Jennifer L. Walden

An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection.

BACKGROUND Approaches for exposure of the muscles of brow depression include transpalpebral, endoscopically assisted, and open coronal techniques. The purpose of this anatomical study was to compare the capacity for visualization and amount of brow depressor muscle resection with each technique. METHODS The corrugator supercilii, depressor supercilii, medial orbicularis oculi, and procerus muscles were studied by gross anatomical dissection carried out on 24 sides of 12 cadaver heads. First, all visible corrugator and depressor supercilii muscles were resected by means of an upper blepharoplasty incision. Subsequently, a subgaleal endoscopic approach was used to evaluate the extent of resection performed and remove the remaining muscle after transpalpebral corrugator resection. This was followed by coronal exposure to assess the anatomical location and extent of muscle resection accomplished by the two previously mentioned techniques. RESULTS In all dissections, endoscopy demonstrated that up to one-third of the lateral aspect of the transverse heads of the corrugator supercilii remained following transpalpebral resection. Oblique corrugator head resections were complete, without significant residual muscle following transpalpebral corrugator resection. The procerus muscle was able to be blindly transected by means of the transpalpebral incision but exposed and ablated in all 12 specimens using endoscopy. Coronal exposure demonstrated that no significant amount of corrugator, depressor supercilii, or procerus muscle remained in any of the 12 heads following endoscopically assisted exposure and resection. The medial head of the orbital portion of the orbicularis oculi was visualized and accessible regardless of the technique used. CONCLUSIONS In 24 anatomical dissections, transpalpebral corrugator resection failed to remove up to one-third of the transverse head of the corrugator muscle. Removal of the brow depressor muscles was accomplished with the endoscopic approach, as confirmed by coronal exposure.

Current methods for brow fixation: are they safe?

BackgroundNo single technique for fixation of the scalp after forehead-lift is universally accepted. Complications such as alopecia, loss of elevation, implant palpability, paresthesia, and dural injury are possible with the variety of techniques used currently. This anatomic study was designed to evaluate the thickness of the calvarium at selected points used in brow fixation. The depth of cranial penetration necessary for currently used techniques is measured and compared.MethodsIn a study of 14 fresh adult cadavers, calvarial thickness was measured at selected points (A–F) used in various brow-lifting procedures. This was accomplished by drilling holes in selected points and using a depth gauge to measure thickness. Immediately adjacent to selected points, the cranium is prepared for brow fixation using the following techniques: cortical tunnels, 2.0-mm screw fixation (10, 12, and 14 mm), the Mitek 2.0-mm Quickanchor screw, and the Endotine 3.5 Forehead Device. The depths required for adequate fixation and the potential for cranial penetration through the inner table with all the standard techniques are compared.ResultsDepth analysis by mean values showed that sites posterior to the coronal suture (points C–F) were thickest. Depth analysis of sites stratified by gender showed that mean values for the thickness of female skulls were greater than those for males. A review of fixation methods found that cortical tunnels at 45° angles never penetrated the inner table in any of the 14 skulls. Mitek screws never penetrated the inner table, and one Endotine post penetrated the inner table on the left side of one cadaver skull. After placement of 10-, 12-, and 14-mm miniscrews at each of the sites, it was found that three penetrated the inner table. The penetrations all were at far lateral sites, posterior to the coronal suture.ConclusionVariation in skull thickness exists among cadaver specimens at different sites on the skull. In this study, thickness increased medially and posteriorly. Women tended to have thicker skulls than men, and age was not a major variable. This is consistent with findings in previous work. Given the unpublished reports of inner table penetration, with cerebrospinal fluid leak after invasive brow fixation, it behooves the surgeon to keep in mind the anatomy of the calvarium and its nuances.

Career development resource for plastic and reconstructive surgery

Plastic surgery is a broad-based discipline with emphasis on areas such as breast, craniomaxillofacial, burn, aesthetic, and hand surgery as well as complex wounds and wound healing. Plastic surgery as a specialty captures a great deal of media attention over many other fields of medicine, so education, training, and credentialing have become an area of national interest. The purpose of this article was to provide information on the organization, basic requirements for training, fellowship, and volunteer opportunities within the specialty.

