Joel J. Feldman

The medial gastrocnemius myocutaneous flap.

Our experience with the medial gastrocnemius myocutaneous flap is presented. We have found it to be a reliable flap which can be transferred in one stage to solve difficult coverage problems about the knee and upper leg.

The λϕ 3 4 field theory in a finite volume

The unnormalized doubly cutoff Schwinger functions converge as the ultraviolet cutoff is removed. The limits, the finite volume unnormalized Schwinger functions, are tempered distributions and areC∞ in the coupling constant. They have asymptotic expansions given by perturbation theory. For λ sufficiently small they can be normalized and then they are the moments of a measure onI′ℝ(IR3).

Neck lift my way: an update.

Background: The author updates prior descriptions of an approach to the surgical neck lift that aims for a maximum degree of control over the size, shape, and position of every anatomical feature of the neck that is negatively affecting its appearance. Methods: A 38-year clinical experience guided the development of the operative tactics that define the strategy. Data collected from a records review of 522 consecutive neck lifts performed during the 10-year period 2004 through 2013 further inform the report. The approach has eight features: (1) nearly routine use of open submental access to all tissue layers of the central neck, including a regimen that curbed the problems that may attend an extensive tissue dissection; (2) management of lax neck skin by lateral excision using a specific postauricular incision, or by using the nonexcisional method of redistribution; (3) open lipectomy for precise removal of excess subcutaneous neck and jawline fat; (4) individualized modifications to subplatysmal fat, perihyoid fascia, and anterior digastric muscles; (5) treatment of large, ptotic, or malpositioned submandibular salivary glands by partial excision using a transcutaneous traction suture; (6) the current version of the corset platysmaplasty, which is used to treat static paramedian platysma muscle bands, and to avoid contour imperfections following subplatysmal maneuvers; (7) an approach that facilitates an isolated neck lift; and (8) durable results. Results: Case examples demonstrate outcomes. Conclusion: Although the updated approach remains relatively complex and invasive, the author believes that the ends justify the means. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Symmastia: the problem of medial confluence of the breasts.

This paper presents the problem of medial confluence of the breasts producing a web across the midline. Significant references in the literature dealing with uncommon clinical problems are virtually nonexistent. The purpose of this paper is to stimulate discussion of this entity and its surgical management and to propose the term symmastia to facilitate retrieval of information about this entity in the future. Two cases that highlight the central problem but which differ in the specifics of the surgical approach are presented. In the first case, the medial web was corrected by elevating an inferiorly based triangular skin flap that was advanced superiorly in an inverted Y-V manner after the excess medial soft tissue was divided and sutured superiorly to the medial pectoralis fascia to create a brassiere-band sling effect. In the second case, a superiorly based medial flap containing both skin and soft tissue was elevated. The excess skin and soft tissue were then excised. The remaining flap was tailored to fit into a V-shaped defect in the inferior incision to place the scar in a less viable place inferior to the sternum. The relative advantages of the two surgical approaches are discussed and a third approach based on the strengths of the two approaches is suggested. This approach would consist of the vertical division and superior rotation of the excess subcutaneous tissue flaps and the elevation of a superiorly based skin flap inserted into a V-shaped defect in the inferior incision.

Cervical Contouring in Face Lift

James M. Stuzin, MD Joel J. Feldman, MD Daniel C. Baker, MD Timothy J. Marten, MD Dr. Stuzin: The first patient is a 45-year-old woman who is concerned about the solitary platys-ma band in the right side of her neck (Figure 1). Dr. Baker, how would you approach treating this patient? Dr. Baker: I see very few options. She has overtreated skin, minimal facial aging, and very little neck fat. I would avoid operating on her. Dr. Stuzin: Dr. Feldman, how would you evaluate this patient? Dr. Feldman: Her neck looks good except for that short platysmal band that bothers her, but she also appears to have an enlarged right submandibular salivary gland. I would free the medial edges of the platysma from the superficial fascia, undermine the muscle to the anterior gland capsule, open the capsule, and, using the electro-cautery, take out just enough of the superficial lobe to flatten the bulge. It appears that there is no need to remove subplatysmal fat. I would repair the platysma with a full corset platysmaplasty to cover the entire anterior neck with a smooth sheet of muscle and, of course, eliminate the muscle band. I would undermine the neck skin flap widely enough to redistribute the skin so that none of it would need to be removed. Dr. Stuzin: Do you believe you could do that effectively and safely through a submental incision? Dr. Feldman: Yes, I would use only the submental incision. Dr. Stuzin: Dr. Marten, how would you approach treatment? Dr. Marten: This patient has a severe, unnatural look and overtreated skin. Her eyebrows are shaved and penciled in higher, hiding her forehead pto-sis. She has lower lid retraction, midface laxity, and scant submental fat, which suggests she has had prior submental lipoplasty. I agree that she has a …

