Aponeurotic System Research Articles

Rhytidectomy Associated With Autologous Fat Transplantation in Parry-Romberg Syndrome

Progressive hemifacial atrophy or Parry-Romberg syndrome is an uncommon degenerative and poorly understood condition characterized by progressive atrophy of 1 side of the face. It may involve several layers of tissue manifesting itself in a more or less aggressive form (mild, moderate, and severe). Generally, the restoration of contour and symmetry are the goals of the therapy in patients affected by this syndrome. In this article, we present the technique and the 6-year postsurgery result of a case of Parry-Romberg syndrome treated with 1-stage anterior lifting, removal of superficial muscular aponeurotic system, and autologous fat transplantation because the patient requested to recover more than atrophy and also 20 years of lost youth.

Distally Based Dorsal Nasal Flap in Nasal Ala Reconstruction

The nasal dorsum is a good skin flap donor site for alar reconstructions because of its qualities: appropriate color, texture, and thickness. An anatomic vascular study on cadaver and the clinical use of the dorsal nasal skin flap, inferiorly based on the nasal septal branches, is reported. Vascular anatomy of the nasal dorsum was demonstrated in five fresh-frozen latex-injected heads. Fourteen patients were operated of reconstruction of the nasal ala using an inferiorly based dorsal nasal flap. Nasal septal branches, from the superior labial arteries, give vascular supply to the nasal tip. Connections of these arteries with lateral nasal branches (facial system) and dorsal nasal arteries (ophthalmic system) form a consistent vascular network in the dorsal nasal superficial muscular aponeurotic system and allow to safely raise cutaneous flaps distally based. No total or partial loss of the flaps was observed in clinical use. The donor site was sutured directly in 13 patients and with a skin graft in one. The inferiorly based dorsal nasal flap provides very good cosmetic and functional results and could be considered an additional adequate surgical option for nasal ala reconstruction, especially when skin from the nasolabial fold, upper lip, and cheek is not available. The authors have indicated no significant interest with commercial supporters.

An Analysis of Unsolved Problems of Face-lift Procedures

The face-lift/rhytidectomy, considered a premier surgical procedure in the specialty, is designed to reverse the effects of aging on the face. Yet our understanding of aging is incomplete, for example, only recently has it been recognized that there are different fat compartments in the face: how aging affects these different compartments is not known. Some surgeons consider the baggy lower eyelid to be due to excess fat and remove the fat. Others consider the problem to be due to a weak orbital septum and recommend septal tightening, while recent work suggests that facial bone retrusion is responsible.Furthermore, many different face-lift techniques exist, with each surgeon showing good postoperative photographs. However, the face is a complex 3-dimensional structure with different contours even within an anatomic subunit, and assessment of results by a 2-dimensional photograph must be crude and inaccurate.Also, these articles discuss the surgical maneuvers necessary to achieve the purported result, but do not discuss the mechanics of the procedure. Is there a rationale for considering the SMASectomy better than submuscular aponeurotic system (SMAS) plication, for example? Basic principles of surgical wound healing will be extrapolated in an endeavor to find an answer.This article aims to highlight the divergent opinions, challenge the present thinking of the facelift procedure, and reevaluate the goals and mechanism for achieving this. Ten facets of the procedure will be examined. New methods of assessment of results are required, as photography is inadequate.

