Quantifying soft tissue loss in the aging male face using magnetic resonance imaging.

BACKGROUND: Quantitative data on soft tissue aging of the face are scarce, particularly in men. OBJECTIVE: Magnetic resonance imaging (MRI) was used to quantify and compare facial soft tissue loss in men. MATERIALS AND METHODS: Two thousand thirty-seven MRIs were screened and 30 male subjects were divided into young, middle, and old-aged groups. A blinded radiologist measured temporal, infraorbital, and medial and lateral cheek areas. RESULTS: The mean thickness of the subcutaneous tissue in the temporal area was 12.5, 10.9, and 9.6 mm in the young, middle, and older age groups, respectively (p < .001). A 40% reduction in the skin thickness was seen in the infraorbital areas. Finally, a decrease of 1.5 and 2.7 mm in medial cheeks (p < .001), and 0.9 and 1.6 mm (p = .03) in lateral cheeks were measured in middle and old age groups. CONCLUSION: A steady and significant decline in the soft tissue thickness was noted at all measured sites in men over time. These findings are in contrast to our recently study in women showing dramatic loss of soft tissue between the ages of 30 and 60 with no significant differences between the middle and old-aged groups. These results have implications for volume correction and maintenance of a youthful appearance in the aging male face.

Quantifying soft tissue loss in facial aging: a study in women using magnetic resonance imaging.

BACKGROUND: Facial aging involves changes in the facial skeleton and soft tissues. There is limited quantitative data on soft tissue aging of the face. OBJECTIVE: Magnetic resonance imaging (MRI) was used to quantify and compare facial soft tissue loss over time. METHODS AND MATERIALS: Two thousand thirty-seven MRI scans from 58 women divided into young, middle-aged, and older groups were screened. A blinded radiologist used MRI to measure the temporal, infraorbital, and medial and lateral cheek areas. RESULTS: The mean thickness of the subcutaneous tissue in the temporal area was 12.3, 8.4, and 8.9 mm in the young, middle-aged, and older groups, respectively (p < .001). A mean difference of 1.6 mm was seen between the young and middle-aged groups and 2.2 mm between the young and older group (p < .001) in the infraorbital area, 3.3 mm between the young and middle-aged groups and 3.2 mm between the young and older group in the medial cheeks (p < .001), and 2.4 mm between the young and middle-aged groups and 2.4 mm between the young and older group in the lateral cheeks (p = .01). CONCLUSIONS: Facial soft tissue undergoes significant deterioration over time, with the most dramatic changes between the ages of 30 and 60 in the temporal, infraorbital, and lateral and medial cheek areas. Soft tissue augmentation and volume correction in these areas may be an effective strategy for facial rejuvenation.

The evolving conception and management challenges of malignant fibrous histiocytoma.

BACKGROUND: Malignant fibrous histiocytoma (MFH) is a rare and aggressive tumor. Mohs micrographic surgery (MMS) has been reported as an effective treatment, although most cases were published before advances in cytopathologic techniques led to reclassification of many tumors. OBJECTIVE: To evaluate a contemporary cohort of individuals with MFH and analyze management practices. METHODS: We reviewed all cases of MFH diagnosed at our institution from January 1995 to December 2010, evaluating 839 records to identify 36 patients undergoing management of tumors of the head and neck. RESULTS: Seventeen of the total 36 patients (47%; mean age 67) experienced tumor recurrence, and 10 (28%) developed metastases. Seven of nine patients initially treated with MMS (78%), and 10 of 24 (42%) treated with WLE experienced recurrence (p = .06). Patients treated with MMS had smaller tissue defects after surgery. The mean contemporary recurrence rate of MFH treated with MMS is significantly higher (58.8%) than the cumulative recurrence rate reported before 2000 (7.4%) (p < .001). CONCLUSIONS: Our study is consistent with reports of MFH as an aggressive neoplasm and describes the largest population treated with MMS in 3 decades. The changing conception of MFH, along with a propensity for in-transit metastases, may explain higher contemporary recurrence rates.

Adamantinoid basal cell carcinoma: a predictor of more-aggressive clinical behavior.

