Farzad R. Nahai

Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Changing the convexity and concavity of nasal cartilages and cartilage grafts with horizontal mattress sutures: part I. Experimental results.

Prior studies indicated that horizontal mattress sutures can control the curvature of a convex lateral crus. This study undertook to ascertain the ideal spacing for mattress sutures, determine what effect they have on the subsequent strength of the cartilage, and compare that to the resultant strength after scoring procedures used to control curvature. Curved fresh cadaver septa of various thicknesses (0.5, 1, and 1.5 mm) were used. The ideal spacing (gap between suture purchases) for the mattress suture was sought in 15 specimens. The consequent change in stiffness (modulus) of the cartilage was measured in nine other specimens before and after suture placement and after scoring. If the spacing was too large, instability resulted. If it was too small, curvature correction could not be obtained. An ideal mattress spacing (6 to 8 mm for 0.5-mm specimens and 8 to 10 mm for 1.5-mm specimens) removed most curvature and provided stability. The mattress suture increased the stiffness (modulus) above normal and far above that when the curvature was removed by scoring. The mean composite modulus before suturing was 4.6 MPa. After ideally spaced sutures, it was 6.2 MPa, a 35 percent increase in stiffness. After scoring to improve curvature, it was 2.4 MPa, a 48 percent reduction in stiffness (p = 0.02, Wilcoxon signed rank test). The horizontal mattress suture technique corrects cartilage curvature if the appropriate spacing is used. The corrected cartilage is stiffer/stronger than normal cartilage and much stiffer/stronger than if scored.

Use of porcine acellular dermal matrix (Enduragen) grafts in eyelids: a review of 69 patients and 129 eyelids.

Background: Spacer grafts in the eyelid are used in both reconstructive and aesthetic procedures. The authors report their experience using a new acellular porcine dermal graft (Enduragen) in 129 eyelids. Methods: A retrospective chart review was performed that included every case in which Enduragen was used by the two primary authors in the upper or lower eyelid. Patient demographics, type of procedure performed, and complications were reviewed. Results: Sixty-nine patients and a total of 129 eyelids were included in the study. Eight procedures were spacers in the upper lid, 104 were for spacers in the lower lid, and 17 were for lateral canthal reinforcement. Twenty-two procedures were in primary cases and 47 were in eyelids for secondary reconstructions, for a total of 69 patients. There were 13 eyelid complications, for a complication rate of 10 percent. Nine cases required surgical revision, and there were four cases of infection, all of which were successfully treated with oral and topical antibiotics. Conclusions: Enduragen has proved to be a very satisfactory substitute for ear cartilage and fascia in eyelid surgery in both reconstructive and primary eyelid cases. It seems to be far superior to other commercially available tissue substitutes because of its predictability of structure and robust behavior. All problems that were encountered in this series seemed to be related more to technical errors than to any deficiency in or reaction to the Enduragen. The increased strength, rigidity, and durability give support to the lids comparable to that obtained with autogenous ear cartilage and fascia.

Transconjunctival Blepharoplasty for Upper and Lower Eyelids

Background: Transconjunctival blepharoplasty remains a popular and safe technique to treat periorbital aging. In the lower lid, it can be used successfully for orbital fat excision, redistribution, or septal tightening. In the upper lid, transconjunctival blepharoplasty has a role in removal of the nasal fat pad via an isolated, direct approach. Methods: The authors review anatomy, indications, and surgical approaches for upper and lower lid transconjunctival blepharoplasty. Results: Potential complications, patient results, and the senior authors personal series are discussed. Conclusions: In the lower lid, this technique can be advocated in an effort to avoid lower lid complications such as sclera show or lid malposition. In the upper lid, it can be effective in treating isolated fat pads with minimal skin excess.

MOC-PSSM CME article: Breast reduction.

