Centro-lateral subperiosteal vertical midface lift.

The use of fiberendoscopic video-assisted technique in facial rejuvenation is one of the most advances in aesthetic plastic surgery of the face. It substitutes the coronal incision without the necessity of skin resection and allows a vertical reposition of the mobile soft tissue of the midface in indicated cases. It can easily be done through a small incision of the scalp just behind the coronal incision and in the temporal area.

Inferior pedicle autoaugmentation mastopexy after breast implant removal.

BACKGROUND: A new method of autoaugmentation mammaplasty is presented to correct ptosis and to increase the projection and volume of the breast in patients who would like a reposition augmentation mammaplasty after breast implant removal but do not want a new implant. METHODS: Between 1999 and 2007, a total of 27 patients (age = 54 +/- 7.3 years) underwent mammaplasty using an inferior-based flap of deepithelialized subcutaneous and breast tissue modularized to its pedicle which was inserted beneath a superior pedicle used for correction of ptosis and to increase the projection and apparent volume of the breast. RESULTS: The results confirmed that autoaugmentation mammaplasty of the breast following removal of the implant yields longstanding results. It corrects ptosis and increases the projection and apparent volume of the breast when mastopexy is planned without use of a new implant. Twelve months after surgery the degree of descent of the inframammary fold generally parallels that of the nipple. The mean level of the inframammary fold was below the mean level of the nipple. Postoperatively, the optimum distance had been largely achieved. CONCLUSION: The advantages of the technique presented here are that it minimizes the skin scar in cases using vertical mammaplasty techniques and optimizes the breast shape after breast implant removal in patients who do not want a new implant.

Autoaugmentation mastopexy with an inferior-based pedicle.

Mammaplasty for breast enhancement and correction of ptosis augmentation is described. Between 2002 and 2007, autoaugmentation mammaplasty was performed for 27 patients (age, 48 +/- 7.3 years) using an inferior-based flap of deepithelialized dermoglandular tissue inserted beneath the breast parenchyma of a superior-based nipple-areolar complex pedicle. The results confirmed that autoaugmentation mammaplasty corrects ptosis while increasing the projection and apparent volume of the breast. The degree of inframammary fold (IMF) descent 6 months after surgery generally paralleled that of the nipple. The mean level of the IMF was below the mean level of the nipple. Postoperatively, the optimum distance had been largely achieved. The advantage of the technique is that it optimizes the shape and volume of the breast without the use of an implant.

Video endoscopic-assisted brow lift: comparison of the eyebrow position after Endotine tissue fixation versus suture fixation.

To improve brow ptosis and forehead rhytids, minimal invasive surgery has successfully been applied more recently. Clinical studies have revealed that inadequate fixation for anchoring a transposed released soft tissue will result in a loss of suspension of the lateral eyebrow. Therefore, we evaluated the results of eyebrow position in a series of endoscopic-assisted eyebrow lift cases by comparing broad base of fixation with an Endotine device versus conventional single-point tissue fixation with suture loop fixation of the soft forehead tissue. Between 2003 and 2005, 47 patients (12 males and 35 females, age 38.5 +/- 6.2 years)) underwent eyebrow lift and a forehead plasty. In one group, which consists of 25 patients (6 males and 19 females, age 36.5 +/- 5.1 years), soft tissue fixation of the elevated forehead was performed conventionally with one suture loop on each side that passed through the galea-periosteum and anchored to the cranial bone (bone tunnels). In the other group of 22 patients (4 males and 18 females, age 39.3 +/- 6.4 years), the elevated forehead was anchored to Endotine 3.5 version. Despite the fact that 6 months after surgery, drooping of the lateral brow position was observed, with a mean of 2.3 +/- 0.8 mm, in the overall cases 12 months after surgery, differences in the position of medial third of the eyebrow were noted between these groups. In the Endotine group, the medial third of the eyebrow portion stayed more stable at its transposed position and was in mean 1.5 +/- 0.6 mm higher compared with the suture soft-fixed group. The results confirmed that Endotine enhances soft tissue suspension by allowing better distribution of tension over multiple points over time and thereby supports re-adherence strength of the transpose medial flap forehead to the frontal bone. For minimizing a relapse of the elevated lateral eyebrow portion after adequate dissection and tissue release, suspension of the lateral soft forehead tissue is paramount. It should be located between the temporoparietalis fascia and the deep temporal fascia, with extensive tension after resection of temporal fascia window additionally supported by reabsorbable threads or gore tex sutures.

Subperiosteal Endotine-assisted vertical upper midface lift.

