Reducing Surgical Risks for Hair Replacement Surgery.

Hair loss is a common problem among men and women. Hair replacement surgery (HRS) has become increasingly popular as technological advancements have been made producing remarkably natural results when performed by a skilled surgeon. Although complications from HRS are low compared with other esthetic surgeries, they can still occur even with the best-trained and qualified surgeon or staff. The process of hair restoration can be a long road for some patients and active patient participation and education is key for successful results. In this article, we seek to discuss the surgical risks of HRS and discuss methods to prevent them in your practice.

The Male Facelift.

Rhytidectomy techniques have evolved significantly since the procedure was first described in the early twentieth century. Techniques vary based on surgeon preference, patient characteristics, and the desired outcome. As facelifts are embraced by the general public and the frequency of rhytidectomy increases, attention to male patient-specific technique is critical. Male and female facelift techniques are fundamentally similar; however, there are nuances to patient selection and technique in males that guide the surgeon to improved postoperative outcomes. Attention to incision placement, trichophytic technique, and adjunct procedures will improve overall cosmesis in the male patient. Understanding of potential risks and their likelihood in the male patient will also minimize complications and allow for rapid recovery.

Nuances in Superficial Musculoaponeurotic System Rhytidectomy.

Rhytidectomy techniques have evolved since the early 1900s. As the understanding of facial anatomy and the aging process expanded, the superficial musculoaponeurotic system (SMAS) became a focal point in developing longer-lasting, natural results. Further evolution led to various approaches in repositioning the SMAS layer, including subperiosteal, composite, and deep plane rhytidectomies. This article describes the nuances of SMAS rhytidectomy, the biplanar SMAS imbrication technique, and adjuvant procedures used. This biplanar SMAS technique has been refined over more than 25 years and has proved to be a reliable and safe technique that leads to high patient satisfaction with minimal complications.

Determining the 2-Dimensional Threshold for Perception of Artificial-Appearing Lips.

IMPORTANCE: Recognizing the perceptual threshold for artificial-appearing lips is important to avoid an undesirable outcome of treatment. OBJECTIVE: To characterize the quantitative measurements for the perceptual threshold of artificial- and unnatural-appearing lips. DESIGN, SETTING, AND PARTICIPANTS: Photographs of a female model's lips were digitally altered incrementally in 5 sets of features (the upper lip, lower lip, upper and lower lips, and shape of the Cupid's bow). From December 1, 2013, to January 30, 2014, participants viewed the photographs in random sequence using an online survey and responded to 2 questionnaires after each photograph. The participants were prompted to respond whether each altered photograph of the lips appeared to have received any cosmetic treatment, and whether the lips looked attractive and natural or artificial and unnatural. The measurement of each lip at which 50% of the observers perceived the lips as being treated and 50% of the observers perceived the lips as being artificial was determined. The difference in these 2 measurements was defined as dTA50, which represents the threshold differential between the perception of treated lips and artificial lips for 50% of the observers. MAIN OUTCOMES AND MEASURES: Survey responses of the participants to the appearance of the lips in the photographs. RESULTS: A total of 98 participants (76 females and 22 males; mean age, 42 years) provided usable responses to the survey. Each area of the lips had a unique quantitative measurement at which the observers perceived the lips as being treated and artificial. Enhancement of the upper lip alone had a narrower margin for artificial appearance (dTA50, 0.9 mm) compared with enhancement of both the upper and lower lips (dTA50, 1.5 mm). Any alteration to the Cupid's bow resulted in the narrowest margin for artificial appearance (dTA50, 0.3 mm). The difference in the perceptual threshold between the age of the observers was the most significant for the upper lip. CONCLUSIONS AND RELEVANCE: The perceptual threshold for treated and/or artificial appearance is unique for each area of the lips. LEVEL OF EVIDENCE: NA.

A review of medical and surgical treatment options for androgenetic alopecia.

IMPORTANCE: Androgenetic alopecia is a highly prevalent condition that can profoundly impair the quality of life in both men and women. OBJECTIVE: To provide the up-to-date medical and surgical treatment options for patients with androgenetic alopecia. EVIDENCE REVIEW: A Medline search of scientific literature was conducted from 1997 to 2013. Search terms included androgenetic alopecia, hair restoration, follicular unit transplantation, and follicular unit extraction. FINDINGS: Oral finasteride and topical minoxidil are the 2 mainstream medical treatments for androgenetic alopecia. These medications have different mechanisms of action and should be combined to have an additive effect in men. Follicular unit transplantation is the gold standard for surgical management. There are 2 types of graft harvest technique: donor strip and follicular unit extraction. Each technique has its own advantages and disadvantages and should be tailored to the individual patient. Understanding of the anterior hairline design is essential to achieving a natural-appearing result. CONCLUSIONS AND RELEVANCE: Medical treatment should be used in conjunction with surgery to achieve a synergistic effect. For the right candidate, follicular unit hair transplantation can lead to a long-lasting, natural result with appearance of dense scalp hair.

