The 3-Level Approach to Facelift Planning: A Simple Paradigm for Surgical Rejuvenation of the Face.

Our role as aesthetic surgeons demands individualized surgical planning that maximizes patient input and understanding. The value of such shared decision-making (SDM) in aesthetic surgery is becoming increasingly appreciated. This is particularly true for potential patients seeking surgical rejuvenation of the face, where the volume of "educational" information available on the internet, and through various social medial channels, may be overwhelming and even misleading. Presented is a "3-Level approach to facelift planning" named for the facial subregions targeted. This novel paradigm maximizes SDM with its simplicity and reproducibility, serves as an invaluable educational tool for patients, novice and seasoned surgeons alike, and facilitates communication between senior surgeons through its descriptive standardization. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nonsurgical Management of Facial Masculinization and Feminization.

BACKGROUND: Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures. OBJECTIVES: The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization. METHODS: A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review. CONCLUSIONS: Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

The U-SMASectomy Facelift.

Manipulation of the superficial musculoaponeurotic system (SMAS) has become a mainstay of face lifting procedures. Traditionally, the various surgical approaches to the SMAS have been classified as either "low" or "high" SMAS techniques, the former of which, while expeditious, have been criticized for suboptimal upper midface rejuvenation. High SMAS techniques, by contrast, are lauded for their ability to improve upper midface contours, but may carry increased surgical risk, particularly in the hands of less experienced aesthetic surgeons. Presented is the U-SMASectomy facelift (USL)- an imbricating approach to the SMAS that builds upon well-described low SMAS techniques with the addition of a malar flap of mobile-only SMAS for orbitomalar rejuvenation. This novel, hybrid technique harnesses the advantages of traditional low and high SMAS techniques while mitigating surgical risk. Of 61 USLs performed, a minor complication rate of 16.4% was observed. No major complications were observed. Mean follow-up was 371 days. The USL is thus a safe and powerful facial rejuvenation technique for both beginning surgeons with advanced aesthetic training, and well-versed aesthetic surgeons alike.

Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the relevant anatomy involved in breast reduction. 2. Understand the different breast reduction techniques and their indications. 3. Appreciate the outcomes of these techniques as they pertain to clinical outcomes. SUMMARY: This continuing medical education article is designed to refresh one's knowledge on breast reduction while placing emphasis on clinical outcomes. It reviews the relevant anatomy, techniques, and published literature on outcomes, including those that are patient-reported. Photographic representations of most techniques are shown, in addition to supplemental digital video content, to demonstrate each technique. This is designed to be an overview, and the reader should appreciate that no one technique is "right," and the technique used should be selected with patient factors and desired outcomes in mind.

Nipple-Areola Complex Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand how to determine nipple-areola complex positioning on the reconstructed breast. 2. Understand the multitude of local flap and distant graft options for nipple-areola complex reconstruction. 3. Draw at least three fundamental nipple-areola complex reconstruction patterns. 4. Understand the forces that are responsible for flattening of the reconstructed papule. 5. Understand the current techniques used in secondary nipple-areola complex reconstructions. SUMMARY: Nipple-areola complex reconstruction and tattooing represent the final two stages of breast reconstruction. Nipple-areola complex reconstruction is typically accomplished with the use of local flaps, local flaps with augmentation grafts, or a combination thereof. Regardless of the technique used, however, all nipple-areola complex reconstructions lose a degree of projection over time. Options for secondary reconstruction include the use of local tissue flaps alone or in combination with acellular biological matrices.

Use of three-dimensional, CAD/CAM-assisted, virtual surgical simulation and planning in the pediatric craniofacial population.