Triple Suture for Neck Contouring: 14 Years of Experience

Preferred techniques for rejuvenation and contouring of the neck region have evolved over the past 40 years. A slender neckline is recognized as an attractive feature of youth, whereas aging of the lower face often includes ptosis of the soft tissues of the chin and banding or cording of the muscles of the anterior and lateral neck. Aesthetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. The authors review their 14-year experience with a technique incorporating standard submental liposuction with a method of triple suturing the medial platysmal bands associated with lateral plication of the superficial muscular aponeurotic system (SMAS)-platysma. Between 1994 and 2008, 507 patients (451 women and 56 men) were treated with this technique which consisted of placing a first line of sutures distributing tension between the medial platysmal bands and the anterior belly of the digastric muscles, a second single suture at the distal medial borders of the platysma, and a third running suture starting at the level of the thyroid cartilage up to the supramental region. In most cases, a lateral plication of the SMAS-platysma and a "stair-like" SMAS plication were performed in order to define the cervicomandibular line and treat midface flaccidity, respectively. Mean follow-up was eight years. Complications included hematomas (4.6%) and seromas (3.6%). Four percent of patients underwent a second procedure approximately seven years after their primary procedure. Overall the majority of patients exhibited long-lasting results satisfactory to both patients and surgeons. The triple-suture technique for neck contouring creates a median vertical vector of traction, whereas lateral plication produces a lateral posterior oblique vector. The combination of these two procedures is an easily reproducible and reliable option for surgeons when patients are seeking a more youthful appearance of the neck.

International Interdisciplinary Rhytidectomy Survey

Facial rhytidectomy is a complex and multi-faceted operation performed by different methodologies between practitioners. This study elucidates current international trends in facelift surgery, including patient selection, operative technique, and postoperative care. A 43-item questionnaire was sent electronically to 7247 members of the following societies: ASPS, ISAPS, CSPS, IFFPS, and the AAFPRS. The survey focused on 3 main areas: (a) background information, (b) intraoperative technique, and (c) postoperative care. The response rate was 11.4%. The majority of our population was from the United States (US) (73%). Most (85%) of the respondents have practices where over 50% of their procedures are considered aesthetic surgery. Statistical differences between the uses of minimally invasive adjuvant treatments (thread lifts, endotine mid-face devices, superficial and deep skin resurfacing procedures) were found between plastic surgeons (PS) and facial plastic surgeons (FPS), as well as between US, Canadian, and international surgeons. Suture imbrication (42%) was the most common way of handling the submuscular aponeurotic system. International surgeons were more likely (49.6% vs. 37.7%, P < 0.05) to use this technique than US or Canadian surgeons. Difference in handling patients who smoke and postoperative management differences were also found between the groups queried. No differences were found between FPS and PS in the handling of the submuscular aponeurotic system, treatment of platysmal bands, treatment of ptotic submandibular glands, or treatment of submental fat deposits (P > 0.05). Differences exist between FPS and PS, and between US, Canadian, and international surgeons with regard to facelift techniques and perioperative management. These differences need to be addressed in order to measure outcomes across specialties and between techniques. This data will additionally be helpful for less experienced and younger surgeons who wish to define best practice patterns.

Management of the Midface During Facial Rejuvenation

The endoscopic midface lift procedure has evolved from experience with postreduction soft tissue repair after facial fracture fixation. The procedure elevates and repositions midface soft tissue, which descends with facial aging; as well, it can correct periorbital congenital abnormalities, such as exorbitism and lateral canthal displacement. The procedure has been refined by the senior author to employ a temporal endoscopic approach alleviating the need for a lower eyelid incision. The plane is sub-SMAS (superficial muscular aponeurotic system) within the pre-zygomatic space with release of the zygo-orbicular ligament and the malar retaining ligament. Using an endoscopically placed suture in the malar retaining ligament, the midface and orbicularis oculi are elevated en bloc, with additional selective sutures applied for specific lower eyelid and cheek morphology. Ancillary lower eyelid procedures including skin resurfacing, skin excision, soft tissue augmentation, and a transblepharoplasty septal reset can all be safely applied to the lower eyelid in the same operative setting. All procedures are technically advanced though once executed deliver an exact correction of the midface, which can be combined with both brow and lower face rejuvenation. The procedure offers limited recovery time and few complications as the facial surgeon becomes facile with the technique.