Learning Objectives: After reading this article, the participant should be able to: 1. Understand and describe the anatomy of the breast as it relates to reduction mammaplasty. 2. Appropriately evaluate a patient considering reduction mammaplasty. 3. Be familiar with the different procedures available for reduction mammaplasty. 4. Describe the common early and late complications following reduction mammaplasty and their management. Summary: The goal of this continuing medical education module is to present the preoperative assessment, formation of a surgical treatment plan and its execution, postoperative patient management, and identification and treatment of early and late postoperative complications in breast reduction surgery. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Isolated Management of the Aging Neck

The contour of the neck is a very important determinant of facial aesthetics. Precise knowledge of neck anatomy is essential for adequate planning and execution of this procedure. There are three anatomic and surgical planes involved in the management of the aging neck; the superficial plane (subcutaneous fat), the intermediate plane (platysma muscles and the fat between the two muscles), and the deep plane (subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands). These planes need to be thoroughly evaluated in the preoperative assessment and dealt with according to each patients needs. Even though this article focuses on isolated management of the aging neck, careful evaluation of the neck and its relationship to the lower third of the face is fundamental. If there is significant jowling and descent of the neck-face interface, an isolated neck-lift procedure will not address that problem and will lead to a suboptimal result. In these patients, a face and neck lift is a more appropriate operation.

Brow or forehead fixation with sutures only: a preliminary communication.

Fixation of the brow, although not technically difficult, can be a time-consuming process. Screws, whether permanent or absorbable, are occasionally associated with minor undesirable problems. We present a technique of brow suspension that is quick, simple, and free of the problems associated with fixation to the calvarium. It involves the use of sutures only. A heavy PDS suture is passed (with the aid of an awl) from the dermis of the brow or forehead that needs to be fixed to the dermis of a small incisional wound located 5–8 cm away. This suture suspension technique has proven to be quick and easy to execute. It has provided satisfactory fixation of the forehead/brow without problems of suture reaction. The cost of calvarial screws has been eliminated. When brow or forehead fixation is necessary, suspension with sutures to the dermis of a more superior location is an excellent method to accomplish the task quickly and easily. Long-term follow-up of a large series of patients will be necessary to validate the initial impression of this new technique.

A Surgical Algorithm Using Open Rhinoplasty for Correction of Traumatic Twisted Nose

Hsiao and colleagues have presented a simple, clear, and effective algorithm for managing the traumatic twisted nose. Their results are excellent and exemplary of a sound approach to a difficult problem. Their argument for the management of these cases using an open approach is sensible and in line with the practice of many rhinoplasty surgeons. The results for 92 patients who underwent open rhinoplasty for correction of a twisted nose are presented. It is not surprising that 95% of the patients were male, indicating that men pursue a riskier lifestyle than women. All the patients underwent a complete history and physical examination including preoperative photo documentation of the nose. Frontal, basal, lateral, and oblique views were recorded. An additional view that proves to be helpful in assessing the twisted nose is the frontovertex view, with the nasion proximal and the tip distal taken from the top of the head. It is the same view the surgeon has from the head of the operating table, and it offers an excellent way to asses the curvature of the nose. The authors infiltrate the nose with the minimum amount of local anesthetic to avoid distortion. This is especially meaningful for a patient population that tends to have thick soft tissue coverage of the bony and cartilaginous framework. In these cases, it can be very helpful to tattoo the midline of each nasal segment (upper, middle, and lower) before injection. These tattoo marks then can be used to assess nasal curvature during surgery. When the three dots are in alignment, straightening has been achieved. The authors algorithm for straightening the twisted nose makes sense and incorporates a top to bottom anatomic approach. Management should start with the bony nasal pyramid, then proceed to the septum, the tip cartilage, the skin and soft tissue, and finally closure. This approach takes into account open exposure of all anatomic landmarks in an effort to correct curvature in a stepwise pattern, with reassessment performed after each anatomic site has been addressed. I agree with the surgical techniques described and offer two points of advice for anyone considering correction of the twisted nose. First, in the case of a deviated nasal pyramid with asymmetric nasal bones, bilateral medial and lateral osteotomies should be undertaken with caution, especially in patients with a flattened nasal dorsum. In performing medial and lateral osteotomies, care must be taken to avoid a ‘‘floating’’ nasal bone that has been completely osteotomized from any bony attachment. This bone can collapse entirely and then be very difficult to restore to an anatomic location.

