High frequency needle dissection rhytidectomy.

Fifty consecutive rhytidectomies were performed utilizing high frequency needle dissection on one side and standard sharp dissection on the other for all incisions and flap elevation. The efficacy of this technique in hemostasis, prevention of hematoma, and wound healing is compared to the conventional technique of rhytidectomy. The advantages and disadvantages of the modality are discussed.

High septal hemitransfixion for the correction of caudal septal deformities.

High septal hemitransfixion has demonstrated superior versatility and reliability in a series of 68 patients for correction of caudal septal deformity. The literature has contained many references to high septal transfixion for use in rhinoplasty to preserve tip support. An alternative application of this approach for repair of caudal septal deformity is herein discussed.

The conservative management of the Negro nose.

The difficulties in obtaining an adequate result in the Negroid nose have been elucidated by other authors. Paucity of lobular cartilage; the flat dorsum; short columella; wide flaring nares; and skin that tends to keloid formation have led many surgeons to attempt radical surgical techniques to obtain rather limited results. To circumvent the complications in the more radical procedures, a more conservative concept of an entirely intranasal operation without external skin incisions is outlined. This technique consists of tip rotation andlobular cartilage trimming; the use of a non-absorbable basal bunching suture, and the placement of a dorsal implant without performing osteotomies. A comparison with other techniques is made, as well as surgical aims, limitations and a discussion of results. Pertinent illustrations and photographs are presented.

An absorbent, non-adherent nasal pack.

A modification of an absorbent, non-adherent material (Telfa) is described for use as an anterior nasal packing. The ideal nasal packing should fulfill certain criteria. It should be easy to introduce and remove, contour to the nasal cavity to exert a tamponade effect, and should not prolapse or react unfavorably with the mucous membranes of the nose. The advantages of Telfa as a nasal packing is discussed and compared to previously described materials in this regard. During the past three years this pack has been used in over 800 patients for anterior epistaxis, septal and rhinoplastic surgery. The results have been extremely satisfactory, and the authors suggest their use in these cases.

Sequential rhytidectomy.

An alternate technique of rhytidectomy is described. After adequate undermining, hemostasis and imbrication, the skin flaps are rotated and advanced with sequential tension in contrast to the use of bipolar or tripolar anchoring points. They are then trimmed and sutured in a step-like sequential fashion starting at the temporal incision and proceeding around the ear to the occipital area. The technique has been used in over two hundred patients during a two-year period. The results have been encouraging in eliminating dog-ear formation, excessive tension on wound edges, and step deformities of the hair bearing tissues. A discussion of the advantages of the method and a comparison with other techniques is outlined.

The nasal bossa: a complication of rhinoplasty.

A study of 1,033 consecutive rhinoplasties was undertaken to focus on etiology and treatment of nasal bossa. Of the 2% that developed bossa, the only consistent, statistically significant etiology factor was that of preoperative nasal asymmetry. There was no correlation with skin or cartilage characteristics. Those tips requiring alteration by the delivery technique were five times more likely to develop bossa than those treated by cartilage split or retrograde techniques. The surgical dilemma of treatment by either augmentation of the lesser side or resection of the bossa was discussed.

Infrabrow lift.

The infrabrow lift is presented as a specific method to correct skin redundancy between the eyebrow and upper lid. Indications are outlined which differentiate this technique from the suprabrow surgical approach. The surgical technique is discussed. Esthetic results have proven most satisfactory.

Treatment of alopecia in temporal region following rhytidectomy procedures.

Satisfactory treatment of alopecia following rhytidectomy is discussed using the punch graft technique. In spite of the presence of scar tissue following rhytidectomy, this procedure has been quite successful because of the rich blood supply in that area.

"Practical suggestions on facial plastic surgery--how I do it". Modifications of the Fomon technique in the approach to the lower lobule.

The advantages of the Fomon technique modifications in rhinoplasty are outlined. The importance of these adaptations is emphasized.

Proplast chin augmentation.

A method of chin augmentation employing a newer synthetic material (Proplast) is presented. The characteristics and biocompatibility of Proplast are detailed. Technical considerations and results of short term clinical trials in 20 patients are discussed. One implant necessitated removal secondary to trauma four months after surgery. All other implants including over 30 additional cases have been without incident.