OBJECTIVE: Virtual Surgical Planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) have recently helped improve efficiency and accuracy in many different craniofacial surgeries. Research has mainly focused on the use in the adult population with the exception of the use for mandibular distractions and cranial vault remodeling in the pediatric population. This study aims to elucidate the role of VSP and CAD/CAM in complex pediatric craniofacial cases by exploring its use in the correction of midface hypoplasia, orbital dystopia, mandibular reconstruction, and posterior cranial vault expansion. METHOD/DESCRIPTION: A retrospective analysis of thirteen patients who underwent 3d, CAD/CAM- assisted preoperative surgical planning between 2012 and 2016 was performed. All CAD/CAM assisted surgical planning was done in conjunction with a third party vendor (either 3D Systems or Materialise). Cutting and positioning guides as well as models were produced based on the virtual plan. Surgeries included free fibula mandible reconstruction (n = 4), lefort I osteotomy and distraction (n = 2), lefort II osteotomy with monobloc distraction (n = 1), expansion of the posterior vault for correction of chiari malformation (n = 3), and secondary orbital and midface reconstruction for facial trauma (n = 3). The patient's age, diagnosis, previous surgeries, length of operating time, complications, and post-surgery satisfaction were determined. RESULTS: In all cases we found presurgical planning was helpful to improve accuracy and significantly decrease intra-operative time. In cases where distraction was used, the planned and actual vectors were found to be accurate with excellent clinical outcomes. There were no complications except for one patient who experienced a wound infection post-operatively which did not alter the ultimate reconstruction. All patients experienced high satisfaction with their outcomes and excellent subjective aesthetic results were achieved. CONCLUSIONS: Preoperative planning using CAD/CAM and VSP allows for safe and precise craniofacial reconstruction in complex pediatric cases with a reduction of operative time.

The use of computer-aided design/manufacturing (CAD/CAM) technology to aid in the reconstruction of congenitally deficient pediatric mandibles: A case series.

BACKGROUND: Microvascular reconstruction of the pediatric mandible, particularly when necessitated by severe, congenital hypoplasia, presents a formidable challenge. Complex cases, however, may be simplified by computer-aided design/computer-aided manufacturing (CAD/CAM) assisted surgical planning. This series represents the senior authors' preliminary experiences with CAD/CAM assisted, microvascular reconstruction of the pediatric mandible. METHODS: Presented are two patients with hemifacial/bifacial microsomia, both with profound mandibular hypoplasia, who underwent CAD/CAM assisted reconstruction of their mandibles with vascularized fibula flaps. Surgical techniques, CAD/CAM routines employed, complications, and long-term outcomes are reported. RESULTS: Successful mandibular reconstructions were achieved in both patients with centralization of their native mandibles and augmentation of deficient mandibular subunits. No long-term complications were observed. CONCLUSIONS: CAD/CAM technology can be utilized in pediatric mandibular reconstruction, and is particularly beneficial in cases of profound, congenital hypoplasia requiring extensive, multi-planar, bony reconstructions.

Cartilage volume quantification via Live Wire segmentation.

RATIONALE AND OBJECTIVES: A reduction in cartilage volume is characteristic of osteoarthritis and hence there exists a need for an accurate and reproducible method to measure in vivo cartilage volume. Quantification of cartilage volume from magnetic resonance (MR) images requires a segmentation technique such as the user-driven "Live Wire" strategy that can reliably delineate object volumes in a time-efficient manner. In the present work, the accuracy and reproducibility of the Live Wire method for the quantification of cartilage volume in MR images is evaluated. MATERIALS AND METHODS: The accuracy of the Live Wire method was assessed by comparing the MR-based volume measurement of a patellar cartilage-shaped phantom versus data calculated via water displacement. The inter- and intra-operator reproducibility of the technique was evaluated from Live Wire segmentation of the patellar cartilage volume from fat-suppressed 3-dimensional spoiled-gradient-echo images of five healthy human volunteers performed by three operators. To provide data for analysis of inter-scan reproducibility, the human scans were repeated five times with the aid of a leg-restraining jig to minimize repositioning error. RESULTS: The volume of the patellar cartilage-shaped phantom measured via Live Wire segmentation of MR images was within 97.8% of its true volume. The average inter- and intra-operator coefficients of variation of three operators were 3.0% and 0.4%, respectively. The average inter-scan coefficient of variation of five repeated scans of each volunteer was 2.7%. CONCLUSION: The data suggest that the Live Wire strategy is an accurate, reproducible, and efficient technique to measure cartilage volume in vivo in a feasible amount of operator time.

An analysis of mandibular volume in hemifacial microsomia.