BACKGROUND: Identifying histopathologic subtypes of basal cell carcinoma (BCC) associated with an aggressive clinical course helps the surgeon to anticipate the size of the postexcision defect and complexity of repair. During Mohs micrographic surgery (MMS), we have observed that BCC with adamantinoid histopathologic features tend to be clinically more aggressive. OBJECTIVE: To characterize the subtype of BCC with adamantinoid histopathologic features and determine whether it is clinically more aggressive than other BCCs. METHODS AND MATERIALS: A chart review was conducted of consecutive cases of MMS performed at Stanford University Medical Center for BCC from June 2002 through March 2004. Cases had been prospectively categorized as adamantinoid BCC if they met histopathologic criteria, including uniform clear areas around the individual tumor cells within tumor islands. We retrospectively compared adamantinoid and control cases in terms of patient age, sex, tumor location, number of Mohs stages required, area of post-Mohs defect, and type of repair. RESULTS: Four hundred eighty-nine cases of MMS for BCC were reviewed. Forty-four (9%) were adamantinoid BCC. Patients with adamantinoid BCC did not differ statistically from the control group in terms of sex (23% vs 32% female, p = .20) but tended to be older (median age 73 vs 66, p = .04; mean age 70 vs 65 years, p = .05). The distribution of cases on the head and neck differed significantly between the adamantinoid and control groups (p = .02), with more adamantinoid cases located on the nose and ears. Adamantinoid BCC required more stages for clear histologic margins (median 3.00 vs 2.00, p < .001; mean 3.68 vs 2.34, p < .001) and had larger post-Mohs defects (median 3.00 vs 1.68 cm(2) , p < .001; mean 4.24 vs 2.78 cm(2) , p = .02). Only 4.5% of adamantinoid BCC cases were able to heal by second intention, with 20.4% requiring complex primary closure. Staged flaps were performed in 13.6% of individuals with adamantinoid BCC. CONCLUSION: Adamantinoid BCC is an aggressive histopathologic subtype in terms of number of stages for clear margins and size of post-Mohs defect. It may also require more-complex repairs. Recognition of this aggressive variant may benefit future patients by facilitating prediction of the clinical extent of tumors.

Accelerated takedown of the paramedian forehead flap at 1 week: indications, technique, and improving patient quality of life.

BACKGROUND: The paramedian forehead flap (PFF) is a common method of reconstruction for large nasal defects. Generally, surgeons divide this flap at 3 weeks. This delay can result in a significant decrease in the quality of life for these patients. OBJECTIVE: We sought to describe the indications and technique for trunk division at 1 week after PFF reconstruction, and to evaluate the clinical outcomes. METHODS: This was a case series of consecutive patients undergoing primarily nasal defect reconstruction by PFF repair during the past 6 years. We explored medical record review of associated complications, patient rating of impact on quality of life and final results of repair, and patient preferences regarding time to flap division. RESULTS: A total of 26 patients underwent accelerated trunk division at a mean of 7.2 days. Of these, 27% had a history of tobacco use, 23% were diabetic, and 19% had cartilage grafts used in their repairs. None developed necrosis and other complications were minor. Most patients considered their trunk very disfiguring, preventing them from daily activities. This was especially true for those younger than 70 years. Of all patients, 94% preferred trunk division at 1 week, rather than 3 weeks. LIMITATIONS: Retrospective study design and number of patients were limitations. CONCLUSION: PFF trunk division at 1 week is safe and effective for resurfacing of large nasal defects, including those reconstructions that require cartilage. Younger and healthier patients may be the most ideal candidates for accelerated division given the greater negative impact of an intact trunk on their lives.

The erbium micropeel: a prospective, randomized trial of the effects of two fluence settings on facial photoaging.

BACKGROUND: Recent studies have suggested that a series of low-energy, single-pass ablative laser resurfacing micropeels can reduce photoaging with decreased downtime. This randomized, prospective single-blinded trial sought to determine the ideal settings of sequential erbium:yttrium-aluminum-garnet (Er:YAG) laser treatments that maximize efficacy and patient satisfaction. METHODS: Forty-six subjects with mild-to-moderate facial dyschromia and rhytides were evenly randomized to two Er:YAG treatment arms. Patients in the lower fluence (LF) (2.5 J/cm2) and higher fluence (HF) (3.8 J/cm2) groups each received three one-pass, full-face treatments one month apart. Patient and investigator assessments of rhytides, dyschromia and global appearance were performed at baseline and at four, eight and 20 weeks using a nominal scale from 1­4. Adverse events and patient satisfaction were also evaluated. RESULTS: Patient scores showed rhytid improvement only with HF treatments. Investigator scores at three months post-treatment showed dyschromia was significantly improved in both study arms, with a 24 and 36 percent reduction for the LF and HF groups, respectively. Global appearance scores improved by 25 and 32 percent, respectively. A trend towards greater post-procedure erythema and time-to-erythema resolution was observed in the HF group. Mild peeling was the most common adverse event. Individuals who underwent LF treatments were more likely to pursue future treatments. CONCLUSION: Both settings resulted in moderate but significant improvement in dyschromia, although only HF treatment improved rhytides. The decreased downtime of LF treatments made this the preferred choice of patients.

