The Need for Overcorrection When Using a Suborbital Cervicofacial Hike Flap.

BACKGROUND: The senior author has previously described a deep-plane cervicofacial hike flap as a workhorse for reconstruction mid-cheek defects. One important modification commonly used involves overcorrection of the defect in order to reduce the incidence of ectropion. This report outlines the senior author's experience in surgical treating complex cheek defects with an overcorrected deep-plane cervicofacial hike flap. METHODS: The authors performed a retrospective review of the senior author's patients with cheek and eyelid reconstruction. The authors initially identified all patients who had undergone a deep-plane cervicofacial hike flap, then filtered those charts for patients who had overcorrection of their deformity in order to prevent ectropion. RESULTS: A total of 3 patients had an overcorrected flap. Overcorrection was accomplished either by cheek advancement with suture fixation to the deep temporal fascia, or by placement of drill holes and bone anchors. Lower eyelid malposition was avoided in all 3 patients. Patient satisfaction at long term follow-up was very high, and no revision surgery was needed. CONCLUSION: If gravitational or cicatricial forces can potentially distort the eyelid in patients with cheek or eyelid reconstruction, it is necessary to overcorrect the cheek flap. This modification of the deep-plane cervicofacial flap is an important tool in reconstructing defects in this area.

Chin Ups and Downs: Avoiding Bad Results in Chin Reoperation.

The senior author (B.M.Z.) has performed 512 chin reoperations over the last 30 years. This paper will describe the usual errors in surgical planning regarding what seems to be a relatively straightforward operation. We will focus on: (1) assessment of the chin; (2) pitfalls with surgical approaches; and (3) problem cases. This paper will not focus on the large chin, but rather on the chin that needs augmentation. Some chins will do well with an implant, others will need an osteotomy or ostectomy, and even others need both. The surgeon is responsible for selecting the correct operation. Thus, it remains incumbent on the surgeon to become diligent in diagnosis and delivery.

Facial Expansion: A Blueprint for Coverage.

SUMMARY: The benefits of tissue expansion go unrealized if flap design and coverage concepts do not exist in preoperative thinking. Without proper analysis, the surgeon will likely burden the patient with more expanders than necessary. Tissue coverage needs can be simplified in forms of triangles and rectangles to determine expanded tissue advancement. Single or double back-cuts allow use of all the expanded tissue. Furthermore, early subtotal excisions, especially in children younger than 4 months, can reduce the number of expanders required. With methods presented herein, the face can be resurfaced with better color and less distortion. Eyebrows should be maintained and positioned by keeping the lower frontalis muscles intact. Cheeks can be covered with a large Schrudde design, and color can be improved by using upper neck skin preferentially over lower neck harvest. Laser hair removal allows larger swaths of forehead to be covered by hair-bearing scalp tissue. Prior incisional delay can expedite success with no tissue loss. The results speak for themselves when surfaces are covered with large, expanded flaps that are expeditiously harvested.

Hemangioma update: pearls from 30 years of treatment.

This manuscript is a compilation of clinical lessons learned from 30 years of treating hemangiomas. We review relevant clinical anatomy, the role of lasers and medications, timing of surgery, and operative judgment, as it pertains to the treatment of hemangiomas.

The "YouTube" method of correcting pixie ear and poor alar base inset.

It is well established that raw edges of the skin have a natural tendency to tube on themselves. Although this often presents a challenge for plastic surgeons, the following article demonstrates how the plastic surgeon can capitalize on this phenomenon to successfully recreate the natural appearance of curved anatomic elements. Two areas that are particularly susceptible to appearing "unnatural" after surgery are the earlobe and alar base. Herein, we present the concept of "autotubing" to recreate the natural curvature of these anatomic regions.

Productivity and Efficiency of a Department Resident Aesthetic Plastic Surgery Clinic.