Revisional neck surgery

Dr. Pitman: The first patient is a 61-year-old woman who is seeking rejuvenation of her face and neck (Figure 1). Fourteen years ago she underwent a superficial musculoaponeurotic system (SMAS)–platysma face and neck lift and lipoplasty of the neck. Dr. Aston, how would you treat this patient? Figure 1 This 61-year-old woman is seeking rejuvenation of the face and neck. Fourteen years ago she underwent neck lipoplasty and SMAS-platysma face and neck lift. Gerald Pitman, MD Dr. Aston: I see laxity in the lower portion of her face. In the front view, I see prominent labiomandibular folds and platysma laxity under the chin that does not appear to extend down to the first cervical crease. In the three-quarter and profile views, I see some laxity along the jawline and in the jowl area, so she would benefit from a secondary face lift. Sherell J. Aston, MD In the grimace view, there is some weakness of lower lip depressor function on the left evidenced by diminished pull down of the left lower lip and less dental show on the patients left side. We do not know what work was initially done to her face. However, work on the anterior neck surface with platysma plication, or dissection in that area, could obviously damage the marginal mandibular branch. The damage could have occurred with a lateral platysma SMAS dissection. Dr. Pitman: She had lipoplasty of the anterior neck and lateral SMAS elevation. Dr. Aston: Then I suspect the damage was connected with undermining of the SMAS platysma flap. Dr. Pitman: Would the past injury influence your present approach? Dr. Aston: Not really. I would counsel her, pointing out that she has lower lip weakness along with platysma laxity, making absolutely sure she understood. I would be aware of the weakness when dissecting, but it would …

Discussion: A 26-year experience with vest-over-pants technique platysmarrhaphy.

I 1973, Rees and Wood-Smith1 described a sideways overlap of the upper medial platysma muscles to treat paramedian bands. In 1998, Fuente del Campo2,3 presented a modification. Now, there is this report of a 26-year experience using another version. I can certainly understand the appeal of the double-breasted submental platysmaplasty described in this article. It is relatively quick and easy to perform, and avoids the possibility of a midline ridge that may attend a midline approximation of the muscle edges. In addition, in the group of patients looked at, the authors identified not a single recurrent platysma band; and for them, there were no other shortcomings of the technique worthy of discussion. As presented, therefore, this method might seem to be a simple and nearly foolproof platysmaplasty that can solve every problem in every neck. Nevertheless, although I do not question its usefulness in some necks, I must admit that I do not understand why it worked as well as it reportedly did in so many necks. All I can do is pose some questions. My first question is fundamental: What is it that causes a static paramedian platysma band? I have long postulated that a medial platysma edge that is left separated from its partner on the other side of the midline will eventually sag along with its overlying skin to form a visible band—and that will occur sooner rather than later if the platysma edge retaining ligaments become loose, the enveloping superficial cervical fascia becomes flimsy, and the attached overlying skin becomes flaccid. In support of that notion, Vistnes and Souther4 observed that platysma bands typically form caudal to the level of a naturally occurring upper midline muscle decussation. The same reasoning has led me to believe that it is an unapproximated and poorly supported muscle edge that becomes a recurrent band after a previous neck lift. If that scenario is correct, why is it that not a single platysma band was identified postoperatively in any neck that had a suprahyoid vest-over-pants overlap that left the infrahyoid platysma edges just as separated and vulnerable as they were before surgery? We all know that at least an occasional platysma band recurs after every other anterior platysmaplasty caudal to the level of muscle approximation or overlap, so why not after this particular submental overlap? I wish I knew. Could it be that those evaluating the postoperative results missed seeing a platysma band in some cases? Might there even be the slightest hint of a submental platysma edge present on the postoperative profile view of the first three of the four patient examples provided in this article (Figs. 2 through 4)? With just a frontal view and that one side view for the reader (me included) to evaluate—without also seeing the other profile view, and the oblique views, and preferably also a photograph of the neck with the head tilted back—it is hard to be certain one way or the other. I know that in the postoperative photographs of my own patients, I often see a perfect neck on the frontal view, and a perfect or near-perfect result in one of the two side views, only to detect an imperfection (which might be a recurrent platysma band) in one of the oblique views or on the contralateral profile view. I also found confusing the description of the process used to select cases for inclusion in this study. Why was it that 88 charts were “randomly selected” from a period of 8 years (1999 to 2006) for evaluation, rather than a nonrandom evaluation of every relevant case during the entire 26year experience under consideration? Why were patients younger than 30 years excluded—even though there were probably relatively few of them? And why were patients who were photographed at less than 8 months after surgery excluded entirely from the study? What if some of those patients had

A minimally invasive approach for correction of chin ptosis.

Although ptosis of the tip of the chin is common and can be seen in persons of any age, it is frequently seen in older patients seeking facial rejuvenation. A variety of techniques have been described to correct ptosis of the chin. The authors describe a minimally invasive method that can be used correct chin ptosis. This technique uses a small intraoral incision to place a U-shaped Prolene suture that gathers the soft tissue of the chin and elevates it above the lower border of the mandibular symphysis. A retrospective review of 314 cases performed in conjunction with face lifts between January of 1994 and January of 2000 was performed to evaluate this technique. There were no significant complications, and long-term results have been very satisfactory and lasting.