Facial Aesthetic Surgery Research Articles

Primary and Adjunctive Use of Botulinum Toxin Type A (BOTOX) in Facial Aesthetic Surgery: Beyond the Glabella

The use of Botox for the treatment of hyperkinetic facial lines and furrows is another effective primary, adjunctive, or prophylactic therapy to offer cosmetic patients in the spectrum of treatment options for full facial rejuvenation. Unwanted side effects can be minimized, and beneficial effects can be maximized with a thorough understanding of the facial soft-tissue anatomy, proper patient selection, and administration of the lowest effective doses with minimal volume of delivery. Most often, Botox injection does not replace surgery, skin resurfacing, soft-tissue augmentation, or skin care; however, it is useful when used alone or with the various treatment options to give selected patients the most effective and comprehensive solutions for a more youthful appearance.

Aesthetic considerations in secondary procedures for gender reassignment

Background: Patients who have successfully undergone gender reassignment surgery seek further aesthetic refinements to suit their new gender role. Objective: The study evaluated secondary aesthetic procedures, laryngeal surgery, and adjuvant hormone therapy in 22 male-to-female gender reassignment change patients. Methods: Thirty-two aesthetic procedures performed in 22 patients were evaluated for operation type, surgical technique, complications, and satisfaction rates. Aesthetic procedures included rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasty, cheek or chin surgery, and body contouring. Results: A wide range of secondary aesthetic procedures was successfully performed with only 1 minor complication and 1 major psychological depressive episode. Conclusions: Secondary surgery in gender reassignment patients extends the frontier of aesthetic surgery and provides lessons that can be extrapolated to facial and body con-tour aesthetic surgery in the general patient population.

Continuing medical education examination—facial aesthetic surgery

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic plastic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts. Learning Objectives: After studying this article, the reader should be able to: Determine the aesthetic objectives of an osseous genio-plasty. Describe the important surgical anatomy for genio-plasty. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 517.

Use Of Expanded Polytetrafluoroethylene In Aesthetic Surgery Of The Face

Aesthetic surgery procedures and materials available to improve the appearance of various subunits of the face have been evolving for the past several decades. Initially, techniques such as direct excision or placement of autogenous tissue grafts (e.g., fat, fascia, tendon, and dermal fat grafts) were used. Additional options became available with the development of silicone, injectable collagen, and ePTFE. These options for facial augmentation can be done rapidly in an office setting and as an outpatient. An important aspect of treatment is discussing clearly all pertinent options with the patient, and recommending the appropriate option based on the patient's anatomic findings and personal needs. For example, patients desiring lip augmentation but unsure about the result may be best treated with collagen injection, which gives temporary results and lets the patient consider a long-term result provided by ePTFE or autogenous grafts. Use of ePTFE in facial aesthetic surgery gradually has increased over the past two decades. Its use in augmentation of lips, nasolabial creases, and nose is becoming an important treatment modality for aesthetic surgeons.

Considerations for Esthetic Facia! Surgery in the African- American Patient

Due to the diverse ethnic nature of most communities, the perception of beauty is not homogeneous. Beauty is a perception of good balance, symmetry, harmony, and features that are pleasing to the eye. It is not possible to quantitate beauty. Many attempts have been made to standardize what is and is not beautiful by establishing the ethnic norms. Surgeons commonly attempt to achieve these ideal norms, but they may not necessarily be considered beautiful by the individual patient. Therefore, it is imperative for the surgeon to completely understand the patients' goals for surgery, which may not fit the ideal norms published in studies for that specific ethnic community. It also has become essential for patients to be made aware of the limitations of surgery, especially if their goals are unrealistic, to avert future distress and medicolegal problems. Thus, what is "normal" is not necessarily beautiful, and perhaps it would be better to strive for what is considered beautiful to the individual patient, rather than normal. Within the African-American population, the concept of what is beautiful can be extremely diverse. The number of African Americans who seek cosmetic or esthetic facial surgery is limited. As the number of esthetic procedures performed in the African-American population increases, however, the more educated this population will become regarding these procedures, and the more comfortable the surgeon will become regarding his or her own sense of "African-American beauty" and specific esthetic facial considerations for this population. It should be mentioned that as the number of African-American surgeons increases, their influence within the African-American population regarding the availability of esthetic procedures will also be felt.

