Botulinum Toxin and Muscle Atrophy: A Wanted or Unwanted Effect.

While the facial rejuvenating effect of botulinum toxin type A is well known and widespread, its use in body and facial contouring is less common. We first describe its use for deliberate muscle volume reduction, and then document instances of unanticipated and undesirable muscle atrophy. Finally, we investigate the potential long-term adverse effects of botulinum toxin-induced muscle atrophy. Although the use of botulinum toxin type A in the cosmetic patient has been extensively studied, there are several questions yet to be addressed. Does prolonged botulinum toxin treatment increase its duration of action? What is the mechanism of muscle atrophy and what is the cause of its reversibility once treatment has stopped? We proceed to examine how prolonged chemodenervation with botulinum toxin can increase its duration of effect and potentially contribute to muscle atrophy. Instances of inadvertent botulinum toxin-induced atrophy are also described. These include the "hourglass deformity" secondary to botulinum toxin type A treatment for migraine headaches, and a patient with atrophy of multiple facial muscles from injections for hemifacial spasm. Numerous reports demonstrate that muscle atrophy after botulinum toxin type A treatment occurs and is both reversible and temporary, with current literature supporting the notion that repeated chemodenervation with botulinum toxin likely responsible for both therapeutic and incidental temporary muscle atrophy. Furthermore, duration of response may be increased with subsequent treatments, thus minimizing frequency of reinjection. Practitioners should be aware of the temporary and reversible effect of botulinum toxin-induced muscle atrophy and be prepared to reassure patients on this matter.

Expanded Role of Alar Contour Grafts.

SUMMARY: Alar rim deformities are among the most common problems affecting patients undergoing both primary and secondary rhinoplasty. They can be caused by several factors such as congenital hypoplasia or malpositioning of the lateral crura, and from acquired surgical weakening during rhinoplasty. Even though altering the structure of the lower lateral cartilage complex can help prevent and correct alar rim deformities, this may not always allow for sufficient control of the alar rim. Alar contour grafts have been proven efficacious not just in the treatment of specific rim deformities but also in their prevention. In this article, the authors present four types of alar contour grafts and discuss their expanded role in the prevention and treatment of alar rim deformities.

Four-Step Spreader Flap: The Pull-Twist-Turn Technique.

SUMMARY: The spreader (or autospreader) flap offers an alternative to the traditional spreader graft in reconstructing the dorsal midvault and preserving internal valve function. This is of particular importance after an aggressive dorsal hump reduction, which has the potential to result in an inverted-V deformity, dorsal narrowing, or saddle-nose deformity. In this article, the authors describe a four-step spreader flap technique that offers a simple, reproducible method of shaping the dorsal midvault while preserving internal valve function.

Pushing the Envelope: Skin-Only Mastopexy in Single-Stage Nipple-Sparing Mastectomy with Direct-to-Implant Breast Reconstruction.

BACKGROUND: Despite advances in skin envelope reduction techniques and experienced nipple-sparing mastectomy flap procedures, the rate of nipple malposition and secondary revision in these patients remains high and eligible candidates are limited. In this article, the authors present a novel technique combining skin reduction nipple-sparing mastectomy surgery with single-stage skin-only mastopexy and direct-to-implant reconstruction. METHODS: A retrospective review was performed at a single institution from 2015 to 2018. All patients were operated on using this technique consecutively, by a breast and plastic surgeon team (A.F. and A.M.). Surgical technique and outcomes were compared with the currently accepted literature. RESULTS: Twenty-six patients (40 breasts) underwent this technique; all were single-stage direct-to-implant reconstructions. The average body mass index was 31 kg/m2. A Wise pattern was used in 35 breasts (87.5 percent) and prepectoral placement was used in 25 breasts (62.5 percent). Overall complications included seroma [n = 6 (15 percent)], vertical/T-junction dehiscence [n = 4 (10 percent)], skin necrosis [n = 4 (10 percent)], superficial or partial nipple necrosis [n = 4 (10 percent)], with no total nipple-areola complex lost and no reconstructive failures at 18.7 months' average follow-up. CONCLUSIONS: In this article, the authors share a novel reconstructive technique in which the skin envelope is reduced, the nipple-areola complex is repositioned, and a direct-to-implant reconstruction is performed in a single stage at the time of mastectomy. Consideration of pearls and pitfalls accompanies a review of the authors' experienced complication profile, and is discussed in the context of current literature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Changing Role of Septal Extension versus Columellar Grafts in Modern Rhinoplasty.

