Lawrence S. Bass

Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations.

Summary: Restoring volume in the middle and lower portions of the face is becoming an indispensable component of modern facial rejuvenation. Radiesse (BioForm Medical, San Mateo, Calif.) is an injectable filler material composed of synthetic calcium hydroxylapatite microspheres (30 percent) suspended in an aqueous carrier gel (70 percent). At present, Radiesse is indicated in the United States for correction of moderate to deep nasolabial folds and for correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. Its off-label use in other facial aesthetic indications is widely reported in the literature. The ability of Radiesse to provide immediate and durable effects has fueled interest in its use for expanded aesthetic applications, particularly in the middle and lower face. The authors’ consensus panel, consisting of a cross-section of experts in plastic surgery, facial plastic surgery, and dermatology, was convened to review the scientific literature and compare clinical experiences regarding the use of calcium hydroxylapatite. This report describes the characteristic effects of aging in the middle and lower face and reviews the composition of calcium hydroxylapatite, its safety and durability, and its appropriate use in a variety of facial applications, including nasolabial folds, correction of human immunodeficiency virus–associated lipoatrophy, augmentation of the malar, submalar, and zygomatic regions, and correction of oral commissure defects, marionette lines, and prejowl sulcus. Recommendations for Radiesse use in each area, including anesthesia, and injection techniques are provided. Measures for enhancing patient comfort, anticipating and minimizing potential complications, and optimizing aesthetic results are also discussed.

Erbium:YAG laser skin resurfacing : Preliminary clinical evaluation

Each of the increasing number of resurfacing lasers uses a unique strategy to produce tissue ablation. Erbium:YAG (Er:YAG) lasers have been used in other applications for precise tissue removal with little thermal effect. Recovery time, duration of erythema, and clinical improvement were evaluated using an Er:YAG resurfacing laser (2.94-microm wavelength, 350-microsec pulse, 2 J, 3-5-mm spot). Twenty-five patients were treated with two passes to the full face and 3 to 5 passes to the most affected aesthetic unit. At each follow-up visit, percent epithelialization, erythema, and swelling were graded, and the presence or absence of complications was noted. Clinical improvement was evaluated at 6 months by optical profilometry on a subset of patients. Er:YAG resurfacing produced a transient whitening of dermis followed by a resumption of pink appearance. The surgical end point was judged by elimination of visible rhytids or presence of punctate bleeding. Bleeding from the dermal surface was encountered less than customarily in dermabrasion, but more than seen with carbon dioxide laser resurfacing. A moderate amount of tissue shrinkage was observable during the treatment. Mean period to full epithelialization was 6.9+/-0.97 days (range, 5-9 days). The mean duration of erythema (4.24+/-1.5 weeks) was relatively short compared with carbon dioxide resurfacing. Clinical improvement was 44+/-30% in the lateral canthal area and 55+/-22% in the upper lip area. There were no infections or hypertrophic scars. Hyperpigmentation and hypopigmentation was seen in 24% and 12% of patients respectively. Er:YAG resurfacing is a reliable means of obtaining rhytid improvement with less recovery time and duration of erythema compared with carbon dioxide resurfacing. The technique is significantly different from carbon dioxide resurfacing in selection of end point, number of passes, and energy settings.

Balloon Assisted Endoscopic Harvest of the Latissimus Dorsi Muscle

&NA; In this study, we present our experience with balloon assisted endoscopic harvest of the latissimus dorsi muscle for extremity reconstruction. The balloon performs most of the dissection under the muscle and creates the optical work space used in the endoscopic dissection. Over the course of this series the operative time has been reduced and averaged 2 hours and 44 minutes. The reconstructive goals were met in all cases. The average axillary incision length was 5.6 cm, and there were an average of 1.3 onecentimeter or smaller counter incisions. (Plast. Reconstr. Surg. 100: 1161, 1997.)

Microvascular anastomoses utilizing new intravascular stents

Evolving microsurgical technique has allowed for the anastomosis of smaller diameter vessels. Standard suture anastomoses cause a measure of stenosis and intimal damage during application and therefore cannot be dependably used in the anastomosis of very small vessels. We developed and tested a fibrin glue–based anastomosis applied over a meltable stent made of mono- di- and tri-glycerides. In vivo rodent studies using the 0.35 mm diameter inferior epigastric artery have shown immediate and short-term patency rates better than those associated with suture technique. The stent technique is significantly faster and easier than the suture technique. The glyceride stent method suffers from decreased late patency due to aneurysm formation. In addition, we developed a glyceride-coated polyethylene glycol–based stent for use in lasered anastomoses. Work on both projects is ongoing.