Amazia with Midface Anomaly

This is an interesting case report of amazia in a syndromic patient. Amazia itself is a rare condition and should be reported in the literature when seen. The facial features of this patient included nasomaxillary retrusion, class 3 malocclusion, and absence of the anterior nasal spine. The skeletal anomalies included camptodactyly, scoliosis, and thoracic vertebral abnormality. Although the described facial features of the reported patient are somewhat similar to those of a patient with Binder syndrome, the absence of the anterior nasal spine is alone insufficient for a diagnosis. Binder syndrome has been described to include findings of nasomaxillary hypoplasia, a convex lip, a vertical nose, no frontonasal angle, no anterior nasal spine, and hypoplastic frontal sinuses attributable to a disturbance of the prosencephalic induction center at a critical phase in development. Binder [1] also described (and the authors note) that the syndrome also is associated with anomalies of the cervical spine affecting the atlas and axis without known clinical sequelae. The key feature is a flat nose with a short columella and maxillary hypoplasia, which the reported patient does not have. Isolated congenital absence of the breasts is a rare congenital anomaly sometimes associated with ectodermal dysplasia, and may be attributable to interference with the persistence of the mammary ridges, hereditary situations, teratogens, and failure in the development of the lower cervical and upper thoracic spine affecting the embryo [2]. It is therefore understandable how a syndrome that affects the embryologic development of central bony and soft tissue structures, including the upper vertebrae, may be associated with interference of future breast development. It would be interesting to know how many young girls with craniofacial defects and syndromes go on to have some type of disturbance in breast development, unilateral or bilateral. I suspect that the incidence may be higher than reported in the literature, yet in our craniofacial centers, we are focusing on the diagnosis and treatment of facial deformities (with the majority of care focused on the prepubertal years). Trier also notes in his article that bilateral absence of the breast also has been associated with cleft palate, high-arched palate, and congenital digital defects. To date, about 22 cases of congenital bilateral breast absence have been reported, with varying presentations. The authors offer another important contribution to the literature with this case of bilateral congenital amazia in a syndromic patient. On a technical note, breast reconstruction for the patient with amazia or amastia can be challenging. A difficult aspect of such surgery is reconstruction of a normal-appearing breast with its distinctive shape of the sloping upper pole, full lower pole, and defined inframammary crease (it is even harder to match a normal breast on the contralateral side!). On the preand postoperative photos of this breast augmentation patient, it appears that she does not have any inframammary connective tissue attachments of a traditional inframammary crease. This leads me to wonder how the authors picked the level of the incision at the proposed new inframammary fold? What was the distance of the proposed nipple to inframammary fold? It appears to be longer than 5 to 7 cm and somewhat bottomed out at the lower pole. Although 5 to 7 cm is not a hard and fast rule, it is a good place to start. It appears that the implant Correspondence to Jennifer L. Walden, M.D.; email: drjenniferwalden@hotmail.com Aesth. Plast. Surg. 31:395 396, 2007 DOI: 10.1007/s00266-007-0066-7

Dallas Rhinoplasty: Nasal Surgery by the Masters

Key Features:Presents the work of recognized pioneers in the fieldProvides comprehensive coverage of primary and secondary rhinoplastyCovers basic fundamentals and anatomyPresents the latest refinements and advances in technique for safer, more consistent resultsIncludes new innovations for achieving a smooth dorsum, avoiding alar notching, and improving tip refinementSupplies comprehensive case analyses to facilitate clinical decision makingFeatures 18 new chapters with numerous color images

Definitive Treatment for Crow’s Feet Wrinkles by Total Myectomy of the Lateral Orbicularis Oculi

