Ashkan Ghavami

The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery: review and technical considerations.

Background: Bioengineered hyaluronic acid derivatives are currently available that provide for safe and effective soft-tissue augmentation in the comprehensive approach to nonsurgical facial rejuvenation. Current hyaluronic acid fillers do not require preinjection skin testing and produce reproducible, longer-lasting, nonpermanent results compared with other fillers, such as collagen. Methods: A review of the authors’ extensive experience at the University of Texas Southwestern Medical Center was conducted to formulate the salient requirements for successful utilization of hyaluronic acid fillers. Indications, technical refinements, and key components for optimized product administration categorized by anatomical location are described. The efficacy and longevity of results are also discussed. Results: Bioengineered hyaluronic acid fillers allow for safe and effective augmentation of selected anatomical regions of the face, when properly administered. Combined treatment with botulinum toxin type A can enhance the effects and longevity by as much as 50 percent. Key components to optimal filler administration include proper anatomical evaluation, changing or combining various fillers based on particle size, altering the depth of injection, using different injection techniques, and coadministration of botulinum toxin type A when indicated. Concomitant administration of hyaluronic acid fillers along with surgical methods of facial rejuvenation can serve as a powerful tool in maximizing a comprehensive treatment plan. Conclusions: Current techniques in nonsurgical facial rejuvenation and shaping with hyaluronic acid fillers are safe, effective, and long-lasting. Combination regimens that include surgical facial rejuvenation techniques and/or coadministration of botulinum toxin type A further optimize results, leading to greater patient satisfaction.

Nasal tip sutures part I: the evolution.

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of todays rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.

The Anatomy of the Corrugator Supercilii Muscle: Part II. Supraorbital Nerve Branching Patterns

Background: This article focuses on delineation of supraorbital nerve branching patterns relative to the corrugator muscle fibers and identifies four branching patterns that help improve understanding of the local anatomy. Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and 50 supraorbital nerves) were dissected and the corrugator supercilii muscles isolated. After corrugator supercilii muscle measurement points were recorded for part I of the study, the supraorbital nerve branches were then traced from their emergence points from the orbit and dissected out to the defined topographical boundaries of the muscle. Nerve branching patterns relative to the muscle fibers were analyzed, and a classification system for branching patterns relative to the muscle was created. Results: Four types of supraorbital nerve branching patterns were found. In type I (40 percent), only the deep supraorbital nerve division sent branches that coursed directly along the undersurface of the muscle. In type II (34 percent), branches emerging directly from the superficial supraorbital nerve were found in addition to the branches from the deep division. Type III (4 percent) included discrete branches from the superficial division, but none from the deep division. In type IV (22 percent), significant branching began more cephalad relative to the muscle and, therefore, displayed no specific relation to the muscle fibers. Conclusions: Contrary to previous reports, both the deep and superficial divisions of the supraorbital nerve are intimately associated with corrugator supercilii muscle fibers. Four supraorbital nerve branching patterns from these divisions were found. Potential sites of supraorbital nerve compression were identified. This more detailed anatomical information may improve the safety and accuracy of performing complete corrugator supercilii muscle resection.

Anatomy of the corrugator supercilii muscle: part I. Corrugator topography.

Background: Complete corrugator supercilii muscle resection is important for the surgical treatment of migraine headaches and may help prevent postoperative abnormalities in surgical forehead rejuvenation. Specific topographic analysis of corrugator supercilii muscle dimensions and its detailed association with the supraorbital nerve branching patterns has not been thoroughly delineated. Part I of this two-part study aims to define corrugator supercilii muscle topography with respect to external bony landmarks. Methods: Twenty-five fresh cadaver heads (50 corrugator supercilii muscles and 50 supraorbital nerves) were dissected to isolate the corrugator supercilii muscle from surrounding muscles. Standardized measurements of corrugator supercilii muscle dimensions were taken with respect to the nasion and lateral orbital rim. Results: Relative to the nasion, the most medial origin of the corrugator supercilii muscle was found at 2.9 ± 1.0 mm; the most lateral origin point, 14.0 ± 2.8 mm. The lateralmost insertion of the corrugator supercilii muscle measured 43.3 ± 2.9 mm from the nasion or 7.6 ± 2.7 mm medial to the lateral orbital rim. The most cephalic extent (apex) of the muscle was located 32.6 ± 3.1 mm cephalad to the nasion–lateral orbital rim plane and 18.0 ± 3.7 mm medial to the lateral orbital rim. There were no statistical differences noted between the right and left sides. Conclusions: The dimensions of the corrugator supercilii muscle are more extensive than previously described and can be easily delineated using fixed bony landmarks. These data may prove beneficial in performing safe, complete, and symmetric corrugator supercilii muscle resection for forehead rejuvenation and for effective decompression of the supraorbital nerve and supratrochlear nerve branches in the surgical treatment of migraine headaches.

