Edward M. Reece

The Anatomy of the Greater Occipital Nerve: Part Ii. Compression Point Topography

Background: Advances in the understanding of migraine trigger points have pointed to entrapment of peripheral nerves in the head and neck as a cause of this debilitating condition. An anatomical study was undertaken to develop a greater understanding of the potential entrapment sites along the course of this nerve. Methods: The posterior neck and scalp of 25 fresh cadaveric heads were dissected. The greater occipital nerve was identified within the subcutaneous tissue above the trapezius and traced both proximal and distal. Its fascial, muscular, and vascular investments were located and accurately measured relative to established bony landmarks. Results: Dissection of the greater occipital nerve revealed six major compression points along its course. The deepest (most proximal) point was between the semispinalis and the obliquus capitis inferior, near the spinous process. The second point was at its entrance into the semispinalis. The previously described “intermediate” point was at the nerves exit from the semispinalis. A fourth point was located at the entrance of the nerve into the trapezius muscle. The fifth point of compression is where the nerve exits the trapezius fascia insertion into the nuchal line. The occipital artery often crosses the nerve, and this frequently occurs in this distal region of the trapezius fascia, which is the final point. Conclusions: There are six compression points along the greater occipital nerve. These can be located using the data from this study, serving as a guide for surgeons interested in treating patients with migraine headaches originating in these areas. Long-term relief from migraine headaches has been demonstrated clinically by using both noninvasive and surgical decompression of these points.

The Paramedian Forehead Flap : A Dynamic Anatomical Vascular Study Verifying Safety and Clinical Implications

Background: Nasal reconstruction with use of the forehead flap has been performed for hundreds of years. Forehead vasculature has been studied; however, anatomical relationships to the forehead flap have not been adequately examined. This anatomical study evaluated the vascular anatomy of the paramedian forehead flap. Methods: Five fresh cadaver heads were used. Four underwent cannulation of internal and external carotids bilaterally followed by injection of a barium sulfate/gelatin mixture and three-dimensional computed tomographic angiography to evaluate vascular anatomy. In one specimen, the supraorbital, supratrochlear, and angular arteries were cannulated. Methylene blue dye was injected to identify vascular territory followed by injection of contrast media for dynamic four-dimensional computed tomographic angiography. A paramedian forehead flap was raised and the injections were repeated. Colored-latex was injected followed by dissection. Measurements were made on a computed tomography workstation. Results: A periorbital plexus extends to 7 mm over the orbital rim. The angular, supratrochlear, and supraorbital arteries communicated into the flap by means of the vascular plexus. The supratrochlear vessel ran axially into the forehead flap and continued across the transverse limb of the flap. The deep branch of the supratrochlear ascended the periosteum under the flap. Noncontiguous vessels were noted to back-fill with latex through the subdermal plexus in the distal flap. Conclusions: Maximal three-vessel flow may be obtained by preserving periosteum at least 3 cm over the orbital rim and beginning the flap 7 mm above the orbital rim. The subdermal plexus of the forehead is robust, enabling preservation of the distal transverse limb of the forehead flap.

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.

The mandibular septum: Anatomical observations of the jowls in aging - Implications for facial rejuvenation

Background: The following study was undertaken to address the following questions: (1) Why do soft tissues over the mandibular body appear to be tethered to the jaw, restricting inferior descent? (2) Why does characteristic surface anatomy appear as it does? (3) What is the anatomical basis of jowl fat? Methods: Sixteen hemifacial cadaver dissections were performed after injecting methylene blue into subcutaneous regions around the mandibular body. Dissection was performed using loupe magnification. Results: Discrete compartments of subcutaneous fat were identified. Two subcutaneous compartments above the mandibular border make up the substance of the jowl fat: A superior compartment and an inferior compartment. A subcutaneous fat compartment below the mandibular border was identified. Buccal fat is distinct from jowl fat. Jowl fat is separated from the submandibular fat by a septum. This septum is adherent to the mandibular body. Fibers from the platysma interdigitate with the mandibular septum and both adhere to the anterior border of the mandible. Conclusions: There are distinct overlapping subcutaneous fat compartments above and below the mandibular border that define jowl fat. Buccal fat is anatomically independent from the jowl fat. The mandibular septum, separating jowl from neck fat, travels across and is adherent to the anterior surface of the body of the mandible. The mandibular septum tethers skin to the border of the mandible. This anatomical relationship is similar to the temporal septa and cheek septa and further suggests that facial rejuvenation should be performed in a site-specific manner.

Patient safety in the office-based setting.

Learning Objectives: After studying this article, the participant should be able to: 1. Discern the importance of the physician’s office administrative capacity. 2. Recognize the necessity of a system for quality assessment. 3. Assess which procedures are safe in the office-based setting. 4. Know the basic steps to properly evaluate patients for office-based plastic surgery. Background: At least 44,000 Americans die annually as a result of preventable medical errors. Medical mistakes are the eighth leading cause of death in the United States, costing between

The zygomaticotemporal branch of the trigeminal nerve: Part II. Anatomical variations.