BACKGROUND: In the typical upper midface lift, tissue fixation is usually accomplished through a series of sutures that may be time consuming, technically demanding, difficult to apply, and also require frequent rearrangement and adjustment. OBJECTIVE: The use of an Endotine Midface (Coapt Systems, Palo Alto, CA) fixation device through a technique termed the subperiosteal Endotine-assisted vertical upper midface lift is described. METHODS: Twelve patients underwent subperiosteal Endotine-assisted vertical upper midface lift, which included simultaneous forehead lift, blepharoplasty and Endotine-assisted transtemporal-transoral subperiosteal upper midface tissue release, verticolateral elevation and fixation of the upper midface. RESULTS: The technique we used achieved a significant improvement of the eyelid-cheek complex and rejuvenation of the nasojugal groove as evaluated 6 months after surgery. Preoperative and postoperative assessments of the lower eyelid distance revealed a mean shortening of 5 mm +/- 2 mm. CONCLUSIONS: The results confirmed that vertical upper midface lifts combined with Endotine-assisted midface fixation can be safely and predictably performed over the zygomatic muscle. This technique allows for simple adjustments of tension and position, thereby providing greater aesthetic control of cheek elevation and projection. It also achieves volume enhancement and projection of the midface tissue.

Contouring of cranial vault irregularities with hydroxyapatite cement: a clinical and experimental investigation.

The biocompatible hydroxyapatite cement (HAC) is a welcome alternative to the traditional use of autogenous bone for postoperative corrections of cranial vault irregularities. The authors performed experimental studies to show the safety and osseointegration capacity of HAC on animal models and confirm the osseous replacement without toxic reactions. The purpose of the current study was to analyze the clinical outcome after correction of secondary cranial vault irregularities with HAC. Twenty-one patients were treated for residual cranial frontal bone defects after craniotomy with HAC (Bone Source, Stryker Leibinger GmbH, D-79111 Freiburg, Germany). The average age was 38.5 years (range, 23-57 years). All of the patients were male. The average volume per patient was 53.83 g. The volume implanted ranged from 25 to 125 g; in all cases the dura was covered with bone. Irregularities resulted from sunken bone. The authors' clinical series demonstrates that a satisfactory and aesthetically pleasing result can be achieved in one surgical intervention in patients for surgical correction of postoperative cranial vault irregularities using HAC. It permits osseointegration, which makes it relatively resistant to infection. HAC is easy to apply and shape to suit individual needs. HAC is a welcome alternative to the traditional use of autogenous bone for postoperative corrections of cranial vault irregularities.

Cellular, histomorphologic, and clinical characteristics of a new octyl-2-cyanoacrylate skin adhesive.

Short-chained cyanoacrylates have been used for many years for topical skin closure. Toxic effects in cell culture of a new long-chained octyl-2-cyanoacrylate tissue adhesive are compared with those of short-chained ethyl-2- and butyl-2-cyanoacrylates. Two cellular tests were used: the agar overlay test and the MTT test. An in vitro test using copper plates coated with the three types of cyanoacrylates serves for evaluating the stability of polymerized skin adhesives. Bilateral neck skin incisions in Goettingen miniature pigs were glued on one side with Dermabond. On the other side, conventional sutures were applied. After the pigs were killed, the resulting skin samples were tested for the tensile strength of their wound stability. Samples of pig dermis were exemplarily and histomorphologically characterized. A clinical examination after submandibular lymph node dissection should examine the application in humans. Cell culture tests were used to show the toxic effects of the three cyanoacrylates. In a copper test, octyl-2-cyanoacrylate was more stabile than ethyl- and butyl-cyanoacrylates. Breaking strength was 30% lower 28 days after operation with the new product than with sutures. In electron microscopy, octyl-2-cyanoacrylate showed no disadvantages with regard to tissue regeneration and no histotoxicity. For plastic surgery, this new topical skin adhesive is a real alternative with attractive results, as compared with conventional suture.

Video-assisted endoscopic transtemporal multilayer upper midface lift (MUM-Lift).

Minimally invasive surgery has been used successfully recently to improve brow ptosis and forehead rhytids. Because the face tends to age more vertically, rather than obliquely, it makes sense to perform the correction in a more vertical direction. Therefore, the authors introduce a video-assisted endoscopic transtemporal approach to allow a multiplanar (subperiosteal, sub-SMAS, and subcutaneous) vertical upper midface elevation (MUM-Lift) avoiding extensive lateral temporal and preauricular incisions. Between 1996 and 2003, 53 patients (8 males, 45 females; age, 47 +/- 6 years) underwent MUM-Lift. This includes simultaneous forehead lift, blepharoplasties and video-assisted transtemporal sub-SMAS and subcutaneous upper midface tissue release, vertico-lateral repositioning, and fixation. Using the various planes of release in the midface produces less tension on each layer and provides a natural and improved facial rejuvenation of the forehead, as well as of the upper midface. The results confirmed that limited incision forehead-plasty techniques in combination with a transtemporal sub-SMAS and subcutaneous upper midface lift (MUM-Lift) reduces unnecessary vascular compromise on any particular layer and can be safely and predictably performed over the zygomatic muscle. This newly introduced procedure is an exciting feature that has evolved into a useful modality. It provides natural and improved facial rejuvenation.

Classification system and treatment of zygomatic arch fractures in the clinical setting.