A Comparison of the Harmonic® Synergy™ Curved Blade and Electrosurgery in Aesthetic Eyelid Surgery: A Prospective, Randomized, Controlled, Double Blinded, Split Face Study

CONCLUSION: Lower blepharoplasty that integrates component techniques tailored to individual anatomical problems and spares the orbicularis muscle is effective and associated with few complications and revisions. Fat transposition by a simplified technique achieves effective blending of the lid-cheek junction. Complete skin flap elevation, as opposed to pinch excision (4), is more effective in eliminating rhytids and is safe for simultaneous resurfacing with a mild peeling agent. Selective use of lateral canthal support minimizes eyelid malposition problems.

Vertical Mammaplasty Marking Using the Key Hole Pattern

Gumus and colleagues from Turkey report on their technique for marking a vertical reduction mammoplasty in 14 patients. We are happy to see that plastic surgeons around the world are recognizing and embracing the short scar technique. The authors describe their adaptation of the preoperative skin markings described by Lejour and the Wise skin pattern. The authors plan their nipple location at or immediately below the inframammary fold 20 to 22 cm from the suprasternal notch. A Wise key hole pattern then is marked on the upper breast according to the newly determined nipple position. Next, divergent lines are drawn from the new nipple position, and markings are made at a point 7 cm below on either side. A ‘‘mosque dome-shaped’’ new areolar line is then drawn in a curvilinear fashion from one 7 cm point to the other crossing the breast meridian 2 cm above the new nipple position. This line is usually 14 to 16 cm long. The classic Lejour method then is used for marking the lower portion of the breast. The described surgical procedure bases the nipple and areola on a superior dermoglandular pedicle. Central, medial, and lateral portions of the breast tissue are resected. The authors explain the importance of a more aggressive resection laterally and preservation of tissue medially. The lateral resection follows a Wise type pattern used in typical inferior pedicle techniques. The dermoglandular flap then is sutured to the underlying pectoralis muscle, with the medial and lateral pillars brought together to provide breast shape and projection. The authors apply this technique to reductions ranging from 285 to 875 g, and do not report any complications except one case of delayed wound healing. We could not agree more with some of the author s principal points regarding vertical skin pattern breast reductions. We congratulate the authors for embracing this technique and using it successfully. The method of shaping the breast tissue by using a Wise pattern resection inferiorly with a superior dermoglandular pedicle and draping of the skin with a vertical incision is not new and has been espoused by other proponents of this technique. The authors have chosen to conceptualize this in preoperative markings by using a Wise pattern on the upper breast and a Lejour pattern on the lower breast. Certainly, there is not one right way to do this, providing the new nipple position is determined preoperatively. With experience, the pedicle choice and parenchymal resection patterns can be modified according to the preference of each individual patient and surgeon preference. The unique part of the authors preoperative marking is the areolar cutout pattern. We agree that the pattern and size of the skin cutout dictates the final shape of the areola more than does the initial circumareolar incision. It is interesting to note that the 14 to 16cm length that the authors mark is within the range of the calculation for areolar circumference based on an areola diameter of 4 to 5 cm using the formula for circumference (C = pr). There is, however, a downside in committing to the areolar cutout so early that one is limited later in the case and unable to adjust nipple position if needed. This is evident in case 3 (Fig. 3d), in which the nipples were too high with breast pseudoptosis. Perhaps by not committing to the areolar cutout so early, this problem could have been avoided. Despite this, the authors have demonstrated a useful method of marking and preoperatively planning a vertical skin Correspondence to Farzad R. Nahai; email: drnahai@ hotmail.com Aesth. Plast. Surg. 30:247 248, 2006 DOI: 10.1007/s00266-005-0142-9