Anatomical Study on the Temporal Fascial Layers and Their Relationships with the Facial Nerve

The recent application of endoscopic techniques in facial rejuvenation has stimulated a new interest in the anatomy of this region. In endoscopic face lift, as in open techniques, one of the main steps is the conjunction of dissections of the upper and midface without damage to the frontal branch of the facial nerve. This article provides an accurate account of the organization of the temporal fascial layers and their relationship with the facial nerve. The authors' dissections confirm that the frontal branch, despite the variations in branching patterns, has an anatomical relationship with the surrounding fasciae that can be deemed constant and predictable: The frontal branch lies in the deep layer of the fatty tissue interposed between the suprazygomatic extension of the superficial musculoaponeurotic system (SMAS) and the superficial leaflet of the temporal aponeurosis. The arrangement of the temporal fasciae on the zygomatic arch is also discussed.     

Preoperative Identification of Psychiatric Illness in Aesthetic Facial Surgery Patients

The purpose of this study was to evaluate the preoperative use of a two-part standardized assessment program (Prime-MD, Biometrics Research Department, New York State Psychiatric Institute) to objectively detect psychiatric disorders in facial plastic surgery patients, and to compare its use to findings identified by the facial plastic surgeon. Seventy-five new patients requesting aesthetic facial surgery at two academic centers and two private practice locations were evaluated.     

Aesthetic Male Facial Skeletal Surgery

Craniofacial surgery concepts developed originally for reconstruction may also be applied to aesthetic surgery. The facial skeleton is an important component of appearance and may be modified using common craniofacial surgery techniques. Three representative male patients are presented, who each desired an improvement in his appearance. The techniques used were different and combined orthognathic and remodeling procedures. Aesthetic male facial skeletal surgery was beneficial in these selected cases. The results were well received and without complications. Surprisingly, we have found that male skeletal aesthetic patients did not have unrealistic expectations and were pleasant to manage pre- and postoperatively.     

Minimally Invasive Facial Rejuvenation Endolaser Mid-Face Lift

Endolaser mid-face lift was performed on patients in a multi-center study over a 36-month period (Feb. 1998 to Feb. 2001). It permits significant facial rejuvenation through small incisions. This technique achieves aesthetic results and wider rejuvenation while being less traumatic and creating minimal morbidity. Combined with other procedures, it rejuvenates the face by three strategic methods: soft tissue suspension, reversal of photo aging, and correction of the depletion of volume. To achieve this triple result, the mid-face lift is performed by endoscopic approach, and in every case is combined with the endoscopic lift of the frontal area. Laser resurfacing was used to reverse skin photo damage. The Ultrapulse CO₂ laser and/or the Ultrafine Erbium YAG(Coherent, Inc, Palo Alto, CA) were used. The third combined procedure was the introduction of fat graft to compensate the atrophy/ptosis of fat and the depletion of bone mass (other filling materials besides fat may be used, depending on the preference of the surgeon). Our method of fixation using the Casagrande Needle (an evolution of Reverdin Needle) makes the mechanical purchase on the tissues to be suspended much easier, permitting the intra-oral and/or infra-orbital incisions to be eliminated. The present study of the technical evolution of the endolaser mid-face lift method allows us to conclude that a very satisfactory outcome has been reached, offering patients a minimally invasive procedure, which can be performed under local anesthesia, with low morbidity, imperceptible incisions, and an excellent long-term result.     

Anesthesia for Facial Surgery

We describe a reliable, simple, and safe method of monitored anesthesia care, with local anesthesia, which was used for 4500 patients undergoing facial rejuvenation procedure, without major complications and with minor side effects. All procedures were performed in a setup of a private clinic not affiliated with any hospital. The disadvantages of general anesthesia were avoided. Using careful monitoring and drug titration, even aged patients with medical problems, can benefit from this method. We are using classical, inexpensive, and safe compounds, which cope with all goals of anesthesia for aesthetic facial surgery.     

Outcomes Research in Facial Plastic Surgery: A Review and New Directions

Outcomes research is a fast-growing field of study that focuses on patient-related aspects of medical or surgical outcomes such as satisfaction and quality of life. In the realm of facial plastic surgery, many outcomes are subjective evaluations based on the patient and physician's judgment as to the surgical result, but little has been done to quantify these qualitative results in an objective manner. This paper discusses the basis for outcomes research and suggests its application to the field of facial plastic surgery. Four new facial plastic outcomes instruments have been developed and are provided for the potential use in measuring the quality of life results of rhytidectomy, rhinoplasty, blepharoplasty, and skin rejuvenation procedures.     