A new classification system and algorithm of zygomatic arch fractures is described that provides the surgeon with a useful starting point from which to organize a valid treatment plan and management of zygomatic arch fractures. Hönig Merten (HM) class I is defined as an isolated tripod fracture, HM class II as an isolated stick fracture of the arch, and HM class III is a combined fracture of the malar bone and the zygomatic arch. Although reduction of the class I and II is usually closed, open reduction is mandatory in class III zygomatic arch fractures.

Facelift approach with a hybrid SMAS rotation advancement flap in parotidectomy for prevention of scars and contour deficiency affecting the neck and sweat secretion of the cheek.

Tumors of the parotid gland are generally be removed by the standard external bayonet-shaped incision approach without reconstruction of the parotid bed. The disadvantage of this approach is frequently an obvious scar affecting the neck and a conspicuous hollow contour around the angle of the mandible in addition to a sweat secretion of the cheek (Frey syndrome). To overcome these disadvantages, especially the facial depressed deformity subsequent to parotid surgery, during the last several years, the author has concentrated on facelift incision used in combination with a hybrid SMAS rotation advancement flap. Twelve patients (7 male; 5 female) ranging in age from 32 to 73 years (mean age, 57.8 years) fulfilled the selection criterion of having a clinically benign discrete parotid lump with a benign preoperative fine-needle cytology result. Parotidectomy was performed using the modified facelift incision in conjunction with the rotation advancement hybrid SMAS flap. All patients were followed up every 3 months during the first year. During follow-up, the patients were specifically asked about their satisfaction with their postoperative appearance and whether they would consent to the operation again. The vascularized hybrid vicryl mesh/SMAS rotation advancement flap is clinically simple to perform and provides satisfactory cosmetic and functional results in patients undergoing conservative parotidectomy and prevents the gustatory sweating. There are no drawbacks to the use of the modified facelift incision to remove tumors of the parotid gland.

Severe granulomatous allergic tissue reaction after hyaluronic acid injection in the treatment of facial lines and its surgical correction.

Hyaluronic acid is considered to be nonimmunogenic. Frequently, it is used for the correction of facial lines. It is believed that hyaluronic acid injection fillers are safe and have no occurrence of serious adverse reactions or allergic reactions. Nevertheless, recent publications have documented the rate of intermittent swelling and severe granulomatous allergic reactions that evolved into abscesses. A clinical case of a 54-year-old patient is presented. After injection of hyaluronic acid in the treatment of nasolabial folds elsewhere, she developed palpable painful erythematous nodules evolving into abscesses several month after injection. Surgical treatment and correction of these lesions after hyaluronic acid injection of the nasolabial folds and the histological findings of these erythematous nodules are described. Histological and clinical examination documented intermittent swelling and severe granulomatous allergic reactions that may render the use of hyaluronic acid unacceptable. Patients should be informed of the potential complications when treating facial lines with hyaluronic acid gel.

Experimental study of the frontal sinus development on Goettingen miniature pigs.

According to the literature, the development of the frontal sinus cavity is a result of the active immigration of cells from the ethmoidal complex into the os frontale. This migration theory is in contrast to the operative outcome of Apert's syndrome patients, after fronto-orbital advancement. When a fronto-orbital advancement at the age of a few months is performed in these patients while the frontal suture is yet closed, a sinus developed even the distance between nasal root and frontal bone bing up to 2 cm. In order to study the development of the frontal sinus, an animal study on 12 five-week-old infant Goettingen minipigs (GMP) was conducted, which did not have any clinical or histological signs of a frontal sinus development to investigate the development of the frontal sinus in "orthotopically" transplanted frontal bone with an open frontal suture. A comparison was made to a control group. The macro- and microscopical comparison with a control group revealed that the orthotopical transplants in the occipital bone developed epithelium-lined sinus, beginning from the thirty-fifth week. Based on these histomorphological results, a development scheme for the genesis of the sinus frontalis as a model were drawn.

Mandibula distraction osteogenesis for lengthening the mandibula to correct a malocclusion: a more than 70-year-old German concept in craniofacial surgery.

Bone distraction is still on the rise again since McCarthy et al. presented in their clinical investigation new osseous formation in the elongated area while performing the distraction of the mandible in 1992. But at the level of craniofacial skeleton, the initial description to the technique of distraction osteogenesis should be credited to the German craniofacial surgeons Rosenthal for the bone lengthening of the mandible in a microgen patient in 1927. The procedure is described and the original schedules and case are presented.

Facial bone distraction osteogenesis for correction of malocclusion: a more than 70-year-old concept in craniofacial surgery.

Bone distraction has been used increasingly since McCarthy and associates showed in their clinical investigation new osseous formation in the elongated area while performing mandibular distraction in 1992. However, at the craniofacial skeletal level, the initial description of the classic technique of distraction osteogenesis should be credited to German craniofacial surgeons Rosenthal (for bone lengthening of the mandible in a microgenia patient around 1927) and Wassmund (for the clinical advancement of a maxilla in a patient with hypoplasia of the upper jaw in 1926). Both procedures are described, and their original schedules and cases are presented.