Mentoplasty--a clinical analysis of alloplastic implants.

Different types of alloplastic implants are currently being utilized in performing mentoplasty. A review of the literature points out the number of prostheses that have been used. Each type of material has inherit physical properties which determine its characteristics for use as a chin implant. The type of implant and method selected in chin augmentation depends upon accurate preoperative evaluation and full understanding of the properties of alloplastic substances. Five hundred and thirty-nine cases of chin augmentation utilizing different materials and methods were reviewed over a nine year period. The limitations of mentoplasty as well as the advantages, disadvantages, and in selected cases, the indications for the use of a particular implant are discussed.

One hundred consecutive deep plane face-lifts.

A subplaytysmal face-lift technique in a deeper anatomical plane of the face was described in the 1970s. The deep plane rhytidectomy is based on sound anatomical principles of tissue mobilization, advancement, and repair. Wide undermining is accomplished in a subplaytysmal plane and continued, extending over the zygomatic muscle to the melolabial fold. This large compound cheek flap of skin, muscle, and fat is then advanced and tightened to dramatically influence the jowl and melolabial fold. A prospective study was undertaken to evaluate the results of 100 deep plane face-lifts using this technique. Postoperative observations and evaluations were made at 1 week, 1 month, and 6 months. A questionnaire response and photographic analysis were obtained after 6 months. The rate of hematomas was low, with none occurring beneath the thick cheek flap. There were no persistent problems, facial irregularities, paralysis, or paresis. Ninety-seven percent of the patients were pleased with the aesthetic results. In conjunction with wide cervical undermining and an anterior platysmal plication, the deep plane face-lift affords a predictable improvement for the aging face and neck.

Minicomposite graft for nasal alar revision.

Auricular composite grafts are being used increasingly for repair of nasal deformities. Most commonly these grafts have been employed to repair alar rim and columellar defects secondary to trauma or tumor resection. A technique for reconstruction of the lateral crural area with auricular minicomposite grafts was used in a series of cases. Results have been satisfactory to alleviate the functional and cosmetic difficulties in patients requiring alar revision.

Revision rhinoplasty. Analysis and treatment.

As rhinoplasty becomes an increasingly popular procedure, the aesthetic expectations of both the facial plastic surgeon and the patient become more discriminating. Thus, the number of revision rhinoplasties increases. Of 697 rhinoplasties performed by the senior author (F.M.K.) during a three-year period, 18% of those procedures were revision surgeries. The senior author was the primary surgeon in 53% of those revision cases. This article presents an analysis of 126 consecutive revision rhinoplasty cases from that period, outlining the major deformities in a clinically meaningful system. Treatment of each problem category is discussed and representative cases are shown. The senior author's own revision rate and observations are discussed and compared with those in the medical literature.

Isolated submentoplasty. A limited approach to the aging neck.

OBJECTIVE: To evaluate the application of a limited submentoplasty for improving the aesthetics of the cervical region. DESIGN: Retrospective analysis. SETTING: Private facial plastic surgery practice. All procedures were performed at an ambulatory surgical facility on an outpatient basis. PATIENTS: Forty patients (36 women and 4 men) ranging from 37 to 68 years of age with a mean age of 52 years. Surgical procedures were performed over a 4-year period and follow-up ranged from 3 months to 3.5 years with a mean follow-up of 1.2 years. INTERVENTION: Isolated submentoplasty operations performed by the senior surgeon (F.M.K.) over a 4-year period. OUTCOME MEASURES: Aesthetic appearance of the neck as determined by comparison of preoperative and postoperative physical examinations and photographs, subjective patient responses, and chart reviews to determine complications. RESULTS: Eighty percent success rate and 10% complication rate, with these complications being minor and easily correctable. CONCLUSION: Isolated submentoplasty is a viable option for correction of cervical deformities in selected patients.

The effect of propofol on hematoma formation in rhytidectomy.

Significant surgical advances in face-lift surgery have evolved over the years, including wider flap undermining, the development of the superficial musculoaponeurotic system as a separate layer, and appropriate platysmal and coronal procedures. These more radical concepts offer improved results, but they may be associated with more complications, the most frequent being hematoma formation. A retrospective study of 386 patients was undertaken over a period of 5 years. Patients were separated into two groups: those that were sedated with a drug combination of diazepam, meperidine hydrochloride, and methohexital sodium; and those sedated with propofol. Patients sedated with propofol were more than twice as likely to develop a hematoma than those sedated with the other drug regimen. Although the hematoma rate with propofol is similar to that reported with other drugs, this increased risk must be carefully considered when one is choosing an anesthetic for rhytidectomy.

