A morphometric study of age- and sex-dependent changes in eyebrow height and shape✰.

BACKGROUND: Rejuvenation procedures of the periorbital region and the forehead, with the eyebrow as a key structure, are often performed in plastic surgery. There is no common consent on the changes of aging in this region and the consecutive treatment options. This study was designed to support the body of literature with a broader data basis about the natural changes of eyebrow position and its shape. METHODS: The brow shape, the lid axis, and the distance between both medial canthi (DMC) were analyzed retrospectively on randomly selected standardized photographs of healthy Caucasian females and males. Six defined heights of the upper brow border, including the position and height of the highest brow point (HBP) and the angle of the upper brow line, were measured. RESULTS: A total of 244 Caucasian females and males in two groups (<34 years and >55 years) were analyzed. The data showed a difference between brow shapes of young females and males, especially relating to the HBP, which is located medially in young females. The brow shape of females assimilates toward a male shape with aging. The eyebrow moves upward, the DMC widens, and the lid axis drops laterally in both sexes with aging. CONCLUSIONS: Our data suggest that rejuvenation procedures should focus on not only lifting the brow but also reshaping and stabilizing the brow, especially the HBP, which plays an important role in defining the upper brow line. Our findings can explain why lifting the brow can create not only an undesired surprise but also an older look.

A 3D Morphometrical Evaluation of Brow Position After Standardized Botulinum Toxin A Treatment of the Forehead and Glabella.

BACKGROUND: Botulinum toxin treatment for forehead wrinkles has been extensively studied and found to be a safe and reproducible procedure. However, the effect on the position of the eyebrows, which relies on the dynamic positioning of the treated muscles, has received less attention and has not been studied with 3-dimensional (3D) technology. OBJECTIVES: The authors sought to evaluate the changes of eyebrow position after standardized botulinum toxin treatment of glabella or glabella and frontalis muscles with 3D imaging. METHODS: In a prospective study, 2 groups of adult females were treated with botulinum toxin A at the glabella only (G) or at the glabella and the frontalis muscle (F/G). The brow position was measured at 5 positions with 3D photography before injection and 2 weeks, 3 months, and 6 months after injection. Results were statistically analyzed and related to patient age. RESULTS: In the F/G group, the brow descended significantly almost across the whole brow length after 2 weeks. The descent lessened after 3 months and moved medially. No clear trend was evident in the G group. There was no significant change attributed to patient age in both groups. CONCLUSIONS: Botulinum toxin treatment of the glabella and frontalis muscle impacts the position and configuration of the eyebrow. The degree of change is affected by the amount of frontalis weakening rather than by treatment of the glabella. While age in general is not a reliable predictor, individual factors play the major role in how pronounced a change of the brow can be expected.

Prospective 3D analysis of facial soft tissue augmentation with calcium hydroxylapatite.

BACKGROUND: Facial rejuvenation is an expanding field with an increasing number of treatment modalities. Several non-autologous filler materials are available for soft tissue augmentation. Calcium hydroxylapatite (CaOH) is aimed at increasing collagen neosynthesis and thereby producing long-term augmentation effects. Despite a multitude of observational reports, the field is suffering from lack of quantitative morphometric evaluation methods. OBJECTIVE: The objective of this proof-of-principle study was to investigate whether the effects of facial tissue augmentation with CaOH (RADIESSE™) can be quantified and followed up using 3D surface scanning. METHODS: 3 female subjects received augmentation of the mid and lower face with CaOH. The faces were recorded prior, directly after, and two weeks and six months after the injection using standardized photos and 3D scanning. Computational analysis allowed quantifying the change in volume and displacement of the facial surface. Additionally, a patient satisfaction questionnaire was administered. RESULTS: In all subjects, increase in facial volume could be quantified and was present after two weeks and six months. CONCLUSIONS: 3D surface scanning is an adequate tool for objective quantification of changes after facial augmentation with filler materials. Persistent volume augmentation after CaOH injections could be quantified after two weeks and six months. Evidence level: IV.

Aging Changes of the Male Lips-A Lesser Evil Than in Females?