Full Face Rejuvenation in Three Dimensions: A ``Face-Lifting' for the New Millennium

Traditional facial rejuvenation techniques address the face by lifting the soft tissues in one or two dimensions. The face is a tri-dimensional structure and aging occurs in three dimensions, therefore, facial rejuvenation should be done in three dimensions. Sagging of facial soft tissues occurs inferiorly and inferomedially. The ideal reorientation during rejuvenation is in the opposite direction: vertically and supero-laterally. Two other elements not routinely addressed by traditional rejuvenative operations are reduction of skeletal framework and atrophy of soft tissues, particularly subcutaneous fat layer. These are the third dimension of facial aging. By principle, any technique that unfolds, pulls, or lifts produces a flattening effect of the structure being treated. They may give a false impression of augmentation if these tissues are advanced over bony prominences. These stretched out tissues also have a tendency to recoil. For that reason, the author suggests use of structures or methods less susceptible to a stretch relaxation or recoil. A prerequisite to 3-D facial rejuvenation is to perform a 2-D-(bi-dimensional) lift. A third dimension is integrated into it. There are four methods to provide the third dimension: (1) augmentation of the skeletal framework; (2) augmentation of subcutaneous layer with fat injection; (3) imbrication of soft tissues; (4) mobilization and repositioning of fat pockets as pedicle flaps. These methods are not exclusive to each other. One, a few, or all methods could be integrated according to the patient's needs and aesthetic goals. Tridimensional changes in facial rejuvenation can be assessed by a standard photographic comparison, using tools for in-vivo measurements or 3-D digital imaging. 3-D facial rejuvenation is an advanced concept in our pursuit to provide superior results with the more aesthetic, natural, and harmonious youthful look to our patients.     

Osteoporosis and Bone Mineral Metabolism Disorders in Cirrhotic Patients Referred for Orthotopic Liver Transplantation

The purpose of this study was to determine the prevalence of osteoporosis, to estimate the bone turnover and hormonal status, and to identify the factors associated with bone disease in patients with end-stage liver disease who were referred for orthotopic liver transplantation. A prospective study was performed on 58 cirrhotic patients (6 with primary biliary cirrhosis, 14 with alcoholic cirrhosis, and 38 with posthepatitic cirrhosis), who were referred for orthotopic liver transplantation. Patients, excluding those with primary biliary cirrhosis, were classified in Child-Pugh groups according to the severity of liver disease (class B [28 patients], class C [24 patients]). Biochemical parameters of bone mineral metabolism and standard liver function tests were measured in all patients. Additionally, serum osteocalcin, urinary hydroxyproline/creatinine ratio, serum intact parathyroid hormone, serum 25-hydroxyvitamin D, serum 1,25-dihydroxyvitamin D, folliclestimulating hormone, and luteinizing hormone levels were determined in patients and controls within the same age range. Plasma testosterone, sex hormone-binding globulin levels, and free testosterone index were obtained for all men included in the study. Bone mass of the lumbar spine and femur were measured by dual X-ray absorptiometry (DPX-L), and were expressed as a standard deviation of mean values (Z-score) from a sex and age-matched control group. Spinal X-rays were obtained to assess vertebral fractures. Osteoporosis was considered as a factor in spinal bone mineral density with a Z-score below 2 or at least one vertebral fracture. Twenty-five patients (43%) had osteoporosis, with lower bone mass measurements in the lumbar spine than in the femoral neck (P < 0.005). Alcoholic and Child-Pugh C patients showed the lowest femoral bone mineral density values. Cirrhotic patients showed lower osteocalcin levels than controls (14.3 ± 5.9 vs. 18.2 ± 8.1 ng/ml; P < 0.05) and showed increased urinary hydroxyproline (125.1 ± 51.5 vs. 107.9 ± 26.6 nM/mg creatinine; P < 0.05). Serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and parathyroid hormone levels were significantly lower in cirrhotic patients than in controls (10.3 ± 9.1 vs. 23.1 ± 26.6 ng/ml; P= 0.000), (12.9 ± 9.1 vs. 48.3 ± 11.5 pg/ml; P= 0.000), (16.6 ± 9.2 vs. 27.9 ± 8.2 pg/ml; P= 0.000), with no differences between Child-Pugh groups. Alcoholic Child-Pugh C patients showed the lowest 25-hydroxyvitamin D serum values (4.5 ± 2.2 ng/ml; P < 0.05). Male patients had lower testosterone levels than controls (302.5 ± 229.4 vs. 556.7 ± 146.5 ng/dl; P= 0.000), with increased sex hormone-binding globulin values. Levels of testosterone and gonadotropin were related to Child-Pugh classification. No correlation was found between bone mass and hormonal values. A significant decrease in bone mass, particularly in the lumbar spine, is seen in end-stage cirrhotic patients. Reduced bone formation and significant disorders of bone mineral metabolism, such as vitamin D deficiency, reduced parathyroid hormone levels, and hypogonadism are involved. Moreover, severity and etiology of the liver disease are the main risk factors for developing bone loss and mineral metabolism disorders in patients referred for orthotopic liver transplantation. Received: 7 March 1996 / Accepted: 24 June 1996     