Biplanar superficial musculoaponeurotic system imbrication rhytidectomy.

Rhytidectomy techniques have evolved significantly since the procedure's introduction in the early 20th century. Significant advancements in rhytidectomy techniques occurred in the 1960s and 1970s with the description of the subfascial rhytidectomy, the identification of the superficial musculoaponeurotic system (SMAS), and development of the SMAS flap. The incorporation of fascial undermining and suspension techniques have significantly improved the longevity and natural appearance of the facelift operation. More aggressive techniques including subperiosteal, composite, and deep plane techniques have been developed in the pursuit of the perfect facelift procedure. On the basis of over 25 years of clinical and surgical experience, a biplane SMAS imbrication rhytidectomy provides a natural, unstretched, and refreshed appearance resulting in high patient satisfaction. This article will present a detailed description of the rationale, technique, and nuances of the biplanar SMAS imbrication rhytidectomy. While the management of the platysma may vary depending on individual patient characteristics, the extent of subcutaneous, sub-SMAS, and neck dissection employed using the biplanar SMAS imbrication rhytidectomy minimizes patient complications and allows a relatively rapid recovery.

Minimal incision face-lifting.

Rhytidectomy has been performed for over 100 years, but only more recently has it become generally accepted by society. Recent improvements in access to information has produced more public awareness of the possible aesthetic enhancements. Additionally, there has been a trend for the younger patient to seek cosmetic surgery, often requesting procedures with minimal incisions and less downtime. The mini-lift, with its decreased operating time and expense, rapid recovery, as well as more limited incisions and tissue elevation, is an ideal procedure for patients with a smaller degree of cheek and neck laxity. We describe our concept of the mini-lift and address what results can be expected.

Laser-assisted facial contouring using a thermally confined 1444-nm Nd-YAG laser: a new paradigm for facial sculpting and rejuvenation.

The micropulsed 1444-nm neodymium-doped lipolysis laser exhibits favorable characteristics for novel application in facial contouring. The study described herein is the first clinical report of laser-assisted facial contouring (LAFC). We retrospectively reviewed records of 478 LAFC patients (mean age 52) who underwent contouring of 1278 individual mid- and lower facial treatment sites over 18 months. Along with clinical assessment, study parameters evaluated among "original" and "modified" (where protocol updates included deep dermal soft tissue coagulation as an optional step) protocol groups included laser power, pulse energy, and total energy delivery as well as lipoaspirate volume at each treatment site. Mean power and pulse energy were similar (within 5%) and total energy use was greater (70% higher for mid- and lower face) in the original protocol group. Lipoaspirate volume was similar for both groups for the midface (within 10%) but elevated in the modified protocol group for the lower face (40% higher). Treatment complications were observed in 47 of 363 treatment sites (13%) in the original and in 12 of 915 treatment sites (1%) in the modified protocol group with the majority (63%) of the complications comprising over- versus undercorrections of desired tissue contour. Clinical efficacy varied with improvements of mid- and/or lower facial contour ranging from marginal to subtle to very apparent. LAFC as detailed herein is a novel treatment modality that enables selective soft tissue removal for greater precision in three-dimensional contouring of the face. Protocol modifications based on laboratory and observed tissue photothermodynamics have improved LAFC safety.

Extended lower eyelid skin muscle blepharoplasty.

A patient presenting to a facial plastic surgeon with lower eyelid aging often has accompanying midface descent. Many surgical options exist to address these deformities. Blepharoplasty techniques include both the transcutaneous skin-muscle flap as well as the transconjunctival approach. The midface can be addressed via a multitude of techniques, including percutaneous suspension of the malar fat pad, deep plane dissections, subperiosteal and endoscopic midface lifts, and transorbital approaches. Patients who have some midface ptosis but do not meet the standard criteria for formal midface lifting, or who want to avoid the extended recovery associated with such techniques, could benefit from less invasive procedures. We propose the extended skin muscle blepharoplasty to address midface descent and lower lid aging to patients as an alternative to formal midface lifting. The extended skin muscle blepharoplasty is an excellent technique for patients with orbicularis hypertrophy, skin redundancy, a tear trough deformity, and premalar ptosis, as it addresses each of these deformities with minimal downtime. Results for patients with mild but visible midface descent are gratifying.