Suspension suture canthopexy: a minimally invasive procedure for correcting mild to moderate ectropion.

BACKGROUND: Ectropion of the lower eyelid can occur after blepharoplasty as well as reconstructive procedures. Even mild ectropion can cause irritation or epiphora. Patients with preexisting lid laxity are at higher risk for post procedure ectropion. AIMS: To describe a method for canthopexy and discuss its indications, benefits and limitations. METHODS: We describe a technique that has been used on dozens of patients by both the authors. RESULTS: This suspension suture canthopexy corrects mild to moderate ectropion. DISCUSSION: Suspension suture canthopexy is effective in patients with the appropriate indications. It can be performed under local anesthesia with minimal complications. Unlike other forms of lid tightening, it does not change the shape of the eye. CONCLUSION: Suspension suture canthopexy which is an ancillary procedure for eyelid rejuvenation is valuable procedure to master by the dermatologic surgeon.

Novel pretrichial browlift technique and review of methods and complications.

BACKGROUND: The upper third of the face is integral to our perception of youth and beauty. While the eyelids anchor this facial cosmetic unit, the eyebrows and forehead are intrinsically linked to the upper eyelids, and their position and texture play an important role in creating pleasing eyes as well as conveying mood and youth. The most common browlifts are performed with endoscopic visualization. Yet, this technique requires special equipment and a prolonged learning curve. OBJECTIVE: To demonstrate a novel pretrichial technique and to review different browlift methods and their potential adverse effects. METHODS Case series and review of the literature. RESULTS: The pretrichial browlift results in a mild to moderate browlift with secondary smoothing of the forehead topography. Aside from bruising and swelling, it results in minimal adverse effects. Other techniques are also effective but may create a larger scar such as a direct browlift, may be more difficult in terms of approach such as the browpexy, or require endoscopes. CONCLUSION: Browlifts are an important procedure in rejuvenating the upper third of the face and improving the overall facial aesthetic appearance. The pretrichial browlift is a less invasive open technique that is safe and effective for the appropriate patient. The authors have indicated no significant interests with commercial supporters.

Dual transposition flaps for the reconstruction of large scalp defects.

BACKGROUND: Large scalp defects can be challenging to repair because of the inelasticity of the scalp. While there are several methods to close this type of wound, they result in either alopecia or unacceptable scarring. We present a dual transposition flap to close a large defect following Mohs surgery for a basal cell carcinoma on the scalp. METHODS: We describe and report the case of a man with a basal cell carcinoma on the scalp vertex who had been referred for Mohs micrographic surgery. The surgery resulted in a large scalp defect. RESULTS: A dual transposition flap performed with tumescent anesthesia was used in a delayed closure of a 78.5-cm2 defect. It resulted in minimal alopecia, minimal distortion of the hair orientation, and minimal scar stretch-back. LIMITATIONS: The limitation of this study is that this technique is based on one case report. CONCLUSIONS: This dual transposition flap is a good reconstructive option for large, immobile scalp defects. It can be performed under local anesthesia with minimal alopecia and camouflaged scars.

Split-face comparison of the erbium micropeel with intense pulsed light.