Rejuvenation of the aging face using Fraxel laser treatment

According to the author, Fraxel laser treatment produces the resurfacing effects of tissue removal, treats pigmentary changes, improves rhytids, and stimulates tissue remodeling. Compared with other classical approaches, it has the advantages of no recovery time, no open wound, few nonresponders, few complications, and the ability to be used in all skin types. Data confirm that improvement with this treatment is substantial but is not yet well defined quantitatively in comparison with laser resurfacing.

Influence of steroids on postoperative swelling after facialplasty : a prospective, randomized study

Steroids are widely used in facial aesthetic surgery to reduce postoperative edema. We performed a randomized, double-blind study to try to document the effectiveness of this practice. Fifty consecutive facialplasty patients of one surgeon were randomized to steroid and no steroid groups. Steroid group patients received betamethasone 6 mg IM preoperatively. Postoperative scoring of swelling was performed at approximately days 5 and 9 by a single observer. There were no significant differences between the two groups at either postoperative interval or in the rate of improvement. Subgroups of patients who underwent additional procedures also showed no significant differences. We were not able to demonstrate any statistically significant difference in swelling after facialplasty with this steroid regimen.

New Technologies and Future Applications of Surgical Lasers: The Right Tool for the Right Job

The real future of surgical lasers, and indeed of surgery itself, will depend on the integration of the surgeon into a system incorporating real-time tissue sensors, computer-directed robotic manipulation, and laser-tissue interactions that are customized to the clinical task. The human surgeon will operate as the central judgmental element in this mechanized and semiautomated laser surgical system. Only then will we really be able to make use of the subtle and varied laser-tissue effects now being discovered.

Feasibility studies for laser solder neurorrhaphy

We present a novel technique of nerve repair attempting to reduce scarring and improve alignment. A laser solder composed of albumin, hyaluronate, and indocyanine green dye (peak absorbance 805 nm) was used. After applying solder to the anastomotic site, nerve ends can be precisely aligned and sealed in place using an 810 nm diode laser. Transected sciatic nerves in the rat were used as the experimental model. Laser repairs had approximately half the immediate strength of suture repairs (130 vs 280 g/cm2) but comparable strength by 7 days (270 vs 250 g/cm2). There was no dehiscence in either group. Thermal damage was confined to the solder and epineurium. At 90 days there was no difference in nerve conduction values or axon counts in suture or laser repairs. Histology was suggestive of a later stage of regeneration in the laser group. Laser soldering produces increased strength compared with traditional laser welding with less thermal injury.

Injectable Filler Techniques for Facial Rejuvenation, Volumization, and Augmentation

Multiple fillers are available: various hyaluronic acid products, calcium hydroxylapatite, and a few others that are biocompatible with good duration and a variety of mechanical properties allowing intradermal, subdermal, and supraperiosteal injection. Facial features can be reshaped with great control using these fillers. Aging changes, including facial volume loss, can be well-corrected. These treatments have become a mainstay of rejuvenation in the early facial aging patient. Injection technique is critical to obtaining excellent results. Threading, fanning, cross-hatching, bleb, and pillar techniques must be mastered. Technical execution can only measure up to, but not exceed, the quality of the aesthetic analysis.

New stent for laser microanastomosis

We have developed a stent specifically for use in the laser welded anastomosis of small blood vessels (outer diameter 0.8 - 1.2 mm). The stent consists of a core composed of a 50% (v/v) mixture of polyethylene glycol 4000 and polyethylene glycol 20,000. This mixture (PEG 4/20), is covered with a coating of mono/diglyceride. Among the properties of PEG 4/20 is a melting point of 60 - 70 C and a high solubility in water. The glyceride portion of the stent has a melting point of 36.0 - 38.0 C and is insoluble in water. The PEG 4/20 center provides a rigid frame to the stent for easy insertion into the artery, while the glyceride component prevents early dissolution. Upon the application of laser energy, the glyceride coating melts and the PEG 4/20 center remains intact until completion of the anastomosis. Following laser anastomosis, the blood flow through the repaired vessel dissolves the PEG 4/20 center leaving no trace of the stent. We have used these stents successfully in pilot studies utilizing an indocyanine green laser solder with an 810 nm diode laser (gallium-aluminum-arsenide).