The accordion-like activity of the sphincteric superficial orbicularis oculi muscle during facial animation leads to folds and wrinkles radiating from the lateral canthus as the muscle shortens while the skin does not. Skin folds in this area and lateral brow ptosis have been technically difficult to improve by standard face-lift and blepharoplasty techniques given the arborization patterns of the terminal temporal and zygomatic branches of the facial nerve that enter the muscle inferiorly and superiorly, thereby maintaining normal function of the portion of the muscle that is not surgically treated. Blepharospasm patients have demonstrated this as the muscle activity is quite persistent in untreated areas. As a result, ancillary methods to improve these stubborn wrinkles that we all know colloquially as ‘‘crow’s feet’’ have evolved over the past 30 years. Cido Carvalho et al. [1] describe a variation on a technique very similar to one published by Viterbo in 2003 [2], except that a more extensive resection of lateral orbicularis oculi (OO) muscle is performed and a SMAS graft if placed rather than a fat graft. The treatment of the OO was initially described in 1974 by Skoog [3], who took the muscle off the temporalis fascia and either split it or splayed it out. My associate, Sherrell Aston, elaborated upon that in 1980 [4], but he left the OO attached to the overlying skin flap after finger dissection of the temporal region when performing a face lift; at that point he either split the muscle or splayed it and sutured it to the temporalis fascia. The advantage of leaving the OO attached to the overlying skin flap and approaching it on its undersurface is obvious: to avoid injury to the temporal branch of the facial nerve (which may occur when resecting and dissecting the muscle from the anterior surface as it lies attached to the temporalis fascia). Cido Carvalho et al. report some transient frontal nerve paralysis and difficulty with eyelid shutting, which is always a stressful situation no matter how long it lasts. Aston noted that muscle ring division and separation of the cut ends reduced folds and wrinkles more than just splaying out the undivided muscle and was ‘‘most useful for the correction of very large skin folds, deep wrinkles, and heavy ptotic lateral brows’’ [4]. Nowadays, in select individuals with hyperactive lateral OO and crow’s feet he usually just cauterizes the lateral aspect with the Colorado needle tip Bovie (Bovie Medical, St. Petersburg, FL) on a coagulation setting of 30, and in about 45 seconds achieves similar results as those displayed by the authors. The authors’ preand postoperative results indeed show decreased muscle activity and it is impressive that this lasts for 5 years; Viterbo’s paper documented only 15 months of follow-up because that was as long as he had been doing the procedure at the time of its publication. The authors should attempt to standardize photographic views better in the future, specifically when demonstrating specific areas of the face and animation views. I also would be interested in knowing if any of the patients sensed any contractile abnormality or differences in the untreated areas of the orbicularis oculi muscle in compensation for an extensive denervated portion laterally; this would be analogous to a blepharospasm patient that I have treated with Botox (Allergan, Irvine, CA) injections along the pretarsal OO of the lower lid who reported a pulling sensation from untreated surrounding areas. J. L. Walden Department of Plastic Surgery, Manhattan Eye, Ear and Throat Hospital, 210 East 64th Street, New York, NY 10065, USA

The Bivectorial Full-Thickness Superiorly Based NAC Flap: A New Option to Increase Plasticity and Decrease Tension in the Superior Pedicle Vertical Mammaplasty Technique

O’Dey et al. [1] describe a superiorly based pedicle for a vertical mammaplasty with bisection of the pedicle for increased superior pole fullness. The superiorly based vertical mammaplasty was described originally by Lassus [2], modified by Lejour et al. [3], and elaborated upon by Hall-Findlay [4]. The main technical variation that O’Dey et al. describe is a horizontal bisection of the superior pedicle to provide a layer of tissue to fold under and tack through the pectoralis muscle to the second or third rib periosteum. The bisected flap offers a twofold purported advantage: (1) to anteriorly displace the more superficial layer of the bisected flap for increased projection and superior pole fullness, and (2) to relieve tension and inferior pull upon closure of the vertical incision on the raised nipple-areola complex. The authors assure us that the vascularity of the nippleareola complex (NAC) is kept intact despite the splitting of the pedicle, stating that the anterior flap should be at least 2 cm thick, even with bisection of the flap in a cephalad direction to the level of the areola opening. The authors do not report any vascular compromise of the NAC and state that breast tissue thickness of 40 mm indicates a minimum of tissue to create the two flaps. The article seems to be the authors’ clinical correlation of a previously published microscopic dissection study of the vascular anatomy of the breast of seven female corpses in the Journal of Plastic and Reconstructive Surgery [5]. It serves to mention that with the inherent variation in the vascular anatomy of the breast (especially in the terminal, more superficial vessels), I would hesitate to base a new reduction technique that involves splitting the pedicle down to the chest wall entirely on a study of seven cadavers. The authors do not mention how large their in vivo series is with this technique and they give only one case example. It would also be useful to know if the authors abort this procedure in certain patients such as smokers, diabetics, or people with vascular disorders. Sometimes I avoid operating on these patients altogether based on medical stabilization, and you could not pay me to split the pedicle in their cases if I did perform the surgery; these are patients in whom tissue resection and pedicle width should be conservative and safe. All of that aside, upon reading this article I was initially captivated by the prospect of better superior fullness without an implant, less tension on the NAC with a superiorly based flap (which I have at times experienced with a superomedial pedicle rotated 45 and closed with a vertical incision), and maximal projection. I could not wait to see the results and do one on my next vertical reduction mammaplasty patient who met the clinical criteria! However, I was soon puzzled. The only set of preand postoperative photos demonstrated a patient with very full and dense-appearing hypertrophic breasts with a dire need for superior pole fullness, but the result left me curious. This prompted me to conduct an informal blinded survey of my colleagues. I asked two aesthetic surgery fellows at Manhattan Eye, Ear and Throat Hospital in New York where I practice and one senior plastic surgery resident from New York University to look at the pre and postoperative photos of the provided patient example who had undergone reduction mammaplasty with the technique. Without giving any other background information, I asked them to examine the photos for a brief moment and tell me J. L. Walden (&) Department of Plastic Surgery, Manhattan Eye Ear and Throat Hospital, 210 East 64th Street, New York, New York 10065, USA e-mail: drjenniferwalden@hotmail.com