BACKGROUND: Although aging changes of the female perioral region and aesthetic procedures for perioral rejuvenation are described in literature, specific data for the male population are lacking. This study aims to evaluate perioral aging process in the male population to compare quality and quantity of the observed changes to the female population. METHODS: Magnetic resonance imaging (MRI) scans of 22 male subjects, were recruited into 2 age groups: young (20-35 years) and old (65-80 years) and the following parameters were measured: length of visible upper lip, thickness of upper lip at the level of vermilion border, thickness of upper lip at the level of the mid lip, and cross-section area of upper lip. Cadaver transverse sections of the upper lip of 10 individuals in 2 age groups, young (<40 years, n = 5) and old (>80 years, n = 5) underwent histological analysis of the relevant anatomical structures. RESULTS: The MRI analyses does not show a statistically significant difference in upper lip lengths of old and young subjects (P = 0.213). Upper lip thickness decreases statistically significant (P < 0.001), the midline sagittal upper lip area does not show a significant change (P = 0.57). Histomorphometry shows a statistically significant decrease of cutis thickness, increase of subcutaneous fat, thinning of the orbicularis muscle, and a broadening of the orbicularis oris angle. CONCLUSIONS: The aging changes of the perioral region in men and women are similar in regard to the general processes, yet the extent of the changes is less striking in the men.

Complication assessment and prevention strategies using midfoot fusion bolt for medial column stabilization in Charcot's osteoarthropathy.

In Charcot's osteoarthropathy stabilization of the medial column of the foot was introduced in order to establish a stable foot and reduce the risk for amputation. This study was performed to analyze postoperative complications, define risk factors for those and develop strategies for prevention. Since bolt dislocation takes place frequently, it was aimed to predict an appropriate time point for bolt removal under the condition that osseous healing has occurred. Fourteen consecutive patients with neuroosteoarthropathy of the foot and arch collapse were treated with open reduction and stabilization using midfoot fusion bolt and lateral lag screws. Age, gender, presence of preoperative osteomyelitis or ulcer, number of complications and operative revisions, Hba1c value, consolidation of arthrodesis, presence of a load-bearing foot and period to bolt dislocation was assessed. The mean follow-up was 21.4±14.6 (mean±SDM) months, 64% of patients suffered from diabetes with a preoperative Hba1c of 8.5±2.4. The mean number of revisions per foot was 3.6±4.1. Bolt dislocation was seen in 57% of the patients following 11.3±8.5 months; in 75% of these patients bony healing occurred before dislocation. There was a significant association between preoperative increased Hba1c value, presence of preoperative ulcer and wound infection. Healing of arthrodesis was demonstrated in 57% and a permanent weight-bearing foot without recurrent ulcer was achieved in 79%. The early and late postoperative complications could be controlled in general. A fully load-bearing and stable foot was obtained, despite osseous consolidation was not detected in all of these cases. Once a stable foot has established early removal of fusion bolt should be considered. To decrease the risk of infection Hba1c should be adjusted and ulcers should be treated before the operation.

Long-Term Comparison of Rib and Ear Cartilage Grafts in Autologous and Allogenic Fascia Lata: An Experimental Study in a White Rabbit Model.

BACKGROUND: Diced cartilage in fascia has become the graft material of choice for dorsal grafts in rhinoplasty. Allogenic fascia lata has not yet been investigated as an isolated fascial graft or as a combined graft with ear and rib cartilage, especially in comparison with autologous fascia and over a long implantation period. METHODS: Ten different grafts were built from either autologous or allogenic fascia lata alone or as diced cartilage in fascia grafts with diced costal or ear cartilage and implanted into the dorsal skin of 15 rabbits. After 3 or 9 months, the grafts were explanted and analyzed histologically. Chondrocytes and cartilage matrix characteristics, including calcification, ossification, formation of bone marrow, fibrosis ingrowth and fibrotic transformation, the presence of immune reactions, vascular ingrowth, regenerative capacity, and capsule formation, were examined in a semiquantitative manner. RESULTS: All grafts were vital and without inflammatory response. The cartilage showed regular nuclei, a normal matrix, and regenerative capacity. A higher grade of calcification and ossification was observed in the fascia/cartilage grafts than in isolated cartilage grafts, and was more pronounced for costal cartilage. Both types of fascia were shown to be equally stable and without degradation. There were no significant differences in the diced cartilage in fascia grafts built with autologous compared to allogenic fascia. CONCLUSIONS: This study shows the equivalency of diced cartilage in fascia grafts and isolated fascial grafts using allogenic fascia lata compared to autologous fascia. The type of cartilage used accounts for different long-term characteristics of diced cartilage in fascia grafts.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation.