Adaptation of seedsnipes (Aves, Charadriiformes, Thinocoridae) to browsing: a study of their feeding apparatus

Korzun L. P., Érard C., Gasc J.-P. & Dzerzhinsky F. J. 2009. — Adaptation of seedsnipes (Aves, Charadriiformes, Thinocoridae) to browsing: a study of their feeding apparatus. Zoosystema 31 (2): 347-368.The present study describes in detail for the first time the skeleto-muscular system of the jaw and hyoid apparatus (i.e. feeding apparatus) of seedsnipes (Thinocoridae), a small (two genera, four species) South-American bird family the biology and particularly the diet of which are still barely known. Morpho-functional analyses interpreted in the light of presently available behavioural and diet data show a strongly developed adaptation to the removal of attached plant items based on the acquisition of the separate control of jaws. In order to acquire this mechanism and because they are separated in two very different size-classes, large Attagis and small Thinocorus species did not modify the same osteo-muscular structures. Attagis species expanded m. pseudotemporalis superficialis of which they increased the intricacy of the internal aponeurotic system. Thinocorus species evolved a specific orbito-zygomatic process (mainly by expansion and fusion of postorbital and zygomatic processes by ossification of aponeuroses), expanded the medial portion of the external adductor of the mandible and increased the complexity of the aponeuroses of this medial portion. Seedsnipes appear to be well specialized in the continuous removal of small plant fragments thanks to a tongue raising mechanism joint to enlarged salivary glands and crenate areas in the buccal cavity. Thinocoridae seem to have followed a morpho-functional evolutionary pathway similar to that followed by sandgrouse (Pteroclididae) in the course of the adaptation of their bill and hyoid apparatus to a vegetarian diet essentially based on the removal of small attached plant fragments in rather similar habitat conditions.

Endoscopic Treatment of Salivary Gland Injuries due to Facial Rejuvenation Procedures

The purpose of this article is to describe innovative surgical techniques for treatment of salivary gland injuries caused by facial rejuvenation procedures. Between 2001 and 2007, a total of 14 patients, all females ages 46 to 70 who suffered from salivary gland injuries caused by facial rejuvenation procedures, were treated, primarily by an endoscopic-guided technique that involved location of the injury and endoscopic repair. There were four types of postsurgical injuries of the salivary glands that were caused by operations for facial rejuvenation: 1) compression of salivary ducts with temporary swelling (n = 1); 2) laceration of the capsule of the salivary gland (n = 3); 3) stretching and compression of the ducts with penetration of the capsule of the duct leading to sialocele and long-term swelling (types 1 and 2 combined) (n = 5); and 4) complete cut or penetration of the main salivary duct or of one of its main branches resulting in sialocele (n = 5). The endoscopic technique treatment was successful in all cases. The main reasons for salivary gland injuries due to facial rejuvenation procedures in our patients were: poor anatomical identification of the border between the superficial muscular aponeurotic system (SMAS) and the parotid capsule; penetration of the salivary gland capsule by blunt or sharp dissection; unnecessary use of sharp-tip scissors; and a tear of the salivary duct by hooks during a face-lift procedure. Plastic surgeons should be aware of these complications and try to improve their techniques accordingly. To avoid atrophy of the salivary gland, once the diagnosis it made, it is advisable to send the patient to a maxillofacial or ENT surgeon skilled in endoscopy.

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

Evaluation of Facial Allograft Transplantation in Humans in a Cadaver

Shortscar Face-Lift with the RoundBlock SMAS Treatment: A Younger Face for All

Performing a face-lift for smokers, bald people, and those looking for a quick recovery is always a challenge. The submucosal aponeurotic system (SMAS) plication technique with limited undermining provides great suspension and has proved to be a safe and fast way to perform a face-lift surgery. The procedure is a suspension technique for face-lifting based on a purse-string suture around the ear that allows all the soft tissues of the face and neck to be elevated and anchored in the strong structures of the cranial muscles and aponeurosis. This allows a harmonic volumetric repositioning and results in almost no dead space because the circular plication diminishes the surgical undermining when stretched. A total of 225 face-lifts were performed. Because this procedure offers quick recovery and long-lasting results with minimal complications, patients become fearless about face-lift surgery. The RoundBlock SMAS treatment is a suspension method for face-lifts that is safe and fast, results in reduced scars and no dead space, requires no drains, and has a quick recovery time.