Background: There has been increasing demand for aesthetic surgery procedures in the United States, highlighting the critical importance of the competence of plastic surgery residents and rigorous methods of aesthetic surgery training. Objectives: The objective of this study was to review procedures and outcomes from our plastic surgery resident aesthetic clinic. Outcomes and costs were compared to national averages and reports from the literature. Methods: A retrospective chart review identified all adult patients who presented to the Resident Aesthetic Surgery Clinic at NYU Langone Health in 2021. Patient demographics, comorbidities, procedural data, postoperative complications, revisions, and surgeon fees were compiled. A brief confidence survey was distributed to participating residents before and after their clinic rotation. Data were analyzed using IBM SPSS software (Armonk, NY). Results: In 2021, 144/379 consultations led to an operation (38.0% conversion rate), resulting in 420 distinct surgical procedures. The majority (53.3%) of procedures involved the head and neck. Complication and revision rates were 5.5% and 1.0%, respectively, with surgeon fees consistently below the national average. Residents reported being significantly more confident performing face lifts, rhinoplasties, and aesthetic surgery in general following their clinic rotation. Conclusions: These data represent the largest annual reported study of plastic surgery resident aesthetic procedures and outcomes, demonstrating the high volume and productivity of the NYU Resident Aesthetic Surgery Clinic. These results further support resident aesthetic clinics as a robust training modality.

Deep-plane angle rotation flap for reconstruction of perioral lesions.

INTRODUCTION: A cervicofacial flap remains the principal method to close defects of the posterior cheek. Schrudde described a variant of this technique, termed the angle-rotation flap, which allowed primary closure of the donor site. This flap has been elevated in the deep plane for the more medial defects. We extend this technique for upper lip reconstruction. METHODS: Two cases were reviewed that underwent upper lip reconstruction with the deep-plane Schrudde flap. RESULTS: Two cases are presented to describe the use of the deep-plane angle-rotation flap. The first patient sustained a burn to his upper lip and the second patient had a partially grafted defect following a Mohs excision. DISCUSSION: In patients with insignificant nasolabial folds, the deep-plane Schrudde flap is a good option to reconstruct perioral defects. The utilization of the deep plane improves the blood supply and allows improved contour for reconstruction of deeper defects.

The treachery of mandibular angle augmentation.

Patients who present for alloplastic jaw angle augmentation have 2 potentially troublesome choices. The use of a silicone implant can mean unpredictable motion, and if the lower pterygomasseteric sling is breached during implant placement, the masseter insertion will ride up without anything to which to adhere. When the patient bites down, a bulge will be present.The porous alternative even has a ledge made to go under the gonial angle, which if not removed, guarantees violation of the pterygomasseteric sling and an implant that is longer than the muscle can cover. The inferior muscle insertion is disrupted and is left to ride up serendipitously.This article presents 5 instances of these issues in which one case required a revision via a modified Risdon approach to access the uncovered material which stuck out beyond the high riding masseter.The basic aim of this article is to advocate the need to maintain the pterygomasseteric sling, and describe the consequences of the failure to do so.

Reconstruction of temporal and suprabrow defects.

Large temple and suprabrow lesions can pose a reconstructive challenge. When the lesion extends anterior to the hairline, esthetically acceptable local flaps may be difficult to design. We describe a modified scalp flap (ie, part Converse scalping flap and part scalp rotation flap) that can be tailored to reconstruct a variety of difficult temple and suprabrow lesions while simultaneously maintaining eyebrow position. The modified scalp flap is raised in a subgaleal plane until approximately 2.5 cm above the brow. At this level, dissection proceeds in the subcutaneous plane to protect the frontal branch of the facial nerve and to keep the flap thin. (The key to the modified scalp flap is the dissection plane change that protects the frontal branch of the facial nerve.) The extent of posterior subgaleal dissection is dictated by the amount of anterior rotation necessary. A temporal dog-ear is removed subfollicularly to permit modified flap rotation and preserve the superficial temporal artery. The modified scalp flap has been used to reconstruct temple and suprabrow lesions in 10 patients ranging in age from 4 months to 22 years. There were no complications. Four typical cases are presented. Temple and suprabrow lesions can be excised and successfully reconstructed in one stage using a modified scalp flap that is extended from the hair-bearing scalp onto the glabrous skin of the forehead. This novel modified scalp flap prevents eyebrow/hairline distortion and avoids facial nerve injury.

Ten Tips Based on Anatomy and Design to Refine Face and Neck Lift Surgery.

