Michele Pascali

Adipose-derived stromal vascular fraction cells and platelet-rich plasma: basic and clinical evaluation for cell-based therapies in patients with scars on the face.

BackgroundActually, autologous fat grafts have many clinical applications in breast surgery, facial rejuvenation, buttock augmentation, and Romberg syndrome as well as a treatment of liposuction sequelae. ObjectiveThe aim of this article was to describe the preparation and isolation procedures for stromal vascular fraction (SVF), the preparation of platelet-rich plasma (PRP), and the clinical application in the treatment of the scar on the face. MethodsTen patients with burns sequelae (n = 6) and post–traumatic scars (n = 4) were treated with SVF-enhanced autologous fat grafts obtained by the Celution System. Another 10 patients with burns sequelae (n = 5) and post–traumatic scars (n = 5) were treated with fat grafting based on the Coleman technique mixed with 0.5 mL of PRP.To assess the effects of their treatment, the authors compared their results with those of a control group consisting of 10 patients treated with centrifuged fat. ResultsIn the patients treated with SVF-enhanced autologous fat grafts, we observed a 63% maintenance of contour restoring after 1 year compared with only 39% of the control group (n = 10) treated with centrifuged fat graft (P < 0.0001). In the patients treated with fat grafting and PRP, we observed a 69% maintenance of contour restoring after 1 year compared with that of the control group (n = 10). ConclusionsAutologous fat grafting is a good method for the correction of scars on the face instead of the traditional scar surgical excision.

Septal crossbar graft for the correction of the crooked nose

&NA; Surgical management of the crooked nose still constitutes a problem that is difficult to solve because of the possibility of recurrence and the risk of weakening the supporting structures. The authors propose an innovative surgical technique for the correction of this deformity that takes into account both aspects of the problem. The technique combines septoplasty by means of staggered intracartilaginous incisions with the original positioning of a unilateral spreader graft. Once realignment of the devi ated cartilages is achieved, this cartilaginous stent, re ferred to as a “crossbar graft,” makes it possible to keep the mobilized axis firmly in the correct position over time. This graft is also quite effective from a functional point of view in restoring the correct angle of the internal nasal valve. Moreover, the technique allows for the harmoniza tion of the aesthetic line from the eyebrow to the tipdefining point on the concave side with the same line on the other side. (Plast. Reconstr. Surg. 111: 629, 2003.)

The use of spreader grafts in primary rhinoplasty

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of “narrow nose syndrome” (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.

An original application of the Endotine Ribbon device for brow lift.

Background: Correction of brow ptosis and lateral temporal laxity is one of the goals of surgical rejuvenation of the aging face. The Endotine Forehead (Coapt Systems, Inc., Palo Alto, Calif.) device is an effective bioabsorbable fixation tool for forehead and brow-lift procedures. However, the Endotine Forehead device alone is not able to correct lateral brow ptosis and temporal laxity. In this article, the authors propose an innovative use of another special device, the Endotine Ribbon (Coapt Systems), to provide long-lasting results in lateral brow-lift surgery and temporal lateral laxity correction. Methods: Between February of 2006 and April of 2007, a total of 30 patients, aged between 38 and 70 years (average, 50 years), underwent brow-lift surgery. With this technique, the Endotine Ribbon is cut in halves and each portion of it is anchored to the deep temporal fascia with sutures, and its multiple tines facing outward grasp the superficial temporal fascia. The amount of brow elevation produced was assessed by comparison of the preoperative and postoperative vertical distances between the superior eyebrow hairline and the midpupil and lateral and medial canthal angle. The average follow-up period was 18 months. Results: Using this technique, perfectly symmetric lateral eyebrows and temporal laxity correction were obtained in all patients. A lasting result was observed, and no significant adverse events were encountered. Conclusions: The application of the Endotine Ribbon for brow-lift procedures provides significant and reproducible lateral brow elevation and temporal laxity correction. This fixation method is effective, safe, and easy to use, and leads to high patient satisfaction.