A New Method to Quantify the Effect After Subcutaneous Injection of Lipolytic Substances

In my opinion, this is a somewhat scientific study of a somewhat nonscientific trendy procedure. The authors examined three injectable solutions purportedly used in Europe to liquefy fat for weight loss and body contouring. None of these solutions are approved for the use of fat dissolution by the Food and Drug Administration (FDA) in the United States. The authors injected groups of New Zealand rabbits with the three substances, then used three-dimensional (3D) ultrasound confirmed by magnetic resonance imaging (MRI) to quantify the amount of fat loss in the animals’ interscapular fat. The study divided the rabbits into three groups according to the compound used to inject the rabbits. The substances included Lipostabil, the trade name for a compound of both phosphatidylcholine and deoxycholate, which has been used off label for the purpose of subcutaneous lipolysis. The other two groups were injected, respectively, with phosphatidylcholine solubilized in ethanol and Alupent (Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA), which is the trade name for orciprenalin (a substance originally indicated for the treatment of bradycardia and also used in an aerosolized form for the treatment of acute asthma and bronchospasm) [1]. The authors conclude that 3D ultrasonography is a useful and noninvasive way to measure fat decrease in the rabbits, although I am not sure how this would be integrated into clinical practice or if it would even need to be. Clinical examination together with preand postoperative photos suffice for the vast majority of body contouring cases in plastic surgery. Making surface area measurements and using a 3D ultrasound (unavailable to most plastic surgeons, who have insufficient time to perform them and probably would not want to send their patients for them because of the expense) seems onerous. In any case, the gold standard for assessing fatty and soft tissues is MRI, which the authors do use to confirm their findings, adding validity to their article. The authors found that Alupent (or orciprenalin) showed the highest lipolytic effect of the three substances investigated with their animal model. In the United States, the trade name Alupent is another name for metaproterenol sulfate, an adrenergic B-2 agonist–stimulating bronchodilator, which in its aerosolized form is used in the treatment of acute asthma. It also has an oral form called orciprenalin. Product labeling and the Physician’s Desk Reference explain that excessive doses of this medication could result in fatalities, and that even therapeutic doses could cause significant changes in blood pressure as well as nausea and vomiting, tremors, tachyarrythmias, and gastrointestinal disturbance [1]. Needless to say, it serves the authors well to issue the caveat that this drug is used in this study experimentally and should be considered only in in vitro or animal models. With the paucity of data confirming the efficacy and safety of the various lipodissolving methods used in the United States, further study is warranted before the addition of any new drugs or compounds to the already rapidly expanding market of fat solvents that are not FDA approved. It would be ill advised for orciprenalin to be injected subcutaneously (or in an inadvertent fashion intraarterially) in a human subject for the purpose of dissolving fat given the physiologic severity of the possible side effects. Interestingly, however, one of its mechanisms J. L. Walden (&) 50 East 71st Street, New York, NY 10021, USA e-mail: drjenniferwalden@hotmail.com URL: www.drjenniferwalden.com

Aesthetic plastic surgery

(Section Headings): Volume I: General Considerations. Rhinoplasty. Volume II: Blepharoplasty. Aesthetic Surgery of Neck and Face. Facial Contouring and Otoplasty. Breastand Body Contouring