BACKGROUND: Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches. METHODS: To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient. RESULTS: Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0). CONCLUSION: A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.

Soft-tissue mobility of the lower face depending on positional changes and age: a three-dimensional morphometric surface analysis.

BACKGROUND: Reliable evaluation of the complex three-dimensional anatomy of the face has proven to be extremely difficult. Three-dimensional surface scanning technology has not yet reached widespread acceptance in clinical research in plastic surgery. This study aimed to describe two parameters that allow quantification of soft-tissue movements and to compare the surface changes of the lower face during positional changes and with increasing age. METHODS: Two groups, each with 20 voluntary female subjects aged 20 to 35 and 45 to 60 years, were examined with a three-dimensional surface scanner in both supine and sitting positions. After registration of the two surface scans, the soft-tissue mobility of the lower face was examined using two new parameters. Deformability describes the mean distance between the surfaces and stretchability describes the relative stretching of one surface when mapped onto the other. RESULTS: Both parameters show highly significant differences for tissue mobility of young versus old lower faces. The trend for the soft tissues to lose projection in the upper posterior aspect and gain projection in the lower anterior aspect increases strongly. In the older subjects, larger parts of the examined area show tissue displacements of up to 6 mm, whereas in the young faces the displacement is far less and does not exceed 4 mm. CONCLUSION: Computational analysis of the authors' experimental results using two new parameters shows a statistically significant increase of facial tissue displacement and surface stretching when comparing young and old subjects.

Morphometric long-term evaluation and comparison of brow position and shape after endoscopic forehead lift and transpalpebral browpexy.

BACKGROUND: Although a multitude of proposed forehead rejuvenation procedures have been described, long-term and systematic morphometric evaluation is rare. There are no studies comparing endoscopic forehead lifts and transpalpebral browpexy techniques according to their efficacy in raising and reshaping the brow. METHODS: In a retrospective study, standardized photographic documentations of patients undergoing an endoscopic forehead lift or a transpalpebral browpexy were morphometrically analyzed. Five measurements were taken to evaluate brow height, and two measurements were taken to describe the change in brow shape. RESULTS: Fifty-six and 29 patients, respectively, in the two groups were analyzed up to 5 years postoperatively. Morphometric evaluation proved a significant elevation of the total brow and an improvement in brow shape for the endoforehead group, whereas the brow position after the transpalpebral browpexy significantly descends, despite an improvement in subjective aesthetic outcome. An additional blepharoplasty after the endoscopic forehead lift does not lower the brow significantly. CONCLUSIONS: The efficacy of the endoforehead lift is supported by extensive, systematic, and long-term data, and its superiority over transpalpebral approaches has been proven. The descent of the brow after transpalpebral browpexy is most likely caused by a decrease of frontalis hyperactivity after the simultaneously performed blepharoplasty. Further studies need to evaluate its effect compared with blepharoplasty alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Monitoring molecular changes induced by ischemia/reperfusion in human free muscle flap tissue samples.

BACKGROUND: Our current knowledge of the pathophysiological sequelae of ischemia or reperfusion (I/R) injury in free tissue transfer in reconstructive surgery is based on data obtained in animal experiments. In this study, we investigated the histologic and molecular changes after 11 free microsurgical muscle transfers in human muscle tissue. METHODS: Biopsies of free muscle flap tissue were taken immediately before clipping of the pedicle and 5 days after ischemia and successful microanastomosis and restoration of the blood flow. Samples were analyzed histologically for edema formation and by immunohistochemistry for infiltration of inflammatory cells and angiogenesis. Expression levels of the inflammatory marker proteins interleukin-1ß and tumor necrosis factor α and of complement component 3 as a major mediator of I/R injury were analyzed by real-time polymerase chain reaction. A TUNEL (terminal desoxynucleotidyl transferase-mediated-dUTP-nick-end-labeling) assay was used to assess apoptosis levels within the human muscle tissue. RESULTS: I/R injury leads to a significant up-regulation of inflammatory parameters, infiltration of inflammatory cells, and angiogenesis. Increased complement component 3 deposition and apoptosis of cells were accompanied by interstitial edema as indication for a pronounced postischemic inflammatory reaction within the muscle tissue after free tissue transfer. CONCLUSIONS: Our findings of molecular changes induced by I/R injury in human striated muscle tissue validate data obtained in animal models of I/R injury. The parameters and inflammatory patterns defined in this study will allow for the monitoring of the success of novel pharmaceutical strategies in the future and will help to transfer data obtained in animal work to the in vivo setting in human beings.