The Emerging Role of Laser Resurfacing in Combination with Traditional Aesthetic Facial Plastic Surgery

Traditional aesthetic plastic surgery procedures (facelift, browlift, blepharoplasty, etc.) can make dramatic improvement in the facial appearance by removing excess skin and fat and tightening and repositioning the soft tissues of the face, but make no improvement in the quality of the skin. Laser resurfacing is the safest, most predictable method for improving facial wrinkles and actinic damage. This paper discusses the combination of these techniques in pursuit of optimal rejuvenation of the face.     

Improving the Aesthetics of the Cheek Bone Projection During Facial Lifting

This paper shows how one of the flaps of the SMAS, which is normally eliminated during a facelift as excess tissue, can be folded up and used to improve the projection of cheekbone. The improvement of the projection of this facial area enhances the aesthetic result, when the desired aesthetic result is discreet, in rhytidectomy without having to resort to biomedical material or complex surgical techniques. Our technique, which is safe and easy to handle, simplifies this procedure, providing a long-lasting satisfactory result for both the patient and the surgeon. Our report was done following rhytidectomy on 126 female patients and after an approximately 3-year follow-up.     

Safety and Efficacy of Restoring Facial Symmetry Using Polydioxanone Thread Face Lift Technique in Patients with Facial Palsy

BackgroundFacial nerve palsy often leads to functional and physiological impairment in patients and they often suffer from social stigma. The use of polydiaxone (PDO) threads has long been used to treat facial furrows and age-related sagging in the face. The basic principle of the thread lift procedure is placing cogged threads in the subcutaneous plane along a planned trajectory. The efficacy and ease of this procedure compared to a traditional face lift has made PDO threads a popular option in the past three decades. MethodsWe treated 50 patients with a drooping face on one side following facial paralysis with thread lifting and botulinum injections to control contralateral hypertrophy and ipsilateral synkinesis. The Facial Grading System or the serial Sunnybrook Facial Grading System (SB scores) was used to assess at all the visits and serial photographs were recorded.ResultsFollowing the threading procedure, all 50 patients displayed improved facial symmetry. There was significant improvement in the baseline SB scores compared to the scores over following year, with all the scores having significant p value less than 0.05.Conclusion Based on our results, subdermal suspension with re-absorbable threads in conjunction with botulinum toxin constitutes an efficient and safe procedure for face lifting and rejuvenation of a drooping face as a result of long-lasting facial paralysis.     

Evaluation of Lip Augmentation with Gore-Tex Facial Implant

Although numerous materials, including autogenous, homogeneous, and alloplastic materials, have been used for lip augmentation with varying degrees of success, no ideal one has been found to achieve a soft and long-lasting result. Gore-Tex implant has been successfully used in cardiovascular surgery. So far, it has not been used much in lip augmentation. In this study, a Gore-Tex SAM facial implant (1.8 mm in diameter) was used for lip augmentation in 23 lips of 17 female patients. In 10 consecutive lips with three segments of the implant each, a computer-assisted imaging system was used to scrutinize the results. The results have shown that the three segments of the implant enhanced the lip projection with about 0.98 mm in mean (p < 0.01) and the exposed vermillion width with about 1.94 mm (p < 0.01) in the over 6 months follow-ups. No major complications, only some minor ones, were seen. For lip augmentation, we find that only minor changes can be achieved with three segments of the Gore-Tex facial implant. We feel that it is safe and believe it gives a permanent result which is not the case with collagen injection and usually not the case with lipofilling despite reinjections. Furthermore, we consider the implant quite expensive at present.     