Facelift: Measurement of Superficial Muscular Aponeurotic System Advancement With and Without Zygomaticus Major Muscle Release

Facelift: Measurement of Superficial Muscular Aponeurotic System Advancement With and Without Zygomaticus Major Muscle Release

Novel Face-Lift Suspension Suture and Inserting Instrument: Use of Large Anchors Knotted into a Suture with Attached Needle and Inserting Device Allowing for Single Entry Point Placement of Suspension Suture. Preliminary Report of 20 Cases with 6- to 12-M

Various suspension suture techniques exist to elevate the mid-face, jowls, and neck. To assess safety and efficacy of a new suspension suture and inserting instrument with both standard and minimal incision (no-skin-excision) face-lifts. A new type of multianchor suspension suture assembled from commercially available 2-0 absorbable monofilament material, with 5 to 9 equally spaced knots through which are secured 7 to 9 mm bits of 0 thickness similar suture material, and an attached straightened needle, was used to elevate and suspend facial tissues to temporal or mastoid fascia. The suspension sutures are placed in the deep subcutaneous tissues, just above the superficial musculo aponeurotic system (SMAS), by use of a novel, blunt instrument, which does not require a second, distal exit point. The suspension suture distal end floats free. The proximal needle end is sutured to fascia. The suture was used on 20 patients. Fourteen of them underwent pure, "no-skin-excision," suspension lifts. Six had suspension suture elevation of the mid-face in conjunction with relatively conservative open lifts. Nine- to 12-month results were evaluated. With open face-lifts, 9- to 12-month results are excellent with significant persistence of the correction initially achieved. Resulting scars remained fine line. There were no complications. With pure suspension lifts, initial results were impressive. By 6 months, correction started to fade. By 12 months 100% of initial correction for jowls, and 80 to 100% for mid-face, appeared lost. Recovery time was 2 to 4 days. There were no significant complications. Large multianchor, absorbable monofilament sutures can safely and effectively enhance results of conservative lifts, with remarkable elevation of the mid-face not achievable with simple SMAS flaps. These suspension sutures can easily and safely achieve impressive, though relatively short-term results, with a minimal incision, "no-skin-excision" technique.

Novel Face-Lift Suspension Suture and Inserting Instrument

BACKGROUND Various suspension suture techniques exist to elevate the mid-face, jowls, and neck. OBJECTIVE To assess safety and efficacy of a new suspension suture and inserting instrument with both standard and minimal incision (no-skin-excision) face-lifts. METHODS A new type of multianchor suspension suture assembled from commercially available 2-0 absorbable monofilament material, with 5 to 9 equally spaced knots through which are secured 7 to 9 mm bits of 0 thickness similar suture material, and an attached straightened needle, was used to elevate and suspend facial tissues to temporal or mastoid fascia. The suspension sutures are placed in the deep subcutaneous tissues, just above the superficial musculo aponeurotic system (SMAS), by use of a novel, blunt instrument, which does not require a second, distal exit point. The suspension suture distal end floats free. The proximal needle end is sutured to fascia. The suture was used on 20 patients. Fourteen of them underwent pure, “no-skin-excision,” suspension lifts. Six had suspension suture elevation of the mid-face in conjunction with relatively conservative open lifts. Nine- to 12-month results were evaluated. RESULTS With open face-lifts, 9- to 12-month results are excellent with significant persistence of the correction initially achieved. Resulting scars remained fine line. There were no complications. With pure suspension lifts, initial results were impressive. By 6 months, correction started to fade. By 12 months 100% of initial correction for jowls, and 80 to 100% for mid-face, appeared lost. Recovery time was 2 to 4 days. There were no significant complications. CONCLUSION Large multianchor, absorbable monofilament sutures can safely and effectively enhance results of conservative lifts, with remarkable elevation of the mid-face not achievable with simple SMAS flaps. These suspension sutures can easily and safely achieve impressive, though relatively short-term results, with a minimal incision, “no-skin-excision” technique.

