Lifting the Anterior Midcheek and Nasolabial Fold: Introduction to the Melo Fat Pad Anatomy and Its Role in Longevity and Recurrence.

BACKGROUND: A limitation of current facelift techniques is the early postoperative reappearance of anterior midcheek laxity associated with recurrence of the nasolabial fold (NLF). OBJECTIVES: This study was undertaken to examine the regional anatomy of the anterior midcheek and NLF with a focus on explaining the early recurrence phenomenon and to explore the possibility of alternative surgical methods that prolong NLF correction. METHODS: Fifty cadaver heads were studied (16 embalmed, 34 fresh; mean age, 75 years). Following preliminary dissections and macrosectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination, and microcomputed tomography. Mechanical testing of the melo fat pad (MFP) and skin was performed to gain insight on which structure is responsible for transmission of the lifting tension in a composite facelift procedure. RESULTS: Anatomic dissections, sheet plastination, and microcomputed tomography demonstrated the 3-dimensional architecture and borders of the MFP. Histology of a lifted midcheek demonstrated that a composite MFP lift causes a change in connective tissue organization from a hanging-down pattern into a pulled-upward pattern, suggesting traction on the skin. Mechanical testing confirmed that, in a composite lift, despite the sutures being placed directly into the deep aspect of the MFP, the lifting tension distal to the suture is transmitted through the skin and not through the MFP. CONCLUSIONS: The usual method of performing a composite midcheek lift results in the skin, and not the MFP itself, bearing the load of the nondissected tissues distal to the lifting suture. For this reason, early recurrence of the NLF occurs following skin relaxation in the postoperative period. Accordingly, specific surgical procedures for remodeling the MFP should be explored, possibly in combination with volume restoration of the fat and bone, for more lasting improvement of the NLF.

Simplified Muscle-Suspension Lower Blepharoplasty by Orbicularis Hitch.

BACKGROUND: The suspension of orbicularis oculi during lower blepharoplasty presents a logical surgical addition for further support of the lid, as well as further improvement to its contour profile. It has traditionally been performed as an extension of the skin-muscle flap procedure, but more recently, and aggressively, as a muscle strap-flap separated from the orbicularis sheet by myotomy. Many benefits of suspension, however, can be achieved without incision into muscle (beyond a single stab-wound "button-hole") and without delamination of the lid, as a safe, simple, single-suture suspension of preseptal muscle to lateral orbital rim. OBJECTIVES: The purpose of this report was to evaluate the results of a simplified approach to muscle suspension during lower blepharoplasty. METHODS: One hundred lower blepharoplasties by orbicularis hitch, performed as two consecutive series of 50, one by a plastic surgeon, the other by an oculoplastic surgeon, were reviewed retrospectively. RESULTS: Skin was resected from all lids, with a mean skin excision of 8 mm and 5 mm, respectively. Average follow-up was 17 and 16 months. Lateral canthal support was added to 2.5% of lids. There was one lid malposition (0.5%), leading to surgical revision, and no other complication or reoperation. CONCLUSIONS: Lower blepharoplasty by orbicularis hitch provides the benefits of muscle suspension by way of a simple, single-suture elevation of descended muscle, without the need for significant myotomy or lateral canthal manipulation. Despite its limited surgical invasiveness, it has proven both safe and effective in reversing muscle descent with skin redundancy, while maintaining lid support and lateral canthal integrity. LEVEL OF EVIDENCE 4: Therapeutic.

The inverted-v chevron umbilicoplasty for breast reconstruction and abdominoplasty.

The umbilicoplasty is a key component of abdominoplasty and closure of autologous abdominal wall donor sites in breast reconstruction (TRAM/DIEP). The aesthetically-pleasing umbilicus tends to be small and vertically-oriented in nature, with superior hooding and shadow, inferior retraction and slope, and positioning at the topmost level of the iliac crest. In this Featured Operative Technique, the authors describe their technique for performing an inverted-V chevron umbilicoplasty, which is their method of choice for restoring the umbilicus to an aesthetic and youthful appearance with minimal scarring.

Applications of the classic dermal fat graft in primary and secondary facial rejuvenation.

Volumetric facial aging occurs primarily as a descent of facial soft tissues, followed by their secondary atrophy. Proper volumetric facial rejuvenation, therefore, demands effective superior redistribution of fallen soft tissues, for which the author prefers malar imbrication. Only then do augmentative adjustments become appropriate, including solid facial protheses, "soft-tissue" fillers, dermal fat grafts, free-fat micrografts, and Erol's "tissue-cocktail." Of these, the author prefers the time-honored dermal fat graft for all primary volumetric augmentations within the surgical field, reserving free-fat micrografts for adjustments outside the field and those performed secondarily. Dermal fat grafts are added to the face in three categories: "camouflage" grafts from the anterior face lift discard specimen to correct contour irregularities in the sculpted subcutaneous cheek in half of patients; "transition" grafts from the suprapubic abdomen to the zone between the midface and lower face in 5 percent of patients with an emaciated quality to their aging; and "secondary" grafts from the abdomen in occasional patients with volumetric deformities following inexpert face lift and other forms of trauma. All grafts were harvested, prepared, and placed according to 10 straightforward technical principles. The grafts were highly effective and predictable in their ability to augment contour; none of 283 total grafts were regarded as a treatment failure. The use of such grafts was extremely safe, with complications limited to cyst formation in 1.5 percent of grafts, all of which were treated nonoperatively. The use of the dermal fat graft is seen as safe, effective, and convenient when the subcutaneous plane of the face is exposed during facial rejuvenation. The majority of grafts were derived from the face lift discard specimen. Although those that came from outside the head and neck presented extra inconvenience and operative time, their use was limited to occasional and challenging circumstances that justified extra investment.