The orbicularis retaining ligament of the medial orbit: closing the circle.

Background: There exists some ambiguity regarding the exact anatomical limits of the orbicularis retaining ligament, particularly its medial boundary in both the superior and inferior orbits. Precise understanding of this anatomy is necessary during periorbital rejuvenation. Methods: Sixteen fresh hemifacial cadaver dissections were performed in the anatomy laboratory to evaluate the anatomy of the orbicularis retaining ligament. Dissection was assisted by magnification with loupes and the operating microscope. Results: A ligamentous system was found that arises from the inferior and superior orbital rim that is truly periorbital. This ligament spans the entire circumference of the orbit from the medial to the lateral canthus. There exists a fusion line between the orbital septum and the orbicularis retaining ligament in the superior orbit, indistinguishable from the arcus marginalis of the inferior orbital rim. Laterally, the orbicularis retaining ligament contributes to the lateral canthal ligament, consistent with previous studies. No contribution to the medial canthus was identified in this study. Conclusions: The orbicularis retaining ligament is a true, circumferential “periorbital” structure. This ligament may serve two purposes: (1) to act as a fixation point for the orbicularis muscle of the upper and lower eyelids and (2) to protect the ocular globe. With techniques of periorbital injection with fillers and botulinum toxin becoming ever more popular, understanding the orbicularis retaining ligament’s function as a partitioning membrane is mandatory for avoiding ocular complications. As a support structure, examples are shown of how manipulation of this ligament may benefit canthopexy, septal reset, and brow-lift procedures as described by Hoxworth.

Rhinoplasty for Middle Eastern Noses

Background: Rhinoplasty remains one of the most challenging operations, as exemplified in the Middle Eastern patient. The ill-defined, droopy tip, wide and high dorsum, and thick skin envelope mandate meticulous attention to preoperative evaluation and efficacious yet safe surgical maneuvers. The authors provide a systematic approach to evaluation and improvement of surgical outcomes in this patient population. Methods: A retrospective, 3-year review identified patients of Middle Eastern heritage who underwent primary rhinoplasty and those who did not but had nasal photographs. Photographs and operative records (when applicable) were reviewed. Specific nasal characteristics, component-directed surgical techniques, and aesthetic outcomes were delineated. Results: The Middle Eastern nose has a combination of specific nasal traits, with some variability, including thick/sebaceous skin (excess fibrofatty tissue), high/wide dorsum with cartilaginous and bony humps, ill-defined nasal tip, weak/thin lateral crura relative to the skin envelope, nostril-tip imbalance, acute nasolabial and columellar-labial angles, and a droopy/hyperdynamic nasal tip. An aggressive yet nondestructive surgical approach to address the nasal imbalance often requires soft-tissue debulking, significant cartilaginous framework modification (with augmentation/strengthening), tip refinement/rotation/projection, low osteotomies, and depressor septi nasi muscle treatment. The most common postoperative defects were related to soft-tissue scarring, thickened skin envelope, dorsum irregularities, and prolonged edema in the supratip/tip region. Conclusions: It is critical to improve the strength of the cartilaginous framework with respect to the thick, noncontractile skin/soft-tissue envelope, particularly when moderate to large dorsal reduction is required. A multitude of surgical maneuvers are often necessary to address all the salient characteristics of the Middle Eastern nose and to produce the desired aesthetic result.

The individualized component face lift: developing a systematic approach to facial rejuvenation.

Background: Accurate preoperative planning combined with facial fat compartment augmentation can improve precision and balance in facial rejuvenation techniques. Understanding the concept of “facial shaping” with respect to symmetry and soft-tissue (fat) distribution preoperatively is critical to optimizing aesthetic outcomes in various face lift techniques. Methods: A review of 822 consecutive face lifts performed from January of 1994 to June of 2007 by a single surgeon (R.J.R.) was conducted. From this database, randomly selected cohorts of 50 preoperative and postoperative photographs were critically analyzed by three plastic surgeons exclusive of the senior surgeon (R.J.R.). Three facial parameters were compared on each facial side: facial height, degree of malar deflation, and orbit size. Long-term improvement was evaluated to delineate factors contributing to success in creating an aesthetically balanced facial shape. Results: Asymmetry between the two facial sides was noted in every patient preoperatively with respect to the three study parameters and was improved postoperatively. There was no statistically significant interobserver bias in the evaluations (p < 0.005). Facial asymmetry dictated differential treatment of the superficial musculoaponeurotic system (SMAS) tissue between facial sides to achieve the desired youthful facial shape. The angle (vector) and extent of SMAS-stacking varied depending on the preoperative analysis. Similarly, the selection of SMAS-ectomy versus SMAS-stacking depended on the degree of malar deflation and resultant cheek fullness. Conclusions: Proper preoperative analysis for evaluating facial shape should address (1) facial height, (2) facial width, and (3) overall distribution/location of facial fullness. This method of evaluating facial shape and symmetry is simple and reproducible, and can aid in formulating a comprehensive treatment plan.