Free tissue transfer in reconstruction following soft tissue sarcoma resection.

BACKGROUND: Radical surgical resection remains the single-most important treatment in the curative multimodal therapy of soft tissue sarcomas. Refinements in surgical techniques have resulted in the development of function preserving approaches increasingly avoiding limb amputation. PATIENTS AND METHODS: The records of all patients (n = 34) who underwent microsurgical soft tissue coverage subsequent to primary resection of soft tissue sarcoma of the upper or lower limb from 1999 to 2009 are reviewed regarding postoperative complications, time until start of adjuvant radiation and functional outcome (Toronto Extremity Salvage Score, TESS). RESULTS: Thirty-four patients (range: 21-86 years) received a total of 35 free flaps. Complete tumor resection was obtained in 33 patients, one patient required re-excision ultimately resulting in tumor-free margin status (R0 resection). Major complications were encountered in four cases including one patient with complete flap loss requiring an additional free flap and three patients with partial flap loss requiring split-thickness skin graft procedures. Minor complications were observed in three patients (9%). Extremity salvage could be achieved in 33 patients with adequate postoperative ambulation (TESS 84 ± 18) and adequate use of the upper extremity (TESS 80 ± 22). One patient underwent amputation. Mean time until start of adjuvant radiotherapy was 37 days (range 24-56 days). CONCLUSION: A synergetic center-based interdisciplinary approach is crucial in therapeutical management of soft tissue sarcomas with the aim of R0 resection status and limb preservation. Plastic surgery contributes by offering microsurgical reconstruction using free tissue transfer, thus broadening surgical possibilities. This increases the chance of both adequate oncosurgical resection and limb preservation.

Necrosis of the 4th and 5th digits after intra-articular injection of diazepam into the wrist.

A 75-year-old woman presented with progressing pain, cyanosis, and hypaesthesia in her left hand after an intra-articular injection with diazepam into the wrist for osteoarthritis-related pain. Due to an iatrogenic intra-arterial injection, malperfusion of the ulnar digits developed. Angiography revealed blockage of perfusion of the 4th and 5th digits. Despite intra-arterial lysis, heparinisation, and vasodilatation, perfusion could not be reinstalled. Necrosis of the distal phalanges of the 4th and 5th digits developed, which had to be treated with amputation. The pathomechanism of tissue damage and the treatment options after intra-arterial injections are reviewed and discussed.

The use of the vacuum-assisted closure in microsurgical reconstruction revisited: application in the reconstruction of the posttraumatic lower extremity.

Introduction of vacuum-assisted closure (VAC) system into clinical practice has revolutionized wound care. Despite its multiple advantages, however, the VAC is only rarely used in the setting of microsurgical reconstruction. Concerns have been the inability to clinically monitor the flap as well the possibility of flap compression by the device. The authors put their postoperative treatment concept of applying the VAC to free flaps to the test by reviewing their experience with this concept in patients undergoing microsurgical reconstruction of posttraumatic lower-extremity soft tissue defects. Twenty-six patients (22 male, 4 female) were included in this study. Use of the implantable Doppler probe allowed for postoperative flap monitoring. Two flap failures were observed, both in patients with peripheral vascular disease. In conclusion, using the VAC device in the setting of microsurgical reconstruction is safe and allows for increased patient comfort.

An algorithm for oncologic scalp reconstruction.

