James M. Stuzin

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face. The significance of the retaining ligaments lies in the fact that as people age, the support from this ligamentous system becomes attenuated, leading to many of the stigmata of the aging face, such as the development of jowling and prominent nasolabial folds. The anatomic changes that occur in the aging face are delineated. With an adequate understanding of the anatomic changes that occur with aging, rhytidectomy can be approached as a reconstructive procedure, restoring facial soft tissue to its original anatomic state and location.

Histologic effects of the high-energy pulsed CO2 laser on photoaged facial skin.

To delineate the histologic effects of laser resurfacing at photoaged skin, a protocol was designed to biopsy laser test sites in conjunction with adjacent actinically damaged skin at the time of rhytidectomy. Five patients with photodamaged skin underwent resurfacing of the preauricular region to examine the effect of increasing pulse energy and increasing number of passes on depth of dermal penetration. Histologic examination of these specimens showed that the depth of laser injury was dose-dependent. Increasing pulse energy created a deeper wound, and increasing the number of passes similarly produced a larger band of necrosis. Ten patients with photodamaged skin underwent resurfacing of the preauricular region 15 days to 6 months prior to undergoing a rhytidectomy. A comparison of the laser-resurfaced test spot with the adjacent untreated photodamaged skin demonstrated consistent histologic changes to both epidermis and dermis in all specimens examined. Following laser resurfacing, epidermal atrophy and atypia were eliminated, and all specimens exhibited a regeneration of epithelium that was normal in its morphology. Melanocytic hypertrophy and hyperplasia were corrected following treatment, although density and function of epidermal melanocytes appeared normal. All specimens exhibited a substantial amount of neocollagen formation involving both the superficial and middermis following resurfacing. In association with new collagen development within the dermis, there was noted to be a similar degree of proliferation of elastic fibers, as well as a diminution of glycosaminoglycans, which are typically present in actinically damaged elastotic dermis. To determine the effect of laser resurfacing on-black skin, laser test spots were placed in the postauricular region of three black patients. Biopsy of these test sites showed that the histologic effects of laser resurfacing were similar to those observed in Caucasian patients, with complete repopulation of epidermal melanocytes in specimens biopsied 3 months following resurfacing. The histologic effects of laser resurfacing are microscopically similar to those of phenol peeling in terms of the amelioration of photodamage. The distinction between these two treatment methods lies in their apparent effect on epidermal melanocytes, which appear to function normally following laser resurfacing.

Refinements in face lifting : Enhanced facial contour using Vicryl mesh incorporated into SMAS fixation

As we have gained experience with the extended superficial musculoaponeurotic system (SMAS) technique in face lifting, refinements in our procedure have led to increased consistency in results. The important factors that have led to our technical modifications include the following: (1) the significance of the retaining ligaments of the midface, which determine the degree of surgical dissection required for both skin and SMAS in rhytidectomy; (2) the changes in facial shape that occur with aging, secondary to the descent of facial fat; (3) the possibility of modifying facial shape through the repositioning of facial fat in an extended SMAS face lift; (4) the improved longevity of result to be obtained by incorporating Vicryl mesh into SMAS fixation; (5) the artistic nuances of incision design that help to minimize scar perceptibility. Understanding these factors enables surgeons to use the extended SMAS technique successfully with more challenging cases, enhancing facial appearance while minimizing signs that the patient has undergone a surgical procedure.

The Cosmetic Use of Botulinum Toxin

The approach to facial rejuvenation continues to evolve. For decades, the primary focus on rejuvenation has centered on modalities such as skin care, skin resurfacing, soft-tissue augmentation, and surgical intervention. A better understanding of the physiologic changes that occur with facial aging lends itself to new approaches and techniques that are mindful of the causes. As animation has shown to be a significant contributor to both the appearance of facial lines and soft-tissue malposition, there has been recent interest in chemodenervating agents and their applications in the field of facial rejuvenation. These agents, by and large, efface rhytides by selective and precise focal paralysis of the underlying facial musculature and, therefore, reduce or eliminate the prominence of the overlying rhytides. In addition, chemodenervation can serve as an adjunct for facial rejuvenation because of its influence on facial soft-tissue position and shape. Botulinum toxin, derived from Clostridium botulinum, is the most widely used agent; therefore, this new modality, its applications in cosmetic plastic surgery, and its applications to other areas will be discussed.

Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning.

