.

Endoscopic brow lift techniques using temporary fixation rely on rapid readherence of the periosteum to calvarial bone. Little is known about the histologic events that occur during the early postoperative period after these procedures. An animal study was designed to compare and contrast periosteal fixation to bone and unelevated periosteum, with endoscopic and bicoronal brow lift techniques. One method of temporary fixation is the use of absorbable (polylactic/polyglycolic acid copolymer) LactoSorb screws; a histologic analysis of implanted LactoSorb screws was also performed. Sixteen rabbits underwent brow lifts; eight underwent endoscopic brow lift and fixation with LactoSorb screws without skin excision, and another eight underwent traditional bicoronal brow lift with skin excision and closure under tension. Animals were killed 1, 2, 6, and 12 weeks after the procedures were performed to evaluate the interaction of periosteum and bone and the normal, unelevated periosteum/calvarium interface at a site distant from the operative area. Histologic specimens were examined for the degree of apposition of periosteum to bone and for any fibrous or bony reaction at this interface. Histologic analysis showed various degrees of periosteal fibrosis and fixation to calvarial bone. After an initial phase of minimal periosteal adherence and moderate inflammation, the periosteum became progressively more adherent to bone in both groups, with no significant differences between treatment groups in rates of fixation. Fixation required at least 6 weeks. LactoSorb screws were surrounded by an area of mild inflammation and were progressively hydrolyzed and digested. Periosteal fixation increases over time for bicoronal and endoscopic brow lifts with minimal differences between the two techniques. With this animal model, periosteal adherence to calvarium requires at least 6 weeks with complete adherence by 12 weeks. In addition, the use of absorbable fixation screws seems to be both effective and well tolerated. The histologic changes associated with periosteal healing observed in this study suggest that permanent or semipermanent fixation may improve the accuracy and early postoperative maintenance of forehead advancement.

Efficacy of serologic testing in asymmetric sensorineural hearing loss.

PURPOSE: The goal of this study was to determine the efficacy of a detailed questionnaire, auditory brain stem response testing (ABR), MRI, and an extensive battery of serologic tests in diagnosing asymmetric sensorineural hearing loss (ASNHL). METHODS AND MATERIAL: Patients with audiograms demonstrating ASNHL of 10 dB or greater in 2 consecutive frequencies or 15 dB in any 1 frequency between 250 and 6000 Hz were asked to participate. Patients underwent MRI scanning of the cerebellopontine angle, internal auditory canals, and posterior fossa with gadolinium contrast, ABR, and an extensive battery of tests. The causative diagnosis was made by the individual clinician based on each patient's history, physical examination, and test results. RESULTS: Forty-five patients completed the study. A review of the data confirmed the utility of a detailed history and physical examination, MRI, and fluorescent treponemal antibody test in all cases. Erythrocyte sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and total hemolytic component (CH50) were helpful in selected cases. Thyroid function testing, complete blood count, Sequential Multiple Analysis-7, prothrombin time/partial thromboplastin time, lipid profile, and ABR were of no value in these patients. CONCLUSION: A careful history and physical examination, MRI, and fluorescent treponemal antibody test should be performed for the evaluation of all patients with ASNHL; however, more extensive serologic testing, including sedimentation rate, glycosylated hemoglobin, Lyme antibody titers, and CH50, should be selectively performed, based on a suggestive history or suspicious physical findings.

Microtia reconstruction using a porous polyethylene framework.

We describe our method for reconstructing microtic auricles using a porous polyethylene framework in two stages. The first stage of the procedure involves rotating a superficial temporoparietal fascial (TPF) flap over the framework. The inferior two-thirds of this framework is next inset into a local temporal skin pocket, while the superior one-third is covered with a full thickness skin graft from the contralateral postauricular sulcus. Lobular transposition is commenced in a second stage procedure at the three-month postoperative period. Hearing restoration surgery is encouraged at a later date in selected patients with unilateral microtia. Use of the porous polyethylene framework permits a more expedient, less invasive, and more reliable method for auricular reconstruction than does the traditional method that employs costal cartilage.

Injectable fillers for facial soft tissue enhancement.

Soft tissue augmentation materials have been advocated for correction of post-surgical or post-traumatic facial defects, as well as for age-related folds and wrinkles. While autogenous tissues may be the safest option, they require a second operative site. Animal-derived or synthetic materials have been advocated since the late 19th century, and have waxed and waned in popularity. In recent years, we have gained a better understanding of the physical events that occur when material is placed within or below the skin. With this knowledge, we stand at the threshold of a new era, where soft tissue fillers can be designed and customized to suit the individual patient. This article will review the major materials that have been or are now advocated for use as soft tissue fillers, and will detail their relative strengths and weaknesses in order to give the clinician a better perspective when considering a material for soft tissue augmentation.

Biology and chemistry of facial implants.

Facial implants have become increasingly more sophisticated in the past 10 to 15 years. The concept of "the ideal implant" has progressed from an inert material that interacts minimally with the host tissue to one that participates in the normal function of the tissues. A thorough understanding of their chemical properties is essential to understand the biologic events that occur around these materials after implantation. This article outlines the salient features of common materials encountered in facial implants used in plastic surgery.

Nasal reconstruction using porous polyethylene implants.

