Evan B. Katzel

Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone computed tomographic scans were obtained from 60 female and 60 male Caucasian subjects. Twenty male and 20 female subjects were placed in three age categories (20 to 40 years, 41 to 64 years, and 65 years and older). Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering. Edentulous patients were excluded. The following measurements were obtained: upper face (orbital aperture area, orbital aperture width, and curvilinear analysis of the superior and inferior orbital rims), midface (glabellar angle, pyriform angle, maxillary angle, and pyriform aperture area), and lower face (bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle). Results: The orbital aperture width and orbital aperture area increased significantly with age for both sexes. There was a significant increase in orbital aperture size (increase in height of the superomedial and inferolateral orbital rim) in both sexes. The glabellar and maxillary angles decreased significantly with age for both sexes, whereas the pyriform aperture area significantly increased for both sexes with age. Mandibular length and height both decreased significantly for each sex. The mandibular angle significantly increased with age for both sexes. Conclusions: These results suggest that the skeletal morphology of the face changes with age. This change in skeletal morphology may contribute to the appearance of the aging face.

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care.

Background: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. Methods: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. Results: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons’ self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. Conclusions: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.

Aging of the mandible and its aesthetic implications.

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how specific bony aspects of the mandible change with age in both genders and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone three-dimensional computed tomographic scans were obtained from 120 Caucasian subjects (60 women and 60 men). Our study population consisted of 20 male and 20 female subjects in each of three age categories (20 to 40, 41 to 64, and ≥65 years). Edentulous patients were excluded. The following measurements were obtained: bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle. The data were analyzed with one-way analysis of variance and two-tailed t tests, with results considered significant at a value of p < 0.05. Results: There was no significant change with regard to bigonial width or ramus breadth across age groups for either gender. Ramus height, mandibular body height, and mandibular body length decreased significantly with age for both genders, whereas the mandibular angle increased significantly for both genders with increasing age. Conclusions: These results suggest that the bony elements of the mandible change significantly with age for both genders and that these changes, coupled with soft-tissue changes, lead to the appearance of the aged lower third of the face.

Impact of Smad3 loss of function on scarring and adhesion formation during tendon healing.

Studies were performed evaluating the role of Smad3, a transcription factor mediating canonical TGF‐β signaling, on scarring and adhesion formation using an established flexor digitorum longus (FDL) tendon repair model. In unoperated animals the metatarsophalangeal (MTP) range of motion (ROM) was similar in Smad3−/− and wild‐type (WT) mice while the basal tensile strength of Smad3−/− tendons was significantly (39%) lower than in WT controls. At 14 and 21 days following repair Smad3−/− MTP ROM reached approximately 50% of the basal level and was twice that observed in WT tendon repairs, consistent with reduced adhesion formation. Smad3−/− and WT maximal tensile repair strength on post‐operative day 14 was similar. However, Smad3−/− tendon repairs maximal tensile strength on day 21 was 42% lower than observed in matched WT mice, mimicking the relative decrease in strength observed in Smad3−/− FDL tendons under basal conditions. Histology showed reduced “healing callus” in Smad3−/− tendons while quantitative PCR, in situ hybridization, and immunohistochemistry showed decreased col3a1 and col1a1 and increased MMP9 gene and protein expression in repaired Smad3−/− tendons. Thus, Smad3−/− mice have reduced collagen and increased MMP9 gene and protein expression and decreased scarring following tendon FDL tendon repair.