Facelift: Measurement of Superficial Muscular Aponeurotic System Advancement With and Without Zygomaticus Major Muscle Release

Multiple authors have sought ways to improve nasolabial folds, jowls, and jaw lines with face-lifting procedures. The retaining ligaments of the face support facial soft tissue in the normal anatomic position. However, with age, gravitational changes occur, and fat descends into the plane between the superficial and deep facial fascia. Face-lift procedures are designed to lift these sagging tissues. To date, the authors have not found a study that quantifies the amount of vertical advancement gain when a face-lift operation is performed with elevation of the superficial muscular aponeurotic system (SMAS). The movement was studied in 22 rhytidectomy SMAS flaps, and measurements of the vertical advancement were compared using two different SMAS patterns. Elevation and fixation of the SMAS was accomplished under the same conditions, and by the same surgeon. A high SMAS elevation was performed after skin and retaining ligaments were released. Precise measurements were obtained at the medial and lateral edges of the SMAS and before and after a backcut release from the zygomaticus major muscle. The results demonstrated an average improvement in medial flap shift gain of 14.04 mm after the release. There were no complications from these measurements during a 16-month follow-up period. The authors believe this is a particularly interesting finding because it demonstrates and quantifies an increased medial SMAS advancement shift with this maneuver, and therefore improves the cosmetic appearance of the jowls and the midface. Excellent aesthetic results were obtained with a high level of patient satisfaction.

Avoiding the “pixie-ear” deformity following face lift surgery by differential insetting and secondary intention healing

The "pixie-ear" deformity has been described by its "stuck-on" or "pulled" appearance, due to the extrinsic pull of the cheek and jawline skin flaps on the earlobe attachment point (O), the otobasion inferius. The tension results in migration of the earlobe attachment point from a posterior cephalad position to an anterior caudal position. Recently, the 2 components of the earlobe, the attached cephalic segment (I to O distance) and the free caudal segment (O to S distance), have been defined. We describe a novel technique involving differential insetting of the cheek and jawline skin flaps to the earlobe and secondary intention healing to create an aesthetically pleasing cephalic attached segment. Rhytidectomy was performed using an extended superficial muscular aponeurotic system (SMAS) technique along with jawline undermining. The earlobe soft-tissue-retaining ligaments to the mastoid were released to the level of the new otobasion inferius to creat a cephalic attached segment less than 1.5 cm, which allowed the caudal free segment to approximate 0.5 cm. Whereas the cephalic segment was directly repaired, the free caudal segment anterior and posterior skin flaps were not reapproximated and were to heal by secondary intention. In a series of 20 consecutive patients, excellent aesthetic results were obtained using this approach without healing complications, hypertrophic scarring, or "pixie-ear" deformity. Our approach for cheek and jawline skin flap fixation to the earlobe eliminates any vector of pull on the free caudal segment of the earlobe and, consequently, any potential for "pixie-ear" formation. We advocate allowing the free caudal segment to heal by secondary intention, which results in the medial edge of the free caudal earlobe attaining a curved and blunt-edged appearance that is aesthetically superior to primary repair.