Nasal reconstruction presents a significant challenge to the facial plastic surgeon. The dual goals of reconstruction are restoration of the desired aesthetic nasal contour and an improved nasal airway. Autologous cartilage and bone are considered optimal grafting material, but their supply is often limited and harvesting entails additional morbidity. Many synthetic materials have been introduced in nasal reconstruction, but high infection and extrusion rates limited their use. Porous high density polyethylene implants present an alternative to autologous material as they allow for fibrovascular ingrowth, leading to stability of the implant and decreased rates of infection. Herein we describe the use of porous high density polyethylene implants for reconstruction of the platyrrhine nose and in revision rhinoplasty. The use of preformed nasal-dorsal tip and alar batten implants are described, as well as the use of columellar strut and premaxillary plumper implants. We believe that porous high density polyethylene implants provide a safe, desirable alternative in functional and aesthetic nasal reconstruction.

Telemedicine applications in otolaryngology.

Under suitable technical and clinical conditions, remote interactive fiber-optic NPL can be used to evaluate a range of commonly occurring pathologies with a high degree of reliability. A clinical protocol appropriate for interactive and store-and-forward fiber-optic NPL was proposed for further evaluation. Additional applications of telemedicine in otolaryngology were outlined, including otoscopy, intra-oral examination, and evaluation of external facial pathology. We envisage tele-otolaryngology taking place in a variety of ways: Interactions between rural-based PCPs and specialists (routine evaluation of hoarseness, dysphagia), using store-and-forward techniques. Consults from emergency medicine physicians at a general service hospital to a specialist (laryngeal trauma, acute peritonsillar abscess, TM perforations) using interactive means. Case discussions between specialist and sub-specialist using a combination of store-and-forward and interactive technologies. Potentially, there are at least three significant benefits from widespread acceptance of telemedicine in the field of otolaryngology, or indeed in any of the medical specialties: Saved lives and reduced medical costs due to early detection of serious pathology (in this case, head and neck cancers). Reduced unnecessary referrals to specialists, and consequent savings to the patient and health-care insurer, accompanied by more efficient usage of specialist time. Enhanced level of medical education and interaction, as the link between the referring and consulting physician is more immediate and direct [27]. For these reasons, combined with the high number of visits at the primary-care level related to issues in otolaryngology-head and neck surgery, tele-otolaryngology is poised to be a leading telemedicine application within the next few years.

Teleconsultation in otolaryngology: live versus store and forward consultations.

OBJECTIVE: To evaluate the relative strengths and weaknesses of interactive and delayed teleconsultations in otolaryngology. SETTING: Ambulatory clinic at an urban tertiary care facility. SUBJECTS: Forty-five adult patients with known or suspected upper aerodigestive tract pathology. INTERVENTION: Patients were interviewed by an otolaryngology chief resident (CR) using a standardized protocol; the results were presented to a board-certified otolaryngologist present locally (LBCO) and a remote physician viewing the encounter by video-conferencing elsewhere in the hospital (RBCO). The CR performed a complete otolaryngologic examination, including fiberoptic nasopharyngolaryngoscopy. The CR and LBCO viewed the examination on a video monitor; the RBCO viewed the same image on the video-conferencing monitor. Each physician independently recorded findings and rendered a diagnosis. A third board-certified otolaryngologist, who reviewed the stored data file (text and stored images) in a delayed fashion (DBCO), documented his findings and made a diagnosis. RESULTS: The CR and LBCO agreed on diagnosis in 92% (36 of 39) of cases. The LBCO and RBCO arrived at the same diagnosis in 29 of 34 (85%) cases. The DBCO agreed with the LBCO for 18 of 28 (64%) diagnoses. Agreement on management recommendations between the LBCO/DBCO pair were also lower than for the LBCO/RBCO pair. CONCLUSIONS: Both interactive and delayed techniques can be used to provide relatively accurate clinical consultations in otolaryngology. Telemedicine can be applied for subspecialty consultations, screening programs, remote emergency triage, second opinions, and resident education.

A graduated approach to the repair of nasal septal perforations.

Septal perforation is an avoidable complication of septal surgery, but it can also occur because of a variety of traumatic, iatrogenic, caustic, or inflammatory reasons. Symptoms usually are related to disruption of the normally laminar flow of air through the nasal passages. Crusting, bleeding, parosmia, and neuralgia can develop, leading the patient to seek medical care. When local hygiene and conservative care are unsuccessful in relieving symptoms, closure of the perforation is considered. Repair is often difficult because of the limited exposure and limited amounts of friable mucosa with impaired vascular supply. The failure of attempted closure of septal perforations can be as high as 80 percent. The authors have developed a graduated approach to the closure of septal perforations that tailors the surgical approach to the size and location of the defect. Perforations 0.5 to 2.0 cm in size were closed in 92.9 percent (13 of 14) of patients using an extended external rhinoplasty approach and bilateral posteriorly based mucosal flaps. Larger perforations (2.0 to 4.5 cm) were closed in 81.8 percent (18 of 22) of patients by a two-staged technique, using a midfacial degloving approach to medially advance posteriorly based, expanded mucosal flaps. With careful preoperative management and selection of the appropriate surgical technique, even moderate-to-large perforations can be repaired reliably with limited operative morbidity.