Comparison of surgical approaches for upper facial rejuvenation

The evolution of endoscopic procedures in aesthetic facial surgery has progressed rapidly during the past decade. Endoscopic forehead and brow lifts have become increasingly incorporated not only into the armamentarium of the aesthetic surgeon, but also into the expectations of patients seeking cosmetic surgery. However, not every patient who desires endoscopic forehead and brow rejuvenation is an appropriate candidate. The variety of techniques available to rejuvenate the forehead and to lift the brow continues to expand, while the more “traditional” techniques maintain themselves as viable options in carefully selected patients. The authors explore the various approaches and techniques available, including their indications/contraindications, advantages/disadvantages, and long-term efficacy. In the arena of endoscopic forehead surgery, the different methods of fixation are highlighted.

Esthetic facial surgery

In the last few years, aesthetic facial surgery--especially soft-tissue surgery--has received increasing attention, not only from the medical profession but also particularly from the media. This is due, in part, to the growing level of general acceptance of the formerly stigmatized issue of aesthetic surgery, and in part to increasing patient expectations. Moreover, the introduction of less invasive procedures with outstanding long-term results have brought about a considerable change in aesthetic surgery. A comprehensive account of face lifting, forehead lifting, brow lifting, blepharoplasty, cervical liposuction and adjuvant techniques of skin rejuvenation will be given and discussed.

Application of endoscope in zygomatic fracture repair

The endoscope has been used to visualise the upper face and brow in aesthetic facial surgery which is performed without a coronal incision. We applied these principles to repair zygomatic fractures with the aid of a 4 mm, 30 degree telescope inserted through a small temporal incision. Fracture sites at the zygomatic arch and the zygomaticofrontal suture were exposed and fixed with miniplates under endoscopic control. This technique was used in 15 consecutive patients including 2 with isolated zygomatic arch comminuted fractures and 13 having displaced zygomatic fractures with segmental, displaced zygomatic arch fractures. Nine patients were men and six patients were women with a mean age of 35 years. Three patients had associated mandibular fractures. The periods of follow-up ranged from 3 to 22 months. Two patients developed transient frontal nerve palsy which recovered within 2 months. One patient had mild temporal hollowing on the side of the facial fracture. All patients achieved the adequate anatomic reduction and satisfactory malar symmetry. There has been no case of chewing problems, cheek numbness or progressive enophthalmos developing postoperatively. Application of the endoscope in zygomatic fracture repair minimises the scalp scar, avoids forehead numbness, provides a comfortable postoperative recovery and shortens hospital stay. Careful preoperative evaluation and proper surgical technique are mandatory for achieving optimal results in selected patients.

Continuing medical education examination—facial aesthetic surgery Importance of the digastric muscle in cervical contouring: an update

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: 1. Make the diagnosis of hypertrophied anterior belly of the digastric muscle contributing to excessive bulging in the anterior neck. 2. Understand a method of treating the hypertrophied anterior belly of the digastric muscle. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 17. Background: A well-contoured neck is essential for a youthful appearance. Prominence of the anterior bellies of the digastric muscles can cause or contribute to an objectionable bulge in the upper neck. Until recent years, contour problems resulting from the digastric muscle have been overlooked because accurate preoperative diagnosis is difficult. Objective: The purpose of this article is to present an update on a procedure initially reported by the first author in 1983. Methods: To achieve a youthful and aesthetically pleasing neck and submental contour, tangential excision of up to 90% of the inferior portion of the anterior bellies of the digastric muscles may be required. The procedure involves piercing the muscle belly with a long hemostat adjacent to the objectionable bulge of muscle, followed by transection of the excess muscle at the symphysis and near the sling. Results: The procedure has been performed in 103 patients with great improvement in cervical contour and no morbidity. Conclusions: The procedure presented is a simple, effective way to treat patients with submental bulges resulting from prominence of the anterior bellies of the digastric muscles.

Continuing medical education examination—facial aesthetic surgery Importance of the digastric muscle in cervical contouring*1an update

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: Make the diagnosis of hypertrophied anterior belly of the digastric muscle contributing to excessive bulging in the anterior neck. Understand a method of treating the hypertrophied anterior belly of the digastric muscle. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 17.

Chin augmentation.