BACKGROUND: The mandibular deformity in hemifacial microsomia is characterized by ramus-condyle unit deficiency. The Pruzansky score classifies the proximal mandible according to aberrant condylar-unit structure. The authors sought to volumetrically evaluate the hemifacial mandible compared with controls, and to assess for Pruzansky score correlation. METHODS: This is a retrospective analysis of children with hemifacial microsomia. Demographic information was obtained, and computed tomographic data were analyzed by segmentation and volumetric calculations. Age-matched controls were compared using the t test. RESULTS: Computed tomographic scans revealed 24 hemifacial and 13 controls: 62.5 percent right, 12.5 percent left, and 25 percent bilateral; and 34 percent type I, 28 percent type IIa, 16 percent type IIb, and 22 percent type III. Type IIb/III compared with type I/IIa were 11,100 and 17,773 mm, respectively (p = 0.0029). Segmental evaluation of type IIb/III versus type I/IIa showed 3590 versus 6510 mm for the proximal segments (p = 0.0022) and 7449 versus 10,829 mm for the dental-bearing segments (p = 0.0221). All hemifacial microsomia hemimandibles (types I to III) were significantly less than controls: 14,837 versus 20,418 mm (p = 0.0005). Both dentate and proximal hemifacial microsomia segments statistically decreased in volume with increasing Pruzansky score. The dentate segment of the unaffected hemifacial microsomia side was statistically less than controls. CONCLUSIONS: This study volumetrically characterized the hemifacial microsomia mandibular deformity. As expected, with increasing Pruzansky severity, hemimandibular and proximal segment volumes declined. Unexpectedly, the hemifacial dentate segment also proved significantly diminished, corresponding to the degree of proximal volume loss.

A phenotypic assessment tool for craniofacial microsomia.

BACKGROUND: Craniofacial microsomia is one of the most common conditions treated by craniofacial teams. However, research regarding the cause of this condition or the surgical outcomes of treatment is scant. This is attributable to the lack of diagnostic criteria and the wide phenotypic spectrum. Standardized description of the craniofacial malformations associated with craniofacial microsomia is a necessary first step for multicenter, interdisciplinary research into this complex condition. METHODS: The authors used the previously published pictorial Orbit, Mandible, Ear, Nerve, and Soft tissue-Plus classification scheme to assign a phenotypic severity score to patients with craniofacial microsomia treated at the Craniofacial Center at Seattle Children's Hospital. The authors modified the tool based on feedback from multidisciplinary focus groups. The authors also developed a standardized photographic protocol to facilitate assessment of patients using two-dimensional images. RESULTS: Feedback from focus groups was synthesized to create a phenotypic assessment tool for craniofacial microsomia based on the pictorial Orbit, Mandible, Ear, Nerve, and Soft tissue-Plus classification system. This tool allows for more comprehensive description of the phenotype of craniofacial microsomia and is found to be effective for clinical use within a multidisciplinary craniofacial team. In addition, the photographic protocol for patients with craniofacial microsomia allows for classification from a two-dimensional photographic database, thereby facilitating research using archived photographs. CONCLUSIONS: The phenotypic assessment tool for craniofacial microsomia protocol provides a simple and standardized method for practitioners and researchers to classify patients with craniofacial microsomia. We anticipate that this tool can be used in multicenter investigational studies to evaluate the cause of this condition, its natural history, and comparative effectiveness research.

Hemifacial microsomia: clinical features and pictographic representations of the OMENS classification system.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Describe the fundamental malformations defining hemifacial microsomia. 2. Distinguish hemifacial microsomia from other congenital craniofacial anomalies sharing similar features. 3. Understand the variety of systems developed to clinically classify the features of this disorder. 4. Describe the format of the OMENS clinical classification system and appreciate its possible advantages and limitations. BACKGROUND: The clinical manifestations of hemifacial microsomia comprise a spectrum that is both broad and complex. The fundamental features include unilateral hypoplasia of the craniofacial skeleton and its overlying soft tissue. Numerous schemes have been developed to classify this spectrum. One of the most recent classification systems, the OMENS system, scores five clinical manifestations of hemifacial microsomia according to dysmorphic severity on a scale from 0 to 3: orbital asymmetry, mandibular hypoplasia, ear deformity, nerve dysfunction, and soft-tissue deficiency. METHODS: The authors describe the diverse features of hemifacial microsomia and the numerous attempts at its clinical classification, with particular emphasis on the OMENS system. RESULTS: With the possible exception of the OMENS scheme, the various systems developed to classify the clinical features of hemifacial microsomia fail to possess the flexibility and versatility needed to categorize all potential phenotypes of this complex disorder. CONCLUSIONS: The OMENS system represents the most comprehensive, versatile, objective, and easily adaptable attempt at clinical classification of hemifacial microsomia to date. The authors propose a concise clinical evaluation form using a modified version of the system to promote the use of the OMENS system, to aid in the evaluation of hemifacial microsomia patients, and to assist in data sharing among academic institutions.