Orchiectomy Increases Bone Marrow Interleukin-6 Levels in Mice

Interleukin-6 (IL-6) appears to be an important factor in disease states associated with bone resorption. There is both in vitro and in vivo evidence supporting the fact that androgens down-regulate interleukin-6 production. These observations, in combination with the fact that osteoblasts and bone marrow stromal cells produce IL-6, led us to hypothesize that orchiectomy-induced androgen loss will result in increased IL-6 expression in the bone microenvironment. To prove our hypothesis we assessed the effect of orchiectomy on IL-6 protein and mRNA expression in bone marrow and spleen. We found that orchiectomy was associated with increased serum IL-6 levels at 3 and 28 days postsurgery. Phorbol ester-stimulated IL-6 levels were also higher in supernatants from bone marrow and spleen cell cultures from orchiectomized mice compared with unoperated or sham-operated mice. Additionally, we found that steady state IL-6 mRNA levels were increased in bone marrow but not spleen cells. Finally, we found that orchiectomized mice had splenomegaly and increased bone marrow cellularity. Histopathology of the spleen revealed lymphoid hyperplasia accompanied by a marked mononuclear cell infiltration of the red pulp. We conclude that orchiectomy induces IL-6 expression in the bone marrow. These findings suggest that endocrine and cytokine interactions contribute to bone pathophysiology. Received: 17 January 1997 / Accepted: 2 September 1997     

Bone Morphogenetic Protein-2 Increases the Rate of Callus Formation after Fracture of the Rabbit Tibia

The effects of human recombinant bone morphogenetic protein-2 (rhBMP-2) on rabbit fractures healing under both stable and unstable mechanical conditions were investigated. rhBMP-2 was administered (1) on bioerodible particles, (2) in a collagen gel, and (3) by injection. rhBMP-2 on bioerodible particles has no effect as the particles prevent the migration of cells that produce the callus. The collagen gel is resorbed more rapidly; the development of the callus of mechanically unstable fractures is similar to controls at 14 days. When rhBMP-2 is injected, the callus of mechanically unstable fractures develops more rapidly so that cortical union occurs by 21 days, as compared with 28 days in control fractures. The effects on fractures healing under stable mechanical conditions are minimal. It is argued that mechanical factors influence the size of the callus of normally healing fractures and, although BMP-2 accelerates the rate of development of the callus and cortical union, it does not affect the amounts of bone and cartilage produced. Received: 9 February 1998 / Accepted: 9 December 1998     

Observations on a New Concept for Correction of the Nasolabial Fold in Rhytidectomy

Correction of the nasolabial fold has been the challenge constantly faced by the plastic surgeon since the start of attempts at facial rejuvenation. In this paper we intend to show observations which were made in a quite different method of approach to the correction of this challenging anatomic detail. It consists of taking the subcutaneous tissue which forms the nasolabial fold, underneath the same fold, following the law of gravity, without touching or dissecting the superficial aponeurotic muscular system (SMAS) and without using any other artifice which could make it difficult to observe this different procedure. The technique was used on 15 patients who requested facial rhytidectomy.     

A Variant of Tietze's Syndrome Occurring After Reconstructive Breast Surgery

Costosternal chondrodynia (Tietze's syndrome variant) should be considered in those rare patients who present with severe breast pain several months after reconstructive breast surgery. The authors treated 25 cases, 3 of which are discussed in detail, where the origin of the pain was traced to the costosternal cartilages. The differential diagnosis and management of this hitherto undescribed problem after breast surgery are discussed.     

Multidisciplinary and Multistage Treatment of Complex Facial Trauma: Case Report

The improved performance of modern automobiles often results in higher driving speeds, rendering traffic accidents much more devastating. Many of our facially injured patients require multidisciplinary and multistage treatment, which is often both sophisticated and radical. We present a patient with complex facial trauma, discuss his injury characteristics and the multistage treatment performed, and review the literature.     