Preexcision blepharoplasty.

Numerous techniques have been described for lower lid blepharoplasty. Over the past 15 years, a preexcision (pinch) technique with preservation of the pretarsal orbicularis oculi muscle has been used in more than 1000 cases presenting with dermatochalasis and pseudoherniated fat without lateral skin redundancy. The amount of lower lid skin to be excised is estimated by pinching the skin. Preservation of the pretarsal orbicularis oculi muscle adds support to the tarsoligamentous complex. This technique aids in preventing the development of both postoperative ectropion and rounding of the lower lid. Technical considerations of the preexcision (pinch) technique and a description of alternative techniques are outlined. Indications, complications, and patient satisfaction are discussed.

Submental surgery. A graduated approach to the aging neck.

Adequate aesthetic contouring of the aging neck often presents a difficult surgical challenge to the facial plastic surgeon. The apparent failure of the classic rhytidectomy to achieve acceptable results in the submental region has encouraged previous surgeons to develop surgical techniques specifically addressing this area. Definitive procedures were developed to treat the excess skin, fat, or muscle. Aesthetic results have progressively improved with the introduction of liposuction, judicious muscle rearrangement, and more conservative submental skin violation. This article describes our experience with these concepts and presents a useful classification devised to serve as an operative guide in the management of the aging neck.

The effect of blepharoplasty on eyebrow position.

OBJECTIVE: To determine if upper eyelid blepharoplasty causes eyebrow position to drop in a cosmetic surgery population. DESIGN: Retrospective, observational study. A treatment group that underwent upper eyelid blepharoplasty was compared with a matched control group that did not undergo the surgery. SETTING: Private facial plastic surgery practice. All surgery was performed at an ambulatory surgical facility on an outpatient basis. PATIENTS: A total of 82 patients (164 eyes) were included in this study: 54 (8 men and 46 women; average age, 46.8 years) in the treatment group and 28 (6 men and 22 women; average age, 43.8 years) in the control group. The treatment group was chosen in a retrospective fashion to include only those patients (1) for whom preoperative and postoperative photographs were available and (2) who had undergone upper eyelid blepharoplasty by the senior author (F.M.K). These patients underwent no other procedures, either before or during the time span between the photographs, that could affect eyebrow position. The control group consisted of patients who had an available set of matching photographs taken over time. These patients did not undergo blepharoplasty or any other procedure that could alter eyebrow position between their initial and final photographs. INTERVENTION: Upper eyelid blepharoplasty performed by the senior surgeon (F.M.K.). The surgical technique was identical in all cases. OUTCOME MEASURE: The change in eyebrow height reflected as a percentage of the pretreatment height. Results are based on measurements taken from standardized photographs. RESULTS: Original treatment and control groups of 108 and 56 eyes, respectively, were restricted to a smaller number to create similar populations for comparison. Therefore, 40 eyes in the treatment group were matched with 28 eyes in the control group to control for the duration between measurements. A t test found no significant difference (P = .94) in eyebrow height between patients who had a blepharoplasty and those who had not. CONCLUSION: In a cosmetic surgery population, upper eyelid blepharoplasty does not cause a lowering of the eyebrow.

Histoacryl. Its use in aesthetic facial plastic surgery.

Since their discovery in 1949, cyanoacrylates have evoked interest as being a possible ideal "tissue glue." Several different forms of these compounds have been developed in order to try to reduce or eliminate tissue toxicity. Butyl-2-cyanoacrylate (Histoacryl) appears to be the closest ideal material as it induces low tissue reactivity and toxicity. It has been used extensively for middle ear surgery with little or no adverse effects. A historical review of tissue adhesives and a discussion of technical considerations is outlined. A clinical trial of 100 patients treated with Histoacryl on various surgical wounds revealed no significant adverse effects with wound healing, graft rejection, or infection over a six-month period. Histoacryl appears to offer many advantages and few disadvantages over conventional suture techniques.