The primary goal of facial aesthetic surgery is to restore, enhance, and rejuvenate the aging face to a more youthful appearance, achieving balance and harmony. The mental area must be addressed in order to have a complete synthesis of the face. The concept of augmenting the mental area with implants has evolved so significantly that it now stands by itself as an important procedure. Various autogenous implants for chin augmentation have been in use for over 100 years but have complications. The advent of synthetic materials has given rise to various types of alloplastic implants: Gore-Tex, Medpor, Supramid, Silastic, and Mersilene. No one implant is perfect for every face. This article overviews several alloplastic implants--their advantages, disadvantages, and complications, in addition to the different techniques of preparing and delivering the implants.

Autologous collagen dispersion (Autologen) as a dermal filler: clinical observations and histologic findings.

To assess the histologic behavior and clinical efficacy of autologous collagen dispersion (Autologen) in augmenting human dermis. Adult patients of the Facial Plastic Surgery Clinic at The New York Eye and Ear Infirmary who were undergoing facial aesthetic surgery with skin excision. Five patients were injected intradermally with Autologen in one postauricular area and bovine cross-linked collagen (Zyplast) on the contralateral side. Patients were examined clinically for signs of infection, skin necrosis, or implant rejection/allergy 2, 4, and 12 weeks postinjection. Impressions and photographs of all implant sites were taken at all follow-up visits. Biopsy specimens of each implant were taken 4 and 12 weeks after injection and examined histologically for signs of integration, rejection, and resorption. All implants were well tolerated. No identifiable differences were noted in the clinical persistence of Zyplast vs Autologen. Histologically, there was more variability in the degree of fibroblast infiltration of Autologen vs Zyplast deposits. Our trial suggests that autologous collagen dispersion may represent a viable alternative to bovine collagen. Clinical persistence and histologic behavior of Autologen appear to be at least as favorable as those of Zyplast, and Autologen obviates the need for allergy testing and eliminates the possibility of disease transmission. Arch Facial Plast Surg. 2000;2:48-52

Muscles that act on glabellar skin: a closer look.

The coronal incision forehead lift became a component of the face-lift procedure 35 years ago and increased the cosmetic benefit for the facial aesthetic surgery patient. Later, this enhanced cosmetic effect achieved from eyebrow resuspension was complemented by treatment of the glabellar skin lines by modifying corrugator supercilii and procerus muscle function through the same coronal incision. In recent years, newer procedures for treating the corrugator supercilii and procerus muscles by using endoscopy or limited incision techniques have eliminated the need for the coronal incision. With these newer techniques has come a renewed interest in the surgical anatomy of the muscle complex that acts on glabellar skin. This study was designed to examine the current understanding of the anatomy of these muscles and to resolve misconceptions and controversy concerning them. Fresh cadaver dissections and simulated muscle action studies done on the glabellar musculature of four specimens were correlated with nerve blockade studies performed in 10 subjects on the temporal and zygomatic branches of the facial nerve. The presence of the depressor supercilii muscle as a distinct entity was confirmed. The little-appreciated oblique head of the corrugator supercilii muscle was identified. The conclusions from this study suggest that the transverse head of the corrugator supercilii muscle produces the vertical component of the glabellar skin line and also contributes to the formation of the oblique component of the glabellar skin line. The oblique head of the corrugator supercilii muscle, the depressor supercilii muscle, and the medial head of the orbital portion of the orbicularis oculi muscle all appear to depress the medial head of the eyebrow and contribute to the formation of the oblique glabellar skin line. The nerve block study provided evidence that the zygomatic branch of the facial nerve supplies the three medial eyebrow depressor muscles, which opens the possibility for future nerve ablation techniques to control the action of the medial eyebrow depressor muscle group. This nerve block study also supports the concept of "physiologic" elevation of the medial eyebrow as an effective component of foreheadplasty.

Managing Narcogenic Obstructed Respiration in the Aesthetic Surgery Patient

Robert N. Cooper, MD, Stuart, FL, and New York, NY , is a board-certified plastic surgeon and ASAPS member. James Noble, MD, Stuart, FL , is a board-certified anesthesiologist. The purpose of this article is to offer a new definition of a frequently observed phenomenon known as the syndrome of narcogenic obstructed respiration (SNOR), which is defined as a narcotic-induced relaxation of muscles in proximity to the airway, leading to obstructive apnea. A study was undertaken to ascertain the safety of adapting continuous positive airway pressure (CPAP) to treat SNOR. While providing adequate sedation, analgesia, and amnesia to complement the administration of local anesthesia during facial aesthetic surgery, the technique offers solutions to several well-documented anesthesia-related risks. This newly defined syndrome, SNOR, …

Endoscopic foreheadplasty: temporary vs. permanent fixation.