The Impact of Smad3 Loss of Function on TGF-β Signaling and Radiation-Induced Capsular Contracture

Background: Capsular contracture remains a major problem following prosthetic breast implantation, especially in patients undergoing irradiation. Recent studies suggest that such radiation injuries are a cascading process of cytokine activation, with transforming growth factor (TGF)-&bgr; acting as the “master switch.” Because TGF-&bgr; signals through phosphorylation of Smad3, a plausible approach to abate TGF-&bgr;–induced capsular contracture would be to interrupt Smad3 signaling. To test this hypothesis, capsular contracture formation in wild-type and Smad3 knockout mice was compared using micro–computed tomographic and histologic examination. Methods: On day 0, 48 mice were implanted with bilateral silicone gel implants. Postoperatively, animals were imaged using live-scan micro–computed tomographic scanning. Animals in the radiation arm then received a 10-Gy directed radiation dose. On postoperative days 21, 28, 35, and 42, animals were imaged again. Histologic evaluation was performed at necropsy. Results: Irradiated implants in the wild-type mice demonstrated shape and contour deformation on micro–computed tomographic scanning beginning on postoperative day 21 and progressing through day 42. Conversely, micro–computed tomographic scanning of irradiated implants in knockout mice demonstrated few changes from day 0 through day 42. Corresponding histologic specimens from wild-type mice demonstrated irregular capsules composed of disorganized collagen that became thicker from day 21 to day 42. Irradiated knockout specimen maintained thin capsules from day 21 through day 42. Conclusions: In this work, inhibiting TGF-&bgr; signaling led to a reduction in radiation-induced capsular contracture as measured by micro–computed tomographic and histologic evaluation. The results of this study suggest a promising target for the prevention of capsular contracture through the development of anti-Smad3/TGF-&bgr;–based therapies.

A novel animal model for studying silicone gel-related capsular contracture.

Background: Capsular contracture remains one of the major problems following prosthetic implantation of the breast, especially in postmastectomy breast reconstruction patients receiving radiation therapy. Advances in this area have been hampered by the absence of an acceptable animal model. This study evaluates a new murine model with which to facilitate research into the cellular and molecular pathways underlying capsular contracture and provides a surrogate for evaluating potential therapies. Methods: On day 0, mice were implanted with silicone gel implants. Postoperatively, animals were imaged using live-scan micro–computed tomography. Animals in the irradiation group then received a 10-Gy directed radiation dose from a slit-beam cesium source. On days 21, 28, 35, and 42, both irradiated and nonirradiated animals were imaged again and histologic evaluation was performed. Results: Nonirradiated implants demonstrated little change in contour from day 0 through day 42 on micro–computed tomography, whereas irradiated implants demonstrated consistent shape deformation and irregularities in contour at these time points. Histologic evaluation showed that irradiated specimens developed thicker capsules and more disorganized capsules than nonirradiated specimens at each time point. Conclusions: In this article, the authors introduce a novel animal model with which to study capsular contracture. This model is the first of its kind to use radiation to induce, and live-scan micro–computed tomography to evaluate, capsular contracture. Radiation was shown to cause reproducible changes that can be consistently evaluated with micro–computed tomography and histology. Future studies with this model will study the cellular and molecular mechanisms underlying capsular contracture using knockout and transgenic mouse strains.

Facial bone density: effects of aging and impact on facial rejuvenation.

BACKGROUND Facial bone aging has recently been described as primarily resulting from volume loss and morphologic changes to the orbit, midface, and mandible. OBJECTIVE The authors demonstrate how the facial skeleton bone mineral density (BMD) changes with age in both men and women and compare these changes to those of the axial skeleton. They also explore the aesthetic implications of such changes in bone density. METHODS Dual-energy X-ray absorptiometry (DXA) scans of the facial bones and lumbar spine were obtained from 60 white subjects, 30 women and 30 men. There were 10 men and 10 women in each of 3 age categories: young (20-40 years), middle (41-60 years), and old (61+ years). The following measurements were obtained: lumbar spine BMD (average BMD of L1-L4 vertebrae), maxilla BMD (the average BMD of the right and left maxilla), and mandible BMD (the average BMD of the right and left mandibular ramus). RESULTS The lumbar spine BMD decreased significantly for both sexes between the middle and old age groups. There was a significant decrease in the maxilla and mandible BMD for both sexes between the young and middle age groups. CONCLUSIONS Our results suggest that the BMD of the face changes with age, similar to the axial skeleton. This change in BMD may contribute to the appearance of the aging face and potentially affect facial rejuvenation procedures.