Forehead and scalp sensation after brow-lift: a comparison between open and endoscopic techniques.

OBJECTIVE: To compare postoperative forehead and scalp sensation for the "open" brow-lift (OBL) (coronal and trichophytic) with that of the endoscopic brow-lift (EBL). METHODS: A controlled outcome evaluation study was designed to objectively (mechanoceptive and thermoceptive) and subjectively (visual analog scale) test forehead and scalp sensation in a group of patients having undergone or scheduled to undergo either OBL or EBL in a single, private facial plastic surgery clinic. Prospectively enrolled participants were tested at defined intervals (A, preoperation; B,1-2 weeks after; C, 4-6 weeks after; D, 12-14 weeks after; and E, 24-26 weeks after). To provide extended follow-up data (≥6 months), patients returning for scheduled follow-up examination who had already undergone either OBL or EBL were subjected to the same test battery. For statistical analysis of the extended follow-up data, the participants were divided into 2 groups (F, 6-18 months; and G, >18 months). The null hypothesis was that there would be no measurable difference between the OBL and the EBL groups related to postoperative forehead and scalp sensation. RESULTS: Twenty-one individuals (EBL, n = 11; OBL, n = 10) were enrolled prospectively. All showed normal objective and subjective values preoperatively. While both groups objectively and subjectively demonstrated decreased sensation over follow-up, the OBL group showed statistically significant decrement in objective scalp sensitivity at times B, C, and D vs the EBL group. Subjectively, the OBL group felt less sensitive than the EBL group at times C and D. Those relationships disappeared at time E. Fifty-eight individuals were retrospectively enrolled. At time F (EBL, n = 16; OBL, n = 10), an objective and subjective difference was again observed with the OBL group demonstrating less scalp sensitivity vs the EBL group. At time G (EBL, n = 20; OBL, n = 12), this difference was no longer observed. CONCLUSIONS: We reject the null hypothesis and state that there is a measurable, statistically significant difference between the studied groups related to postoperative forehead and scalp sensation and that those observed differences are objective and subjective in nature as well as time dependent. However, almost no patients (57 of 58), irrespective of the technique used for their brow-lift, viewed their experienced forehead and/or scalp numbness to have been significant enough to deter them from undergoing the surgery again.

Nitrogen plasma skin regeneration and aesthetic facial surgery: multicenter evaluation of concurrent treatment.

OBJECTIVE: To evaluate the safety and efficacy of aesthetic facial surgery with concurrent nitrogen plasma skin regeneration. METHODS: During a 28-month period, we independently completed 272 concurrent procedures in 95 patients aged 42 to 80 years in whom nitrogen plasma skin regeneration was performed immediately on completion of various aesthetic procedures, including brow-lift, blepharoplasty, lateral canthoplasty, midface-lift, rhytidectomy, cheek augmentation, lip vermillion advancement, filler injections, and augmentation mentoplasty. The treatment variables evaluated included nitrogen plasma pulse energy, pass number, and pulse count, and outcomes monitored included complications and subjective aesthetic improvement. RESULTS: The various treatment combinations were well tolerated at all anatomical sites. Rhytidectomy flap treatment included escalation of single-pass low-energy to high-energy nitrogen plasma treatment. Although perioperative complications did not otherwise negatively affect results, they included erythema with acneiform eruption (in 2 patients) and presumed herpes simplex virus infection, brief healing delay, and postinflammatory hyperpigmentation (in 1 patient each). In general, the treatment combinations were synergistic. CONCLUSIONS: Combining nitrogen plasma skin regeneration with aesthetic facial surgery enhances outcomes for procedures in the forehead and in the periorbital, midface, and perioral regions. It does not seem to increase the risk of dermatologic or surgical complications for the procedures described herein.

Core competencies for hair restoration surgeons recommended by the International Society of Hair Restoration Surgery.