Medial thighplasty: Horizontal and vertical procedures after massive weight loss

Background: The ‘medial thigh lift’ was first described by Lewis in 1957, but did not receive the widespread acceptance because of the various postoperative complications, such as scar migration with vulvar deformities and early recurrence of ptosis. For this reason, Lockwood developed a technique of anchoring the dermis to the Colles’ fascia, to make the surgical outcome more stable over time and to prevent scar migration. In this article, we describe our approaches to the medial thigh lift in post-bariatric surgery patients. Materials and Methods: A total of 45 females underwent medial thigh reduction. In 15 patients with Grade 2 on Pittsburgh Scale (PS), we performed a thigh lift with a horizontal scar; in 15 patients with Grade 2 on PS, we used a technique with a vertical scar; in 15 patients with Grade 3 on PS, the above-mentioned two procedures were combined. When it was really necessary, we also did the liposuction of the medial thigh. The patients were observed every 6 months with a 60-month median follow-up (range: 12–108 months). Results: In six patients was observed scar enlargement due to poor wound healing (one patient with a horizontal scar, three patients with a vertical scar and two with the combined procedure). In two patients with a horizontal scar, minimal scar migration was observed. In three patients, the recurrence of ptosis was evident (one patient with a horizontal scar and two patients with the combined procedure). No skin necrosis was observed. Conclusion: The medial thigh lift surgery is remarkably simple and free of major complications, if the basic anatomy of this region is understood, in order to preserve important structures such as the great saphenous vein and femoral vessels. The only complication is the presence of extensive and visible scars along the thigh, in the case of vertical procedure, and along the inguinal canal, with a possible distortion of the labia major, in the case of horizontal procedure.

Midface rejuvenation: a critical evaluation of a 7-year experience.

Background: Although “traditional” face-lifting techniques can achieve excellent improvement along the jawline and neck, they often have little impact on the midface area. Thus, many different types of procedures have been developed to provide rejuvenation in this region, usually contemplating various dissection planes, incisions, and suspension vectors. Methods: A 7-year observational study of 350 patients undergoing midface lift was analyzed. The authors suspended the midface flap, anchoring to the deep temporal aponeurosis with a suspender-like suture (superolateral vector), or directly to the lower orbital rim with a belt-like suture (superomedial vector). Subjective and objective methods were used to evaluate the results. The subjective methods included a questionnaire completed by the patients. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury instructed to compare the “critical” anatomical areas of the midface region: malar eminence, nasojugal groove, nasolabial fold, and jowls in the lower portion of the cheeks. The average follow-up period was 24 months. Results: High satisfaction was noticeable from the perceptions of both the jury and the patients. Objective evaluation evidenced that midface lift with temporal anchoring was more efficient for the treatment of malar eminence, whereas midface lift with transosseous periorbital anchoring was more efficient for the treatment of nasojugal groove. Conclusions: The most satisfying aspect of the adopted techniques is a dramatic facial rejuvenation and preservation of the patient’s original youthful identity. Furthermore, choosing the most suitable technique respects the patient’s needs and enables correction of the specific defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical treatment of frontoethmoidal encephalocele: a case report.

&NA; This study reports a patient affected by congenital frontoethmoidal encephalocele. The cause of this malformation is unknown. A preoperative selective diagnosis evaluation is necessary. The workup should include an accurate clinical examination associated with radiological study (two‐ and three‐dimensional computed tomography, magnetic resonance imaging, etc). The aim of the surgical treatment is to restore the functional brain tissue in the cranial cavity, perform dural repair, correct bone lack and other associated facial malformations (hypertelorism, orbital dystopia, etc.). A multidisciplinary team approach is necessary to resolve the brain herniation and to correct splanchnocranium malformations frequently associated with encephalocele. Cranial flap with orbital osteotomies has been performed; this operation permits correction of the hypertelorism and of the orbital dystopia associated with this malformation. In bone reconstructions, miniplates have been used as fixation devices. In adults we generally use titanium, but resorbable devices are required in children because of growing tissues. A restoration of craniofacial malformations with good aesthetic and functional results is achieved with early surgery.