Treatment of plagiocephaly with helmet molding therapy: do actual results mimic perception?

Purpose Actual and perceived improvements from helmet molding therapy for deformational plagiocephaly are demonstrated here. Effective communication of these data by craniofacial teams can help avoid unrealistic expectations and inform parents of expected outcomes. Methods Parents of 61 patients with plagiocephaly were asked to rate their childrens head shape and ear position before and after helmet therapy (a score of 1 being abnormal and 10 being normal). Topographic laser head scans for an aged-matched cohort of 91 patients with deformational plagiocephaly were acquired. Cephalic ratio, overall symmetry ratio, radial symmetry index, ear offset, and left and right oblique were recorded before and after molding. The cranial vault asymmetry index (CVSI) score was calculated. Results Parent ratings before and after molding, respectively, were head shape 2.99 ± 1.50 (mean ± SD) versus 7.88 ± 1.64 (p < .0001) and ear position 3.75 ± 2.5 versus 7.73 ± 2.34 (p < 0.0001). Measurements before and after molding were cephalic ratio 0.89 ± 0.07 versus 0.87 ± 0.08 (p < .0001), overall symmetry index 0.87 ± 0.05 versus 0.90 ± 0.04 (p < .0001), radial symmetry index 59.9 ± 26.9 mm versus 46.3 ± 25.1 mm (p < .0001), CVSI 7.2 ± 3.75 versus 4.8 ± 2.8 (p < .0001), and ear offset 5.7 versus 5.5 mm (p = .58). Conclusions Helmet molding produces reproducible changes in head shape. Despite relatively small actual changes on topographic laser imaging, parents perceive a large correction in head shape and ear position following helmet molding. Craniofacial teams can use these data and head scans before helmet molding to provide parents with realistic expectations for the outcome of their childs helmet molding therapy.

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Summary: This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

Midcarpal and Scaphotrapeziotrapezoid Arthritis in Patients with Carpometacarpal Arthritis

Background: Carpometacarpal arthroplasty provides well-documented pain relief with preservation of thenar function in basal joint arthritis treatment. Nevertheless, some patients continue to have pain following surgery. The authors hypothesize that unrecognized midcarpal (capitolunate) arthritis is a contributor to persistent pain after carpometacarpal arthroplasty. The prevalence of midcarpal arthritis in patients with basal joint arthritis is unknown. This article establishes the radiographic prevalence of midcarpal arthritis in patients with carpometacarpal arthritis. Methods: Patients with basal joint arthritis were identified from a search using International Classification of Diseases, Ninth Revision code 716.94. Hand radiographs were reviewed and graded using the Eaton classification and Sodha classification for carpometacarpal arthritis. Scaphotrapeziotrapezoid arthritis and midcarpal arthritis were graded using the Sodha classification for arthritis as follows: grade 1, no or nearly no arthrosis; grade 2, definite arthrosis but not severe; and grade 3, severe arthrosis. Results: Eight hundred ninety-six radiographs were reviewed. The prevalence of scaphotrapeziotrapezoid arthritis in this population was 64 percent. The prevalence of midcarpal arthritis in this population was 23.5 percent. The prevalence of midcarpal arthritis in patients with radiologic evidence of carpometacarpal arthritis was 25.4 percent. The prevalence of severe midcarpal arthritis was 7 percent. Conclusions: The prevalence of midcarpal arthritis in patients with basal joint arthritis is 24 percent. The presence of two locations of arthritis may explain persistent hand and wrist pain in this population despite carpometacarpal arthroplasty. Clinically, these data will allow hand surgeons to better educate patients with basal joint arthritis regarding the possibility of incomplete pain relief following carpometacarpal arthroplasty.