Congenital Infantile Fibrosarcoma Associated With a Lipofibromatosis-Like Component: One Train May Be Hiding Another.

Congenital infantile fibrosarcoma (CIFS) is a soft tissue sarcoma of infants mainly involving lower extremities and usually developing during the first year of life. At another end of the spectrum of pediatric fibroblastic lesions, lipofibromatosis is a rare benign infiltrative soft tissue tumor that affects children. The authors report in this study a particular presentation with a CIFS surrounded by lipofibromatosis-like areas. The presence of a surrounding benign tumor confused and delayed CIFS diagnosis.

Treatment of depressor anguli oris weakening with the face recurve concept.

The authors have created a strategy for rejuvenation of the peribuccal region based on the concept that the repeated contraction of certain fascicles of the mimetic muscles, and not gravity, is the primary cause of structural aging. Treatment is based on a 4-stage strategy, with interventions including botulinum toxin, hyaluronic acid, autologous fat transfer, and surgery of the depressor anguli oris.

Structural aging: the facial recurve concept.

Cutaneous facial aging is responsible for the increasingly wrinkled and blotchy appearance of the skin, whereas aging of the facial structures is attributed primarily to gravity. This article purports to show, however, that the primary etiology of structural facial aging relates instead to repeated contractions of certain facial mimetic muscles, the age marker fascicules, whereas gravity only secondarily abets an aging process begun by these muscle contractions. Magnetic resonance imaging (MRI) has allowed us to study the contrasts in the contour of the facial mimetic muscles and their associated deep and superficial fat pads in patients of different ages. The MRI model shows that the facial mimetic muscles in youth have a curvilinear contour presenting an anterior surface convexity. This curve reflects an underlying fat pad lying deep to these muscles, which acts as an effective mechanical sliding plane. The muscle's anterior surface convexity constitutes the key evidence supporting the authors' new aging theory. It is this youthful convexity that dictates a specific characteristic to the muscle contractions conveyed outwardly as youthful facial expression, a specificity of both direction and amplitude of facial mimetic movement. With age, the facial mimetic muscles (specifically, the age marker fascicules), as seen on MRI, gradually straighten and shorten. The authors relate this radiologic end point to multiple repeated muscle contractions over years that both expel underlying deep fat from beneath the muscle plane and increase the muscle resting tone. Hence, over time, structural aging becomes more evident as the facial appearance becomes more rigid.

The face recurve concept: medical and surgical applications.

The application of the Face Recurve theory gives rise to new technical opportunities in the fields of both aesthetic medicine and aesthetic surgery to block the action of the age marker fascicules largely responsible for aging of the paramedian folds. With respect to aesthetic medicine, the combination of botulinum toxin and soft tissue fillers has proven effective. On the basis of the authors' theory, however, two new technical refinements become pertinent. First, the filler must be injected predominantly deep to the muscle to treat the skin depressions in a more natural manner, bringing restoration to the curve of the overlying muscle. Second, a very low number of botulinum toxin units (one-fourth to one unit) should be injected into specific muscles to diminish their resting tone without diminishing their maximal contraction strength. With respect to aesthetic surgery, the authors present new techniques for the treatment of early aging, specifically a combination of segmental muscular section, microliposuction, and retromuscular fat grafting, all of which can be performed readily with the patient under local anesthesia. For more advanced aging, surgery offers new treatment opportunities that include the concentric malar lift for correction of the midface region, with repositioning of suborbicularis oculi fat back onto the orbital rim from its descended eccentric displacement at the hands of repeated orbicularis oculi contractions. At the same time, specific muscles can be weakened and fat volume restored. Each area can be studied in a specific way and treated definitively. Currently, the skin does not need to be tensioned to a maximum during a face-lift for treatment of the irregular jaw line, the palpebromalar groove, and so forth. Skin tension can be moderated to remove only the true excess of skin. Facial contour is improved, whereas the specific glide is restored between muscles and their underlying fat.