Summary: Aesthetic analysis in facial rejuvenation has traditionally been subordinate to technical solutions. While concerns regarding correction of facial laxity, a reduction in the depth of the nasolabial fold, and improvement of both the jowl and the jawline are worthy goals in rhytidectomy, the aesthetic concept of restoring facial shape to a more youthful appearance is equally important. Restoring facial shape in face lifting requires an understanding of how the face ages and then the formulation of a treatment plan that is individualized for the patient. Re-establishment of facial contour is significantly influenced by the re-elevation of descended facial fat through superficial musculoaponeurotic system manipulation; it can be approached through a variety of technical solutions. Underlying skeletal support affects not only the appearance of the face in youth but also how the face ages and influences the operative plan in terms of the requirements for fat repositioning. Formulating a treatment plan that is patient specific and based on the artistic goals as influenced by skeletal support is the key element for consistency in restoring facial shape in face lifting.

A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles.

Facial skin treatments with laser resurfacing, dermabrasion, and chemical peels were responsible for a significant portion of the 2.7 million cosmetic procedures performed in 1998. Perioral wrinkles are a common problem for which plastic surgical consultation is obtained. The aim of this study was to compare and quantify the advantages and disadvantages of laser resurfacing versus dermabrasion in the treatment of perioral wrinkles. Twenty female patients provided informed consent and participated in the study. Half of the perioral area was treated with dermabrasion and half was treated with the UltraPulse CO2 laser. The two procedures were compared using high-quality photographs; a biophysical evaluation of skin color, hydration, and mechanical properties; and patient evaluation of outcomes. Photographs were evaluated by 10 board-certified plastic surgeons who were blinded to the treatment methods. The laser treatment had a significantly higher erythema score at 1 month and a small but significantly greater improvement in perioral wrinkles at 6 months. Thirteen subjects selected the laser treatment as producing the best result, despite the greater intraoperative pain for this procedure. Biomechanical measurements suggest that the laser treatment produced a skin state more similar to skin in younger patients, presumably with higher levels and/or greater organization of the collagen and elastin. Patient preference was inferred from the resurfacing method that they would recommend to a friend. Although the laser was selected as the best result in a majority of cases, patient preference was equally distributed between the two treatments. The authors think that by studying and quantifying the biophysical changes that occur as a result of CO2 laser resurfacing, greater improvements in restoring actinic damage (e.g., wrinkles) can be achieved. Patients consider more than the objective skin changes from a resurfacing technique when making a recommendation to a friend.

MOC-PSSM CME article: Face lifting.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand and describe preoperative medical conditions pertinent to patient selection in facial rejuvenation. 2. Understand and describe anatomical and aesthetic changes that occur with facial aging and how they affect surgical treatment planning. 3. Understand and describe operative approaches to the aging face. 4. Understand and describe the avoidance and treatment of complications following face lifting. Summary: Surgical rejuvenation of the aging face has evolved into one of the most frequently performed cosmetic surgery procedures. Although there are many techniques that are used in facial rejuvenation, the key to consistent results is not technique but rather the surgeon’s ability to individualize the treatment plan according to the aesthetic needs of the patient. To ensure safety, preoperative medical conditions need to be both well defined and stabilized preoperatively, and procedures are best performed with anesthesia supervision. Consistency in postoperative result is obtainable through a thorough understanding of facial soft-tissue anatomy, the anatomical changes that occur with aging, and an appreciation of the technical nuances required to reposition descended soft tissues toward the anatomical position of youth. Recognition of potential complications and an appreciation of how to both limit and manage them when they occur are imperative in delivering a satisfying outcome for both patient and physician. 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.

Does hyperbaric oxygen therapy work in facilitating acute wound healing: A systematic review

Background: Adjunctive hyperbaric oxygen therapy is a safe and effective modality with which to increase tissue oxygenation and aid in healing of difficult wounds. The majority of the literature surrounding hyperbaric oxygen therapy supports its use in chronic wounds, but its use in acute wounds, flaps, and grafts is less well supported. Methods: The authors reviewed the Ovid, PubMed, and Cochrane Library databases, and selected studies, level III and above, using hyperbaric oxygen therapy in the treatment of complicated acute wounds, flaps, and grafts. Results: A total of eight studies were found to meet criteria for evaluation of adjunctive hyperbaric oxygen therapy in the treatment of complicated acute wounds, flaps, and grafts. Conclusions: When combined with standard wound management principles, hyperbaric oxygen therapy can augment healing in complicated acute wounds. However, it is not indicated in normal wound management. Further investigation is required before it can be recommended as a mainstay in adjuvant wound therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Botulinum toxin: expanding role in medicine.