颌面部爆炸伤后面神经、下颌神经和迷走神经创伤恢复过程的差异

目的：不同类型的神经受到损伤后其恢复的过程也有所不同。在头面部爆炸伤中，由于爆炸致伤范围广，同时头面部有多种不同类型脑神经分布，因此常伴有不同类型的神经间接性损伤。以往对不同类型的神经比较颌面部爆炸伤后运动、感觉及植物神经创伤恢复过程的差异。方法：20只犬爆炸致伤后分别在伤后不同时间取材面神经、下颌神经和迷走神经，并用免疫组化检测三种神经中神经特异性烯醇化酶（the neuron-specific enolase，NSE）的表达变化，来分析这三种类型神经爆炸伤后恢复过程的差异。结果：三种神经伤后均出现NSE水平的迅速下降，随着神经的恢复，神经的NSE免疫组化染色逐渐恢复阳性。面神经最早在伤后1周出现阳性，而下颌神经和迷走神经均在伤后24h内即开始恢复NSE阳性。结论：在颌面部爆炸伤中，面神经往往伤情较迷走神经和下颌神经重。     

Revision of Neoclassical Facial Canons in Young Adult Afro-Americans

The validity of seven neoclassical facial canons was tested in 100 young, adult, Afro-American (A-A) males and females, and the results were compared with 103 North American Caucasians, producing the first reliable information about the differences of facial proportions in the two populations. Although the canons should not be regarded as strict directives in reconstructive and esthetic surgery, the data obtained from the study offered the first information about the facial proportion qualities of Afro-Americans in relation to the white population. In the absence of a detailed facial proportion study in A-As, the findings in canons can assist in planning the surgery. Comparison of the two populations revealed that the three sections of the facial profile were not equal in either population. In an A-A sample it showed the prevalence of the long lower face height also in relation to the height of the forehead. In horizontal canons of the orbital regions, the similarity between the two populations was demonstrated by the great frequency of intercanthal spaces to be wider than the length of the palpebral fissures [1]. The facial canons, including the nose width, relatively wider [2] in A-A than in white subjects, prompted the difference between A-A and Caucasians in frequency and degree in the dominant canon variations. The greater inclination of the nasal bridge than that of the medial longitudinal axis of the ear was a very frequent canon variation in both populations. Generally, the frequency of valid canons was greatly surpassed by their variations.     

Prevention of Corticosteroid-Induced Osteoporosis with Alendronate in Sarcoid Patients

Prolonged corticosteroid administration, as often required in the treatment of sarcoidosis, increases the risk of osteoporosis and fracture. The aim of the present study was to evaluate the usefulness of alendronate, a third generation bisphosphonate, in preventing corticosteroid-induced osteoporosis. Forty-three consecutive, previously untreated, sarcoid patients (17 men and 26 premenopausal women) were included in the study: 13 needed no treatment and served as controls (Group 1) and 30 needed glucocorticoids (prednisone) and were randomly selected to also receive either placebo (n = 15, Group 2) or alendronate 5 mg/day (n = 15, Group 3). Bone mineral density (BMD) at the ultradistal radius by dual photon absorptiometry (Osteograph 1000, NIM, Verona, Italy) and biochemical markers of bone turnover were measured at baseline and after 6 and 12 months of glucocorticoid therapy. No significant difference was found between Groups 2 and 3 in the mean cumulative dose of prednisone (4945 ± 1956 mg and 5110 ± 2013 mg, respectively). At the end of the study period, BMD increased by 0.8% in the alendronate-treated group; in the placebo-treated group, BMD decreased by 4.5%. The difference between groups was significant (P < 0.01, ANOVA). A significant decrease in markers of bone formation was found in all patients treated with prednisone (Groups 2 and 3), independently of alendronate. Alendronate, however, counteracted the increase in markers of bone resorption induced by glucocorticoid therapy. Our data suggest that alendronate is effective in preventing glucocorticoid-induced bone loss in sarcoid patients. Further studies on alendronate use in steroid-induced osteoporosis are needed. Received: 30 September 1996 / Accepted: 30 April 1997