BACKGROUND: A variety of photorejuvenative techniques have been utilized to reverse the signs of cutaneous photoaging, including ablative and nonablative laser resurfacing as well as light-based devices. OBJECTIVE: The purpose of this split-face randomized prospective open-label trial was to determine the effectiveness of sequential erbium:yttrium-aluminum-garnet (Er:YAG) laser versus intense pulsed light (IPL) for the treatment of mild to moderate facial photodamage. MATERIALS AND METHODS: Ten subjects (ages 35-63) with facial dyschromia and rhytides were enrolled. Study patients were randomized to the two treatment arms, Er:YAG (3.8 J/cm(2), 30% pattern overlap, 0% interpulse overlap, 15 microm per pass with no coagulation) and IPL (560-nm filter, 30 J/cm(2), 2.4/4.0-ms pulse with 10-ms delay), each receiving three sequential treatments spaced 1 month apart. Subjective and blinded physician evaluations were performed at baseline and 4, 8, and 20 weeks posttreatment using a nominal scale from 1 to 4. Erythema and adverse events were assessed 1 week following each treatment. RESULTS: Ten female subjects with mild to moderate facial photodamage were treated with one pass of either IPL or Er:YAG in a split-face fashion. Patients received three treatments each spaced 1 month apart. Nine of 10 patients completed the trial; 1 withdrew due to pain during the second Er:YAG treatment. Baseline subjective and blinded physician dyschromia and rhytid scores revealed no significant difference between the IPL and Er:YAG randomly assigned sides. Up to three IPL or Er:YAG treatments did not result in a significant improvement in rhytid scores. Subjective and blinded physician dyschromia scores improved 26 and 38%, respectively, 3 months after the final IPL treatment, but only by 7 and 29%, respectively, with Er:YAG. Subjective global facial appearance scores worsened by 5% while blinded physician scores improved by 16% 3 months after 3 Er:YAG treatments, but by 28 and 20% for IPL, respectively. The overall incidence of adverse events and subsequent downtime was increased for Er:YAG (1/10 patients experienced hyperpigmentation, 3/10 exfoliation, 1/10 blistering, and 5/10 discomfort) compared to IPL (1/10 exfoliation and 1/10 discomfort), although no permanent side effects were observed with either treatment arm. CONCLUSIONS: While low-fluence erbium resurfacing has a modest effect on facial photodamage, patients preferred IPL because it resulted in less downtime. The authors have indicated no significant interest with commercial supporters.

Management of visible granulomas following periorbital injection of poly-L-lactic Acid.

PURPOSE: Injectable poly-L-lactic acid (PLA) is a recently FDA-approved soft-tissue filler. Although approved only for treatment of HIV-associated lipoatrophy, there has been increased interest in its use for cosmetic purposes. Here we describe a case of a granulomatous reaction to injectable PLA in the inferior periorbital region resulting in visible papules and discuss treatment options. METHODS: We review literature pertaining to medical and surgical treatment options for our patient, and we discuss relevant techniques for both the injection of PLA and the management of this complication with surgical techniques. RESULTS: After failing several nonsurgical treatment options, our patient had excellent results with surgical excision of her persistent visible nodules. This technique is minimally invasive, provides definitive removal of the nodules, and can leave minimal residual scarring. CONCLUSIONS: Given the high frequency of subcutaneous nodule formation reported in early trials of injectable PLA, it is important for physicians to be well informed regarding its potential side-effects and how to minimize risk of adverse reactions. Based on our experience, we suggest that surgical excision is an excellent treatment option for persistent papules and nodules that arise after injection of PLA in the periorbital area.

A pilot study on the effect of epinephrine on botulinum toxin treatment for periorbital rhytides.

BACKGROUND: Relaxation of hyperactive facial muscles by injection of botulinum toxin type A (BOTOX, Allergan Inc., Irvine, CA) represents the most common cosmetic procedure performed in the United States. OBJECTIVE: The objective of this split-face randomized double-blind study was to determine the effect of epinephrine (EPI) on the efficacy of BOTOX treatment of muscle hyperactivity in the upper face. MATERIALS AND METHODS: Fourteen subjects (ages 39-57 years) with moderate to severe periorbital rhytides were enrolled. Study patients were blinded to the two treatment arms, BOTOX and BOTOX plus EPI 1:100,000. Subjective and objective evaluations were performed at 0 and 4 days and 1, 3, and 6 months, and clinical improvement was assessed using a nominal scale from 0 to 4, corresponding to 0, 1% to 25%, 26% to 50%, 51% to 75%, and 76% to 100% improvement, respectively. The incidence of adverse events was also recorded. RESULTS Fourteen subjects with moderate to severe periorbital rhytides were treated with BOTOX or BOTOX plus EPI. One subject was discontinued from the study after receiving asymmetric doses of BOTOX. At 4, 30, and 90 days after treatment, subjective and objective improvement scores revealed that EPI enhanced the efficacy of BOTOX when compared to BOTOX alone. By 3 months, the effect of BOTOX and BOTOX plus EPI had peaked and continued to fall through 6 months. One of 14 patients did not appear to respond to BOTOX treatment. Both treatments were well tolerated with no serious adverse events. CONCLUSION: To our knowledge, we are the first to test under randomized double-blind conditions the effect of EPI on efficacy of BOTOX. Our data suggest that addition of EPI may accelerate the rate of onset as well as the short-term efficacy of BOTOX for treatment of periorbital rhytides.