BACKGROUND: Because hair restoration surgery has changed so significantly, the International Society of Hair Restoration Surgery (ISHRS) recently developed and published a Core Curriculum for Hair Restoration Surgery (CCHRS). The ISHRS organized a task force to develop training programs that would not only present the CCHRS but also provide the practical experience necessary to allow a physician to practice safe, aesthetically sound hair restoration surgery. The task force recognized early on that identification of core competencies for hair restoration surgeons was essential to guiding the development of these training experiences. This article presents the competencies that have been identified. OBJECTIVE: The intent of the Core Competencies for Hair Restoration Surgery is to outline the knowledge and skills that are essential to accurately diagnose and treat hair loss, to ensure patient safety, and to optimize aesthetic results. The ISHRS hopes that all existing surgery and dermatology training programs teaching hair restoration surgery procedures will find the Core Competencies useful in developing their curriculums. METHODS: The Core Competencies were developed through an organized review of the CCHRS by a team of experienced hair restoration surgeons and educators and reviewed and approved by the ISHRS Board of Governors. RESULTS: The diversity of these competencies demonstrate that contemporary hair restoration surgery is a specialty requiring knowledge of several medical disciplines, including genetics, endocrinology, dermatology, tissue preservation, and surgery. CONCLUSION: The International Society of Hair Restoration Surgery believes identification of these Core Competencies is an important contribution to physician education in hair restoration surgery, and physicians who demonstrate competency in these skills will satisfy patients with contemporary results in a safe environment.

Follicular unit transplantation.

Follicular unit transplantation (FUT) is the culmination of decades of refinement and evolution of hair transplantation techniques. Hair naturally grows in groups of one to four individual follicles separated by intervening soft tissue. These clumps or groups of hairs are termed FOLLICULAR UNITS. FUT uses microscopic dissection to separate these units for transplantation in a fashion that most closely resembles naturally occurring hair. FUT has grown to become recognized by many prominent hair restoration surgeons as the state-of-the-art method of hair replacement surgery for both male and female pattern alopecia. Although larger punch grafts, scalp flaps, and alopecia reductions may play a role in certain cases, FUT achieves results that are difficult to differentiate from naturally occurring hair. The central attributes of the technique are the provision of natural-appearing hairlines with reasonable density together with low morbidity and minimal "downtime." Nevertheless, the technique is only as effective as the technician, and results are heavily dependent on the forethought of the architect.

Autologous superficial musculoaponeurotic system graft as implantable filler in nasolabial fold correction.

OBJECTIVE: To determine whether superficial musculoaponeurotic system (SMAS) graft implantation can improve the appearance of the nasolabial fold. METHODS: Single-blinded cohort study in a private facial plastic surgery practice. Treatment and control patients were selected from those presenting for aesthetic surgery. All patients underwent rhytidectomy with SMAS imbrication by a single surgeon. In addition, treatment patients underwent subcutaneous implantation of excised SMAS strips to the nasolabial fold. Treatment and control patients were matched for any other simultaneous procedures known to affect appearance of the nasolabial folds. Preoperative and postoperative photographs were graded by 3 blinded observers using the Wrinkle Severity Rating Scale to evaluate the nasolabial fold. Postoperative photographs were evaluated approximately 3 months and again 1 year after the procedure. RESULTS: Compared with controls, there was a significant difference in the nasolabial folds of patients undergoing SMAS implantation at the 3-month postoperative evaluation (P = .03; chi(2) = 4.696). This benefit was lost when the results were evaluated 1 year after the procedure (P = .88; chi(2) = 0.0212). CONCLUSION: Superficial musculoaponeurotic system implantation to the nasolabial folds offers modest temporary improvement to this area in patients undergoing rhytidectomy with SMAS imbrication.

Core curriculum for hair restoration surgery, recommended by the International Society of Hair Restoration Surgery (ISHRS).

BACKGROUND: Because hair restoration surgery (HRS) has changed so significantly, the International Society of Hair Restoration Surgery (ISHRS) presents the recently developed Core Curriculum for Hair Restoration Surgery (CCHRS). Physician competence in HRS demands a sound understanding of all of the alternate pathologic causes of hair loss, as well as their risks and treatments. OBJECTIVE: The CCHRS defines the knowledge, didactic information, medical insights, and surgical techniques that are essential to physician competence in the correct diagnoses and treatment of hair loss problems, in a manner consistent with patient safety and sound esthetic results. The ISHRS hopes that all existing surgical and dermatology training programs that teach HRS procedures will find the CCHRS useful in developing their curriculum relative to HRS and that this will facilitate the development of a new standard of training within the profession. METHODS: Developed and reviewed by a committee of experienced hair restoration surgeons. RESULTS: The CCHRS clearly defines the diagnosis and treatment of hair loss as a multidimensional specialty requiring knowledge of several medical disciplines, including genetics, endocrinology, dermatology, and surgery. CONCLUSION: The ISHRS believes that the CCHRS is an important contribution to physician education in HRS and that a clearly defined core curriculum will facilitate achieving contemporary results and higher patient satisfaction.