Effective control of nasal tip projection and rotation is a key component in modern rhinoplasty. Tip projection is a product of several anatomical factors: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle. Several cartilage grafts have been described for effectively altering nasal tip projection and rotation. Columellar struts and septal extension grafts are both commonly used in modern rhinoplasty to affect projection and rotation of the nasal tip. Although columellar strut grafts have shown moderate efficacy in maintaining tip projection and unifying the tip complex, their effect on increasing tip projection has been shown to be very limited. In comparison, septal extension grafts have been shown to effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Varieties of septal extension grafts have been described to support the medial crura and control tip shape, all of which depend on the presence of a stable caudal septum. The type of graft used is dependent on the specific characteristics of the underlying tip structures. The authors' aim is to provide an updated classification of cartilage grafts for altering nasal tip projection and rotation, and an algorithmic approach for their implementation. Although both columellar struts and septal extension grafts offer the modern rhinoplasty surgeon a way to alter tip projection and rotation, they do vary in efficacy. Understanding which graft to use and in what setting is key in successfully controlling projection, rotation, and shape of the nasal tip.

Brachioplasty Refinements.

With a growing massive weight loss population, upper arm contouring continues to rise in popularity. Refinements in technique, such as modification of skin excision patterns and the adjunct use of liposuction, have allowed for safe and reproducible results. This article helps to understand the evolution of upper arm contouring and provides an update on the limited-incision medial brachioplasty. Details of preoperative markings and operative technique are clearly illustrated in the video included.

Warping Characteristics of Rib Allograft Cartilage.

When septal cartilage is lacking, commercially available costal cartilage allograft can be used. Such allografts have "off-the-shelf" accessibility, are available in multiple sizes, are aseptically processed to meet sterility, and are screened to minimize infectious risks. The purpose of this study was to evaluate the effect of donor age, storage temperature, and orientation of a bilayered construct on the degree of warping of a commercialized fresh frozen costal cartilage allograft in vitro over time. A total of 140 fresh frozen costal cartilage cadaveric specimens were separated into three donor age groups. These were allocated into three harvesting subgroups: group a, single pieces (cephalocaudal segments); group b, two laminated pieces of the same rib sutured together in anatomical position (laminated group); and group c, two pieces from the same rib reversed onto each other and sutured together (oppositional group). Photographs were examined and analyzed to determine the degree of cartilaginous warping. Decreased rates of warping were seen in commercially available, aseptically processed costal cartilage allografts procured from older cadavers. Warping was also decreased when oppositional suturing techniques were used as a way to address those intrinsic cartilage forces.

The Lift-and-Fill Facelift: Superficial Musculoaponeurotic System Manipulation with Fat Compartment Augmentation.

The focus of modern face-lifting has shifted from isolated superficial musculoaponeurotic system (SMAS) manipulation to providing necessary volume restoration and overall facial shaping. Volume deflation is a major component of facial aging but cannot be corrected solely by rhytidectomy. This article presents a detailed overview of facial fat compartment anatomy and examines its role in facial rejuvenation. A good understanding of facial fat compartment anatomy cannot be overemphasized. In combination with methodical preoperative visual analysis, this allows surgeons to target the specific areas that have undergone deflation with fat grafting before selective SMAS manipulation.

Adipofascial Flap in the Recipient Incision Site for Coverage of Vascular Pedicle in Free Tissue Transfer.

The recipient incision adipofascial flap offers a simple approach to address a tight skin closure over a vascular pedicle. This technique is not just fast and easy to perform but also adds little to no morbidity, removing a potential source of flap failure.