During the last decade, the aesthetic use of botulinum toxin type A has risen dramatically. Because of the tremendous growth in its cosmetic clinical applications, we have dedicated this first supplement of Plastic and Reconstructive Surgery exclusively to botulinum toxin. Botulinum toxin type A, or Botox (Allergan, Inc., Irvine, Calif.), as it is commonly called, has become a ubiquitous drug for all seasons. A myriad of applications for the treatment of facial aging are now available that can be performed safely and effectively with minimal side effects. Within this supplement, we have endeavored to provide you with all the current information on botulinum toxin from top medical professionals who are experienced in its use. In the 1930s, botulinum toxin, produced by the bacterium Clostridium botulinum, was responsible for devastating the canning industry in the United States. The Army later purified the toxin for use in biological warfare research, but until the 1980s, botulinum toxin’s reputation was solely that of a deadly poison. In 1980, botulinum toxin started finding medicinal use for certain conditions, such as the treatment of strabismus in children. Its use expanded over the next several years to include the treatment of facial spastic disorders as well as asymmetries caused by facial nerve paralysis (spontaneous or iatrogenic). Subsequently, it was proven to efface deep glabellar furrows in patients with benign essential blepharospasm. It garnered U.S. Food and Drug Administration approval for use in treating glabellar rhytides in 2002. Applications for botulinum toxin continue to be developed in aesthetics and other fields with great success. Now, botulinum toxin type A is the new wonder drug, and Botox has almost become a household name. Other botulinum toxins, including botulinum toxin type B (Myobloc; Elan Pharmaceuticals, Inc., San Francisco, Calif.) and C. botulinum type A toxin– hemagglutinin complex (Dysport; Ipsen Pharmaceuticals, Ltd., Dublin, Ireland), have developed specific indications in this arena as well. According to the American Society of Plastic Surgeons’ statistics, 1,123,510 people were treated with botulinum toxin in 2002, making it the number 1-ranked nonsurgical procedure performed by board-certified plastic surgeons.1 The use of botulinum toxin continues to expand, both in volume and in number of applications. Aside from its use in the effacement of dynamic or hyperkinetic facial lines, it has also found use in treating conditions such as dystonias, facial and generalized muscle spasms, incontinence, autonomic disorders, migraine headaches, jaw pain and spasm, hyperhidrosis, and involuntary movement disorders. Recently, it has also been used in the morbidly obese to decrease hunger, in those with peptic ulcer disease to decrease gastroesophageal reflux, in those with vaginismus and dyspareunia to improve quality of life, in those with anal fissures resulting from a variety of lower gastrointestinal disorders, and in infants born with clubfoot as a potential method of nonsurgical treatment. It appears that novel uses are being

Five-step neck lift: integrating anatomy with clinical practice to optimize results.

Background: A harmonious and youthful appearing neckline is arguably the most vital aspect of a successful facial rejuveation. Without sound principles, the neck appears skeletonized, tethered, and hollow. The anatomical studies that the authors have performed regarding the neck, jowl, and subplatysmal elements have influenced the techniques that they now use. The authors’ approach modifies the classic techniques of the past, and seeks a nuanced approach to each patient by resuspension and reshaping of deeper neck elements. Methods: In this article, the authors apply their anatomical research and cadaveric studies to demonstrate and support their neck-lift techniques. The authors integrate their knowledge to describe how the technique of one of the senior authors (R.J.R.) has evolved over time. Results: The main tenets of the authors’ approach have evolved into a sequence that involves skin undermining over the neck and cheek, submental access to the neck, with possible excision of fat and midline plication of the platysma with release of the muscle inferiorly, platysmal window suspension laterally, precise release of the mandibular septum and ligament if needed, and finally redraping of the superficial musculoaponeurotic system (SMAS) by plication or SMASecomy. These five steps ensure correction of jowling, a smooth jawline, and a well-shaped neck. Conclusions: The five-step neck lift helps to optimize results in creating the ideal neck contour. The authors provide four points that should be considered in any neck-lift procedure. The end result is a well-defined, well-contoured neck, with an approach grounded in sound anatomical principles.