Seamless Face-Lift with Aptos Thread: The Belo Medical Group Experience

Introduction: Aging is manifested on the face as loss of normal volume and contour in all dimensions. The classic methods of face lifting normally leave unsightly scars, especially on Asian skin. In 1999, M. A. Sulamanidze used Aptos thread to lift soft tissue in both the subcutaneous muscular aponeurotic system and in the supraorbital area, restoring the normal contours of the face with excellent results. Aptos threads are polypropelene sutures with dents or cogs along their surface. Here, we present the results of a study using the device introduced by Sulamanidze on patients in the Belo Medical Group. Materials and Methods: Our study group consisted of 257 patients ranging in age from 28 to 73 years. Women made up 91.5% of the population. The population was 98% Asian. From November 2002 to November 2003, surgical procedures using Aptos threads were performed on 257 patients, and 27 patients had additional procedures at the same time. Results: The immediate postoperative period was mostly uneventful. Most cases showed excellent improvement in the ptotic tissues. In 9 cases (3.5% of patients) a “blue pimple” was observed 2–3 weeks postoperatively. These were noted to be thread edges sticking out of the skin and required minimal trimming. In 1 case, the patient developed persistent infection at the puncture site. Wound exploration and removal of implanted thread was performed and antibiotics were shifted to a broader spectrum, which addressed the problem quickly. Five cases (1.9%) required unilateral or bilateral implantation of additional threads. Discussion: The earliest outcome was seen on the operating table. Rehabilitation time was as short as 5–7 days and, if patients comply with elementary recommendations (abstaining from abrupt mimicking and chewing movements, avoiding facial massages for 2–3 weeks), the lifting effect is expected to remain for a considerable length of time. Conclusion: Using the Aptos thread technique was as successful in treating facial ptosis in 257 patients at The Belo Medical Group facility as it was in the Russian study. It proved to be a simple, quick, safe, conservative, and time-saving procedure that did minimal tissue damage and left no visible scars, even on Asian skin.

Combined Arcus Marginalis Release, Preseptal Orbicularis Muscle Sling, and SOOF Plication for Midfacial Rejuvenation

Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.

Different levels of undermining in face lift - experience of 141 consecutive cases

ABSTRACT CONTEXT: The most revolutionary concept in rhytidectomy is the role of Sub Muscular Aponeurotic System (SMAS), even if many alternative approaches have been proposed. The main aim of face lift is to bring back the time, preventing the "lifted-face" appearance. SETTINGS AND DESIGN: The authors present their personal experience with different levels of undermining, i.e. subperiosteal forehead lift, subcutaneous midface lift with SMAS plication and platysmal suspension, and discuss the anatomical and biomechanical elements of rhytidectomy. RESULTS: Optimal aesthetic results were achieved by repositioning the neck, face and forehead tissues in a global and harmonious fashion, without distorting face characteristics and disguising surgery trails as much as possible. CONCLUSIONS: Different levels of undermining can give good and stable aesthetic results minimizing the risks and preventing face distortion.

Total Ambulatory SMAS Lift by Hidden Minimal Incisions Part 2: Lower SMAS–Platysma Face Lift

The superficial muscular aponeurotic system (SMAS) of the lower face can be tightened with a simple retrolobular incision that is hidden and is rapid to perform. Visible scars in the preauricular and retroauricular areas are avoided. This procedure can be combined with other facial beautifying methods

Nose muscular dynamics: the tip trigonum.

In 1995, the senior author (E.E.F.) published an article in which he described the musculus digastricus septi nasi labialis. In the article presented here, work carried out by anatomists and other researchers who, over the last two centuries, studied nose muscular dynamics is described. The present study is based on Gray's Anatomy, which, in 1858, first described the nasal tip muscles, along with the other nasal muscles. Later works not only used different terminology for these muscles but also ignored some, creating tremendous confusion. The study presented here provides an update of the exact terms, location, insertions, and muscle functions of the muscles of the nose. Each nose muscle is described with regard to the two portions able to produce separate contractions. In this study, the term "dual function" is used and characterizes the nasal mimetic muscles that do not have well-defined fascia. Therefore, there is doubt about the existence of a real nasal superficial muscle aponeurotic system. The musculus myrtiformis seems to have a dual function, inserting in the canine fosse and in the periosteum of the central incisors, forming two portions-one to the septum and the other to the nostril-each of which has specific functions. This study has been based on research in physiognomy, the science of expression. With regard to the basis for nose expressions, common anatomical research is excluded because it provides a different view of the dynamics studied to date. The term trigonum musculare apicis nasi defines the interaction of the musculi compressor narium minor and dilator naris anterior, connecting with the columellar bundle of the musculus digastricus and levering the nasal spine. This muscular trigone creates circular concentric and eccentric movements of the nasal tip.