54.6 billion and

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

79 billion, or 6 percent of total annual national health care expenditures. Office-based procedures comprise a 10-fold increase in risk for serious injury or death as compared with an ambulatory surgical facility. Methods: This article reviews the literature on office-based patient safety issues. It places special emphasis on the statements and advisories published by the American Society of Plastic Surgeons’ convened Task Force on Patient Safety in Office-Based Settings. This article stresses areas of increased patient safety concern, such as deep vein thrombosis prophylaxis and liposuction surgery. Results: The article divides patient safety in health care delivery into three broad categories. First, patient safety starts with emphasis at the administrative level. The physician or independent governing body must develop a system of quality assessment that functions to minimize preventable errors and report outcomes and errors. Second, the clinical aspects of patient safety require that the physician evaluate whether the procedure(s) and the patient are proper for the office setting. Finally, this article gives special attention to liposuction, the most frequently performed office-based plastic surgery procedure. Conclusions: Patient safety must be every physician’s highest priority, as reflected in the Hippocratic Oath: primum non nocere (“first, do no harm”). In the office setting, this priority requires both administrative and clinical emphasis. The physician who gives the healing touch of quality care must always have patient safety as the foremost priority.

Breast augmentation today: saline versus silicone--what are the facts?

Background: Musculofascial and vascular entrapments of peripheral branches of the trigeminal nerve have been thought to be trigger points for migraine headaches. Surgical decompression of these sites has led to complete resolution in some patients. The zygomaticotemporal branch of the trigeminal nerve has been shown clinically to have sites of entrapment within the temporalis. A cadaveric study was undertaken to elucidate and delineate the location of this nerves foramen and intramuscular course. Methods: The periorbital and temporal regions of 50 fresh cadaveric hemiheads were dissected. The deep temporal fascia and lateral orbital wall were exposed through open dissection. The zygomaticotemporal nerve was located and followed through the temporalis muscle to its exit from the zygomatic bone. The muscular course was documented, and the nerve foramen was measured from anatomical landmarks. Results: In exactly half of all specimens, the nerve had no intramuscular course (n = 25). In the other half, the nerve either had a brief intramuscular course (n = 11) or a long, tortuous route through the muscle (n = 14). The foramen was located at an average of 6.70 mm lateral to the lateral orbital rim and 7.88 mm cranial to the nasion-lateral orbital rim line, on the lateral wall of the zygomatic portion of the orbit. Two branches were sometimes seen. Conclusions: The zygomaticotemporal branch of the trigeminal nerve is a site for migraine genesis; surgical decompression or chemodenervation of the surrounding temporalis can aid in alleviating migraine headache symptoms. Advances in the understanding of the anatomy of this branch of the trigeminal nerve will aid in more effective surgical decompression.

The aesthetic jaw line: management of the aging jowl.

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.

Expert witness reform.

Controversy breeds excitement, and the epic saga of breast prosthesis in the United States has been no exception. In 1992, U.S. plastic surgeons began what can be considered an experiment. With new U.S. Food and Drug Administration restrictions, saline breast implants became the only option available to patients seeking breast augmentation surgery. This restriction spanned the course of almost 15 years. Initially, when we treated patients desiring breast augmentation, we were hopeful that one day silicone implants would be available again to provide our patients with a variety of options and choices. In 2006, the experiment ended as the Food and Drug Administration approved silicone implants for general clinical use in breast augmentation. A vociferous buzz surrounding silicone implants ensued, resulting in new interest and questions from our patients. With the promise of “new cohesive gels” and better durability, the floodgate was opened, and many of us have again embraced the use of silicone gel implants for breast augmentation. A recent survey conducted by the American Society of Plastic Surgeons revealed that the majority of responding members felt that many primary augmentation patients would return to exchange their saline implants for silicone implants.1 Further, members anticipated that more than 60 percent of future primary augmentation candidates would request silicone implants.1 Underneath all of this enthusiasm, have we found ourselves “back to the future”? If it were not for the health concern controversies surrounding silicone implants, which have been largely unsubstantiated in the scientific literature, it is conceivable that saline implants would never have been thoroughly investigated in the United States. The controversies led to multicenter trials and Food and Drug Administration endorsement of the safety of saline implants.2 With the reintroduction of silicone implants, comparisons between silicone and saline are inevitable. Although there is an abundant amount of general data concerning silicone implants, the relative brevity of follow-up for the current silicone implants approved recently by the Food and Drug Administration makes the analysis between saline and silicone implants unbalanced. We are now told about the “new generation” of silicone gel implants, but long-term data are not yet available. Although the current data are alluring, we must remember a straightforward fact: the data from the latest generation of silicone implants are approximately 3 to 4 years old. As physician and scientists, we know that long-term, verified, scientific knowledge is needed on potential changes in the contracture and rupture rates of these implants. One advantage of the moratorium on silicone implants was the long-term collection of data on saline implants. This data collection period spanned more than 15 years in the United States, and the information gathered substantiated that saline implants are safe and effective in our patients. Despite the uncertainty of outcomes with silicone implants, a plethora of data exists. What are the data and what should we discuss with our patients in consultation? The data we currently have are less than clear. With regard to rupture rates, studies have shown an 8to 13-year average for silicone implants; corporate data also cite a 0.5 to 3 percent 3to 4-year rupture rate.3–6 In their 2006 study, Heden et al.5 found that the rupture rate was 8 percent for silicone implants; this was contrasted with a rupture rate of 4.3 percent for saline implants,7 which increased with variance in time (Table 1). At 10 years, third-generation silicone gel implants are projected to maintain integrity at a rate of 83 percent to 85 percent; this estimate,