The introduction of fiberoptic endoscopes has fostered the development of minimally invasive aesthetic facial plastic surgery. The application of this new technology is most widely used in rejuvenation of the mildly to moderately ptotic brow. The concept of endoscopic foreheadplasty is based upon the following maneuvers. First, a sub- or supraperiosteal dissection of the parietal, occipital, and frontal scalp to the level of the superior and lateral orbital rims and zygomatic arch must be accomplished. Second, incision and release of the superior and lateral orbital periosteum are performed. Third, selective myotomies of the brow depressor muscles are completed. These maneuvers allow the brow to be permanently elevated into a desired position following fixation and healing. A significant limitation of this procedure appears to be the ability to predict the long-term forehead and brow elevation. We believe that permanent fixation is one of the best methods to ensure that the desired elevation is maintained. We contrast two series of patients, one with temporary fixation technique and the other with permanent fixation. We review the results and discuss the rationale and advantages of permanent fixation.

Book Review: Ethnic Considerations in Facial Aesthetic Surgery

Book Review: Ethnic Considerations in Facial Aesthetic Surgery

Anesthesia for facial surgery.

We describe a reliable, simple, and safe method of monitored anesthesia care, with local anesthesia, which was used for 4500 patients undergoing facial rejuvenation procedure, without major complications and with minor side effects. All procedures were performed in a setup of a private clinic not affiliated with any hospital. The disadvantages of general anesthesia were avoided. Using careful monitoring and drug titration, even aged patients with medical problems, can benefit from this method. We are using classical, inexpensive, and safe compounds, which cope with all goals of anesthesia for aesthetic facial surgery.

Continuing Medical Education Examination—Facial Aesthetic Surgery Avoiding Hairline Displacement: A “High” Flap to Eliminate Transverse Retroauricular Scars

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying the article, the participant should be able to: 1. Review the surgical anatomy of the temporal scalp area. 2. Evaluate a surgical approach to the periauricular area that minimizes visible postoperative scarring. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 194. Background: Hiding the scars and avoiding hairline displacement are crucial in performing face lift surgery. Objective: We review temporal and retroauricular flap techniques aimed at avoiding hairline displacement. Methods: We introduce a new “high” retroauricular flap, used since 1997, which avoids the usual transverse retroauricular scar. Results: The objective of maintaining the hairline has been achieved with this incision. Conclusions: To diminish hairline displacement and retroauricular scars in face lifts, the temporal rotation flap and the retroauricular flap with and without a “high” skin flap are used.

Continuing Medical Education Examination—Facial Aesthetic Surgery Lifting the Malar Fat Pad for Correction of Prominent Nasolabial Folds

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: 1. Describe the anatomy of the malar fat pad and the changes it undergoes with the aging process. 2. Comprehend the author’s technique of lifting the malar fat pad to treat the prominent nasolabial fold. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 159.

Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery.

Our improved understanding of the pathophysiology of facial lines, wrinkles, and furrows has broadened the treatment options for a variety of facial cosmetic blemishes. The persistence or recurrence of certain facial rhytids after surgery has confirmed the lack of full comprehension of their origin. Glabellar forehead furrows (frown lines) and lateral canthal rhytids (crow's feet) have been the most popular facial lines that have been shown to be mostly the result of regional hyperkinetic muscles, and their eradication may be more suitable, at times, to chemodenervation than to soft-tissue fillers, skin resurfacing, or surgical resection. Aesthetic surgical procedures that have yielded suboptimal results may also occur from failure to recognize other causative factors including hyperkinetic or dynamic musculature, which may contribute to etiology of the visible soft-tissue changes and lack of persistent effect after surgery. Chemodenervation with botulinum toxin A (Botox) has proven to be useful both as a primary treatment for certain facial rhytids and as an adjunctive agent for a variety of facial aesthetic procedures to obtain optimal results.