Lift-and-fill face lift: Integrating the fat compartments

Background: Recent discovery of the numerous fat compartments of the face has improved our ability to more precisely restore facial volume while rejuvenating it through differential superficial musculoaponeurotic system treatment. Incorporation of selective fat compartment volume restoration along with superficial musculoaponeurotic system manipulation allows for improved control in recontouring while addressing one of the key problems in facial aging, namely, volume deflation. This theory was evaluated by assessing the contour changes from simultaneous face “lifting” and “filling” through fat compartment–guided facial fat transfer. Methods: A review of 100 face-lift patients was performed. All patients had an individualized component face lift with fat grafting to the nasolabial fold, deep malar, and high/lateral malar fat compartment locations. Photographic analysis using a computer program was conducted on oblique facial views preoperatively and postoperatively, to obtain the most projected malar contour point. Two independent observers visually evaluated the malar prominence and nasolabial fold improvements based on standardized photographs. Results: Nasolabial fold improved by at least one grade in 81 percent and by over one grade in 11 percent. Malar prominence average projection increase was 13.47 percent and the average amount of lift was 12.24 percent. The malar prominence score improved by at least one grade in 62 percent of the patients postoperatively, and 9 percent had a greater than one grade improvement. Twenty-eight percent of the patients had a convex malar prominence postoperatively compared with 6 percent preoperatively. Malar prominence improved by at least one grade in 63 percent and by over one grade in 10 percent. Conclusions: The lift-and-fill face lift merges two key concepts in facial rejuvenation: (1) effective tissue manipulation by means of lifting and tightening in differential vectors according to original facial asymmetry and shape; and (2) selective fat compartment filling of deep malar and high malar locations and nasolabial fold fat grafting to precisely control facial contouring. This was shown with objective numerical grading and through observer assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Thumb trapeziometacarpal arthritis: treatment with ligament reconstruction tendon interposition arthroplasty.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the pathomechanical and biochemical basis for thumb trapeziometacarpal joint degeneration. 2. Diagnose and grade trapeziometacarpal joint disease based on presentation, physical examination (including provocative testing), and radiographic evidence. 3. Understand the principles of ligament reconstruction and tendon arthroplasty procedures. 4. Describe the surgical technique for ligament reconstruction tendon interposition arthroplasty and its variants. Background: Osteoarthritis of the trapeziometacarpal joint is the second most common site of degenerative joint disease in the hand, and mostly affects postmenopausal women. Degenerative arthritis of the thumb trapeziometacarpal joint is associated with a lack of bony constraints and laxity of the supporting ligaments, particularly the anterior oblique (“beak”) ligament, which is consistently implicated in disease progression. Resultant increases in joint stress loads leads eventually to metacarpal and trapezial articular destruction, thumb instability, and pain. Methods: In this article, the authors review the diagnosis and treatment modalities available to the surgeon in the treatment of patients with trapeziometacarpal osteoarthritis. The technique of ligament reconstruction tendon interposition arthroplasty is discussed in detail. Results: Ligament reconstruction tendon interposition arthroplasty procedures center on three common principles: (1) excision of the diseased trapezium; (2) reconstruction of the beak ligament; and (3) interposition of a tissue substance to maintain metacarpal position. Conclusions: Both conservative and surgical management can be effective in the treatment of trapeziometacarpal arthritis, when properly selected. The success of ligament reconstruction tendon interposition arthroplasty in treating trapeziometacarpal arthritis has withstood the test of time.

Primary breast augmentation today: a survey of current breast augmentation practice patterns.

A study was undertaken to survey current practice patterns concerning primary breast augmentation. Members of the American Society for Aesthetic Plastic Surgery (ASAPS) were electronically surveyed concerning issues such as incision location, implant size and type, and complications, as well as information about the surgeons, their practices, and where procedures are performed. The survey response rate was 30%. Plastic surgeons from the South and Southwest made up 40% of respondents. Forty-six percent of respondents had more than 20 years of experience in practice. Forty-three percent of primary breast augmentations were performed in outpatient surgery centers. An anesthesiologist was in attendance in 60% of cases. The average operative time--indicated in 80% of responses--ranged from 45 to 90 minutes. Thirty-three percent of responding plastic surgeons used the base diameter to determine implant size and respondents most commonly used a smooth saline implant placed through an inframammary incision in a submuscular pocket. The most frequently reported complication was nipple sensation changes. Although the reintroduction of silicone gel implants was accompanied by expectations of a sharp increase in their use, this survey revealed that among ASAPS members, saline implants currently are used more often than silicone gel implants. However, both saline and silicone gel implants are used frequently, safely, and reliably. This survey represents a snapshot of current practice and future trends in primary breast augmentation will require additional assessment, although increased use of silicone gel breast prostheses over time is expected.