BACKGROUND: Modern reconstructive surgery allows for radical resection and reconstruction of any scalp tumor. However, a significant number of patients are still not treated optimally because of incomplete reconstructive guidelines. METHODS: The treatment of scalp tumors was documented in 60 patients over a 10-year period. Data regarding tumor type, size, and localization; reconstructive procedure; oncologic, functional, and aesthetic outcome; and complications were collected and analyzed retrospectively. These data were correlated to recurrence and survival rates. The findings extracted from the data were amalgamated to produce the proposed reconstructive algorithm. RESULTS: Five reconstructive categories were defined and their application could be described in an algorithmic approach. Indications, limitations, and adequate reconstructive procedures for each category were identified. The most important decisions are when to use local flaps versus primary closure and when to use free tissue transfer. CONCLUSIONS: Radical surgical resection and reconstruction presents the best available method to cure scalp tumors or to establish local disease control in palliative settings. The authors present an algorithm to assist in the planning process of oncologic scalp reconstruction. If this algorithm is applied, the occurrence of inadequate resections and the need for repeated procedures can be minimized.

Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures.

BACKGROUND: : Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates. METHODS: : Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed. RESULTS: : Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures. CONCLUSION: : These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

A new evaluation tool for monitoring devices and its application to evaluate the implantable Doppler probe.

Evaluation parameters for free flap monitoring devices are used inconsistently, leading to considerable confusion about the quality and applicability of these devices. A comparison of different systems and different clinical series is almost impossible. The ultimate questions that need to be answered are those regarding the efficiency and the effectiveness of the system. A new tool consisting of two simple parameters that sufficiently and comparably describe the quality of monitoring devices is developed. The flap failure reduction rate describes the percentage of saved flaps (effectiveness). The revision success rate describes the efficiency. Literature reevaluation shows inconsistent results, although all authors describe a positive experience. This shows the limited value of the classical parameters. Larger studies have flap failure reduction rates of 5 to 12% (5 to 12% of monitored flaps are saved). Revision success rates of 75 to 90% prove that the system is efficient enough in daily use. Reevaluation of the smaller reported series result in lower parameters, which shows that there is a significant learning curve for this device. The new parameters alleviate the confusion surrounding evaluation of monitoring systems by giving specific information about effectiveness and efficiency. The benefits of the implanted Doppler probe can now be clearly described. However, in several studies the benefit of the system is overrated.

The aging lip: a comparative histological analysis of age-related changes in the upper lip complex.

BACKGROUND: Upper lip rejuvenation is achieved by a large variety of different treatment approaches that clearly lack a unified theoretical background of the aging processes of the upper lip complex. In this study, the histological changes that occur in the aging upper lip were systematically evaluated for the first time. METHODS: Histological cross-cuts of the upper lip complex of 20 individuals in two age groups, young (<40 years, n = 10) and old (>80 years, n = 10), were analyzed. The specimens were collected during the autopsies of individuals with no facial injuries. Hematoxylin-eosin and elastica van Gieson staining was performed, and the relevant anatomical structures were measured and compared using Student's t test. RESULTS: Histomorphometric analysis revealed statistically significant thinning of the cutis, thinning of the orbicularis oris muscle, and an increase of the orbicularis oris muscle angle defining the vermilion border in the old lip group. Elastic and collagen fibers in the cutis undergo degeneration processes during aging. The orbicularis oris muscle is not subject to fatty or fibroblastic degeneration, but shows signs of atrophy. CONCLUSIONS: The histomorphometric and histomorphological analyses shed light on the, so far, only unsystematically and episodically described process of upper lip aging on a histological level. The distinct changes add further evidence to the theory that the aged look is due to a loss of elasticity and resultant ptosis of the upper lip rather than to often-postulated but unproven total volume loss.

Simultaneous pectoralis major myocutaneous flap combined with breast reduction for sternal defect coverage.

BACKGROUND: The pectoralis myocutaneous island flap is a well established technique for tissue reconstruction. In female patients with concomitant breast hypertrophy there may be a simultaneous indication for breast reduction mammoplasty. The inferior pole of the breast and the inframammary fold coincide with the skin island territory of myocutaneous flaps supplied by the thoracoacromial artery. METHODS: A technique is described where this tissue is preserved as the flap skin island in combination with a superior pedicle reduction mammoplasty. The technique is illustrated with two exemplary cases. RESULTS AND CONCLUSION: The technique is suitable in women with relative unilateral or absolute bilateral large breasts with a combined sternal defect and should be taken into consideration for respective cases.