Vertical Midface Lifting with Periorbital Anchoring in the Management of Lower Eyelid Retraction: A 10-Year Clinical Retrospective Study

Background: Lower eyelid retraction can be the unfortunate result of aesthetic surgery, trauma, disease, or the aging processes. The purpose of this article is to assess whether midface lifting based on purely vertical repositioning constitutes an effective procedure for its correction. Methods: A retrospective study was carried out on 199 patients (311 eyelids) operated on between January of 2004 and January of 2014. The various causes of eyelid retraction in this population included cosmetic blepharoplasty (56.8 percent), involutional ectropion (23.1 percent), tumor resection (9.5 percent), facial nerve paralysis (8.5 percent), and trauma and related surgery (2 percent). The study was restricted exclusively to cases of moderate and severe lower eyelid retraction addressed by means of midface lifting. The mean follow-up time was 16.8 months. All of the patients were subjected to midface lifting with strengthening of the lateral canthus. A spacer graft was also used in 37.7 percent of the cases. Results: One hundred ninety-five patients (97.9 percent) displayed objective improvement of the eyelid retraction and a marked degree of improvement both in aesthetic terms and as regards the functional disorders reported. Only four patients (2 percent) presented complications such as needing another operation. Conclusion: Midface lifting based on purely vertical repositioning makes it possible to recruit a considerable amount of “new” skin at the lower eyelid, thus ensuring a decrease in vertical distraction and correct recovery of the height of the external lamellar plane. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reshaping of the Anterior Nasal Spine: An Important Step in Rhinoplasty

Background: The importance of analysis of the nasal spine should not be underestimated in the correct planning of rhinoplasty. Deformations in position with respect to the midline and/or in size are often present, and their correction to ensure harmony between the spine and the other components of the nasal pyramid constitutes a key step in rhinoplasty that can lead to excellent results. Methods: The study includes 160 patients who underwent surgical treatment of the anterior nasal spine with or without other techniques of nasal reshaping. Eighty-seven of these patients presented with hyperplasia of the nasal spine, 43 with hypoplasia, and 30 with deviation. A combination of deviation and hyperplasia was present in 15 cases. Results: No patients developed postoperative complications. Five patients who underwent anterior nasal spine reduction reported postoperative numbness in the premaxillary area, but sensitivity was fully regained within 4 months after surgery in these patients. All the patients reported postoperative improvement of nasal airflow. A total of 142 patients considered their postoperative aesthetic result as excellent and 18 as good. Conclusion: The simplicity of the surgical procedures performed on the nasal spine and the marked aesthetic improvements thus achieved suggest that greater attention should be paid to this anatomical region.

Comparison among three different fixation techniques in temporal brow lift surgery.

Introduction:The eyebrow lifting with temporal approach is an increasing widespread technique. Many surgical procedures are described, but the long-term stability is dependent on the effectiveness in the fixation of elevated tissues. The authors compared 3 different fixation techniques in temporal brow lift. Methods:Forty-five consecutive patients aged between 33 and 70 underwent brow lift surgery with temporal approach. Patients were divided into 3 groups; in group 1, anchorage was performed with Endotine Ribbon, group 2 with a Mersilene mesh, and group 3 with a Prolene suture. The amount of brow elevation was assessed comparing the distance between interpupillar line and superior eyebrow hairline, measured at the midpupil and at the lateral and medial canthal angle. The follow-up was 1 year. Results:All patients had a pleasant improvement in brow shape. The average initial brow position was 19.84 mm near the head of the eyebrow area, 20.74 mm at the body, and 19.57 mm in the region of the tail. A progressive recovery and a partial relapse regarding the eyebrow body (23.88 mm at 6 months and 23.02 mm at 1 year) occurred, but overall for the lateral region, it passed from 27.53 mm at 6 months to 25.80 mm after a 12-month follow-up. Final brow position was dependent upon surgical technique used in fixation. Discussion:Different options in brow elevation and stabilization affect the final shape and position of the brows. From the statistical analysis, mesh suspension provided the best results in terms of long-lasting stability. Level of evidence:Therapeutic III