Adverse effects when injecting facial fillers.

Facial soft-tissue augmentation has become ubiquitous in cosmetic dermatology. In the appropriate patient and with appropriate training, fillers can temporarily eliminate rhytides, creases, and defects, thereby producing a rejuvenated appearance. Yet, even in the most experienced injectors, there can be complications. These adverse effects can be divided into early and late and range from bruising to necrosis. Understanding the anatomy, limitations of the filler and proper technique can reduce the risk of adverse effects. When a complication occurs, the practitioner should understand how to manage them from observation to surgical intervention.

Anatomic demarcation by positional variation in fibroblast gene expression programs.

Fibroblasts are ubiquitous mesenchymal cells with many vital functions during development, tissue repair, and disease. Fibroblasts from different anatomic sites have distinct and characteristic gene expression patterns, but the principles that govern their molecular specialization are poorly understood. Spatial organization of cellular differentiation may be achieved by unique specification of each cell type; alternatively, organization may arise by cells interpreting their position along a coordinate system. Here we test these models by analyzing the genome-wide gene expression profiles of primary fibroblast populations from 43 unique anatomical sites spanning the human body. Large-scale differences in the gene expression programs were related to three anatomic divisions: anterior-posterior (rostral-caudal), proximal-distal, and dermal versus nondermal. A set of 337 genes that varied according to these positional divisions was able to group all 47 samples by their anatomic sites of origin. Genes involved in pattern formation, cell-cell signaling, and matrix remodeling were enriched among this minimal set of positional identifier genes. Many important features of the embryonic pattern of HOX gene expression were retained in fibroblasts and were confirmed both in vitro and in vivo. Together, these findings suggest that site-specific variations in fibroblast gene expression programs are not idiosyncratic but rather are systematically related to their positional identities relative to major anatomic axes.

Safety of radiofrequency treatment over human skin previously injected with medium-term injectable soft-tissue augmentation materials: a controlled pilot trial.

BACKGROUND AND OBJECTIVES: Several soft-tissue augmentation materials are now available for reduction of nasolabial fold creases and perioral rhytides. Nasolabial folds and perioral rhytides can also be improved by skin tightening delivered by non-ablative radiofrequency (RF) treatment. The purpose of this study was to assess the safety of RF treatment over skin areas recently injected with medium-term injectable soft-tissue augmentation materials. STUDY DESIGN/MATERIALS AND METHODS: Five subjects were assigned to the experimental arm (augmentation materials plus RF) and one to the control arm (augmentation materials alone). Each subject received injections of 0.3 mL of hyaluronic acid derivative (Restylane) and calcium hydroxylapatite (Radiesse) 3 cm apart on the upper inner arm. Two weeks later, two non-overlapping passes of RF (Thermage ThermaCool TC) were delivered at 63.5 setting with medium-fast 1.5 cm2 tip over injected sites in all of the experimental subjects. Punch skin biopsies were obtained 3 days later from each of the two injection sites on each subject. RESULTS: Light microscopy and digital photomicrographs obtained at low, medium, and high power showed no difference between filler materials in experimental and control subjects. In both cases filler was evident at the deep dermal-subcutaneous junction. Nodule formation, foreign body extravasation, or hemorrhage/clot was not observed grossly or histologically. Subjects and physicians did not report any difference in signs and symptoms between the experimental and control arms. Slightly increased transitory pain was noted when RF was delivered over filler versus over normal skin. CONCLUSION: Applying RF treatment over the same area 2 weeks after deep dermal injection with hyaluronic acid derivatives or calcium hydroxylapatite does not appear to cause gross morphological changes in the filler material or surrounding skin. Further studies with different parameters are necessary to confirm these findings.