Any face/neck lift operation has a natural flow of slower and speedier portions; slower when dissecting under the superficial musculoaponeurotic system and around nerves while faster during opening, undermining, defatting, and closing. Surgeons can maximize efficiency with these simple maneuvers. METHODS: We introduce and demonstrate ten reproducible surgical techniques based on anatomy, which span aspects of the entire face and neck lift procedure including markings, skin flap elevation, sub-superficial musculoaponeurotic system manipulation, preplatysmal fat management, skin re-draping, and post-operative dressings. RESULTS: As examples, altered scissors facilitate "push" undermining, scoops reduce time for fat removal in the neck, a non-inset method for lobule creation, and digital measurements for certain technical maneuvers are discussed. Moreover, a block and tackle method of facial nerve blocks is reviewed which permits local-only face and neck lifting as well as hematoma drainage without patient intolerance. CONCLUSIONS: Implementation of these surgical techniques in face and neck lift procedures allows the surgeon to potentially decrease operative time and work towards minimizing post-operative edema while attaining aesthetic and natural results.

Control of the Suborbital Cheek in Pediatric Patients: Working in the Deep Plane.

Reconstruction of suborbital cheek and lower eyelid defects can be challenging in pediatric patients due to the need for lower eyelid support, lack of reliable local tissue, and difficulties of scar concealment. The deep-plane cervicofacial rotation-advancement flap is a useful technique for cheek reconstruction in adults; however, its utility in the pediatric population has not been described. METHODS: Experience using the deep-plane Schrudde flap for large suborbital defects in pediatric patients is presented. RESULTS: Safe flap elevation and successful reconstruction requires utilization of critical anatomic landmarks, a standardized sequence of dissection and appropriate fixation.

Elegance in Upper Lip Reconstruction.

Restoration of the upper lip provides a reconstructive challenge because of its anatomical and aesthetic requirements. This article provides a "where is it on the lip" approach to reconstruct small to subtotal defects of the upper lip that are feasible to perform in the office setting. Emphasis is placed on adherence to core principles, attention to macroaesthetic and microaesthetic landmarks, and technical refinements of well-established reconstructive techniques. These tenets include algorithms for central and lateral defects, precise use of the Abbe flap, use of local tissue rearrangement and skin grafts, and appropriate management of scars. A strong understanding of the anatomical and aesthetic nuances of the upper lip will allow for enhancement of conventional reconstructive procedures to optimize functional and aesthetic outcomes.

Chin surgery III: revelations.

This article is a logical extension of previous articles written on the topic of aesthetic chin surgery. In it, the authors expand on previously published surgical techniques and provide specific updates to increase success in some unusual situations. They review the indications for and uses of reduced-height implants, discuss the validity of centralized chin incisions in both reconstruction and revisions, show the diversity of mentalis muscle anatomy and chin pad variations, reveal the importance of the lip-to-labiomental crease inclination in cases of macrogenia, note a key update on reefing the mentalis muscle to a higher position for permanent sulcus position, discuss the issues of lower lip position and lower incisor show, and expound on the horizontal smile/chin ptosis phenomenon.

The subunit approach to nasal tip hemangiomas.

Many surgeons who operate on nasal tip hemangiomas find a central vertical scar frustrating. Alternatives such as open rhinoplasty provide great exposure, but the redraping leaves unsightly scars along the alar rim and columella. Therefore, a new aesthetic incision was needed to allow hemangioma reduction in both the horizontal and vertical dimensions while providing adequate access to the lower lateral cartilage for soft-tissue reduction and/or suturing. The subunit incision, based on the pioneering work of Burget and Menick, was developed to provide both excellent exposure and cosmesis. By designing the incision to lie along the contour lines of the nasal subunits, the senior author (B.M.Z.) believed that the border scars would reflect lines of light and cast linear shadows that would mimic the normal ridges and valleys that separate the topographic subunits of the nose. Based on the results of nine recent cases, the authors believe the subunit incision is currently the best approach to correcting nasal tip hemangiomas.

Radiance Short-term experience.

Over a 9-month period, the author has injected Radiance (BioForm, Inc., Franksville, WI), a soft tissue filler, into lips, nasolabial folds, glabellar creases, labiomental folds, tear troughs, and lateral jawlines in 130 patients. Here he presents his clinical findings. (Aesthestic Surg J 2003;23:495-499).