23Na MRI accurately measures fixed charge density in articular cartilage.

One of the initiating steps of osteoarthritis is the loss of proteoglycan (PG) molecules from the cartilage matrix. One method for assessing cartilage integrity, therefore, is to measure the PG content or fixed charge density (FCD) of cartilage. This report shows the feasibility of calculating FCD by (23)Na MRI and introduces MRI protocols for human studies, in vivo. (23)Na MRI was used to measure the sodium concentration inside bovine patellar cartilage. The sodium concentration was then converted to FCD (mM) by considering ideal Donnan equilibrium. These FCD measurements were compared to FCD measurements obtained through standard dimethylmethylene blue PG assays. There was a high correlation (slope = 0.89, r(2) = 0.81) between the FCD measurements obtained by (23)Na MRI and those obtained by the PG assays. These methods were then employed in quantifying the FCD of articular cartilage of human volunteers in vivo. Two imaging protocols were compared: one using a birdcage coil, the other using a transmit/receive surface coil. Both methodologies gave similar results, with the average sodium concentration of normal human patellar cartilage ranging from approximately 240 to 260 mM. This corresponds to FCDs of -158 mM to -182 mM.

Quantifying sodium in the human wrist in vivo by using MR imaging.

The authors quantified sodium content in the wrist joints of six healthy volunteers with no known history of arthritis or pain. Average sodium concentrations ranged from 115 to 150 mmol/L in noncartilaginous regions and from 200 to 210 mmol/L in cartilaginous regions. The feasibility of quantifying sodium in vivo was demonstrated. This method has potential applications in monitoring the integrity of cartilaginous tissue in vivo.

In vivo measurement of T1rho dispersion in the human brain at 1.5 tesla.

PURPOSE: To measure T1rho relaxation times and T1rho dispersion in the human brain in vivo. MATERIALS AND METHODS: Magnetic resonance imaging (MRI) was performed on a 1.5-T GE Signa clinical scanner using the standard GE head coil. A fast spin-echo (FSE)-based T1rho-weighted MR pulse sequence was employed to obtain images from five healthy male volunteers. Optimal imaging parameters were determined while considering both the objective of the study and the guarantee that radio-frequency (RF) power deposition during MR did not exceed Food and Drug Administration (FDA)-mandated safety levels. RESULTS: T1rho-weighted MR images showed excellent contrast between different brain tissues. These images were less blurred than corresponding T2-weighted images obtained with similar contrast, especially in regions between brain parenchyma and cerebrospinal fluid (CSF). Average T1rho values for white matter (WM), gray matter (GM), and CSF were 85 +/- 3, 99 +/- 1, and 637 +/- 78 msec, respectively, at a spin-locking field of 500 Hz. T1rho is 30% higher in the parenchyma and 78% higher in CSF compared to the corresponding T2 values. T1rho dispersion was observed between spin-locking frequencies 0 and 500 Hz. CONCLUSION: T1rho-weighted MRI provides images of the brain with superb contrast and detail. T1rho values measured in the different brain tissues will serve as useful baseline values for analysis of T1rho changes associated with pathology.

Correlation of T1rho with fixed charge density in cartilage.

PURPOSE: To establish the specificity of T1rho with respect to fixed charge density (FCD) as a measure of proteoglycan (PG) content in cartilage during the onset of osteoarthritis (OA). MATERIALS AND METHODS: T1rho-weighted and sodium MRI were performed on cartilage samples of enzymatically degraded bovine explants and natural osteoarthritic human samples representing controlled and physiological models of OA, respectively. Spatial maps of T1rho and FCD (measured using the previously validated method of sodium MRI) were calculated from image data. Data were extracted from the maps and subjected to linear regression to compare changes in T1rho with changes in FCD in each model. Tissue samples were subjected to histological staining for a reduction in PG content. RESULTS: Plots of normalized T1rho rate vs. FCD were found to be strongly correlated (R2 > 0.75 and 0.85) in both models with nearly the same slope of approximately 1/2 (P > 0.51). Loss of PG in bovine and human tissue was confirmed by histology. CONCLUSION: The strong correlation of the FCD and T1rho data in both the controlled and physiological models demonstrates that changes in T1rho are due predominantly to changes in PG content. This work is a first step in establishing T1rho as a method of quantifying PG changes in early-stage OA.