Flaccid Skin Research Articles

Body vectoring technique with Radiesse(®) for tightening of the abdomen, thighs, and brachial zone.

BackgroundThe objective of this study was to investigate the efficacy, safety, and subject satisfaction of the calcium hydroxylapatite-based dermal filler Radiesse® in a novel body vectoring technique to correct skin flaccidity in the thighs, abdomen, and brachial zones.MethodsFemale subjects with self-evaluated flaccidity scores ≥3 on a 6-point scale (0, no flaccidity; 5, very severe flaccidity) in the zones of interest were included. Radiesse was injected according to predesigned vector maps (3 mL per thigh, 1.5 mL per hemiabdomen or brachial zone). Clinical assessments (skin density and thickness) were made by an independent reviewer at an exact position before and 5 weeks after treatment using a cutometer and an ultrascan. Subjects rated skin flaccidity before and 5 weeks after treatment on the 6-point scale and performed a pinch test to self-assess changes in skin thickness. All adverse events were recorded.ResultsTwenty females (aged 28–67 years) were enrolled, contributing 36 treatment zones. Across all zones, 78% of flaccidity measurements improved after treatment. Improvements in skin flaccidity were most common in the thighs (82% of cases). An improvement in skin density versus baseline was observed in the majority across all zones, most frequently in the abdomen (88% of cases). Skin thickness in each zone also improved versus baseline for the majority, most frequently in the thighs (88% of cases). Mean self-assessed flaccidity scores at baseline were 3.6 (thighs), 3.7 (abdomen), and 3.8 (brachial zone), and 2.6, 2.7, and 3.0, respectively, posttreatment. All subjects reported a positive pinch test. In total, 47.0% of subjects had bruising after treatment, which resolved within a week. No serious adverse events were reported.ConclusionUsing this novel technique, Radiesse had notable results on skin flaccidity, density and thickness in the thighs, abdomen, and brachial zones, and was well tolerated.

Retrospective analysis of 70 patients who underwent post-bariatric abdominoplasty with neo-omphaloplasty

Introduction: With the increasing surgical treatment of obesity, a new group of patients is being attended by plastic surgeons: those with large flaccid skin following weight loss. For patients treated with conventional or open bariatric surgery, vertical, anchor-line, or inverted “T” abdominoplasty has been widely used to improve the abdominal contour. In this study, abdominoplasty was associated with umbilical amputation followed by neo-omphaloplasty. Methods: Seventy patients with stable weight for at least 18 months underwent surgery at the UNICAMP Plastic Surgery Outpatient Clinic, from March 2011 to April 2013. In all patients, anchor-line abdominoplasty with excision of the original navel was executed, together with the surgical specimen and preparation of neo-umbilicus, through bilateral dermal-fat flaps. A retrospective analysis of medical records and photographic archives was performed. Results: The 70 patients were predominantly female (91%) and white (83%) with a mean age of 40 years. After a wait time of approximately 16 months, they were subjected to anchor-line abdominoplasty associated with neo-omphaloplasty, which lasted an average of 2 hours. There were post-operative complications in 29.85% of the patients, including small dehiscence, unsightly, enlarged, or hypertrophic scars, keloid, seroma, relevant dermo-fatty excesses, and wound infection. The neo-umbilicus obtained from the surgery is very similar to the original umbilicus. We did not observe necrosis, stenosis, morphological distortions, or bad positioning. Conclusion: This technique has made it possible to obtain an umbilicus with a natural look, is easy to perform, and shortens operating time.

Examining and choosing patients for body contouring after massive weight loss

Summary Background I n the past decade, overweight and morbid obesity in Europe have come to be nearly as common as in the United States. Fifty percent of the Austrian population is overweight, and nearly a quarter of that number is morbidly obese. In Germany and Austria, 8 % of children are morbidly obese. The costs for the treatment of this new epidemic and its consequences put considerable strain on health budgets that are already stretched to the limit. Hence, the main emphasis is on the treatment of those who are already ill, and on prevention. Treatment of obesity is a long-term proposition. The many comorbidities can be improved by weight reduction, whereby plastic surgery also plays a role. Bariatric surgery is the surgical option of treatment. But when that works, deformity due to obesity is replaced by disfigur ing flaccid skin after weight loss. Body contouring with plastic surgery is the only way to correct this problem. Methods P lastic surgery after massive weight loss must be planned on an individual basis. Preferably, even before a weight-reduction regime has begun, is the best time to discuss with the patient the corrections and total body concept. This will improve emotional stability, patient satisfaction, and has a positive effect on social reintegration at the end of treatment. Results F ull-body contouring will usually require two or more very time consuming operations. The result cor relates directly with initial body mass index. Complications are frequent but can often be managed with conservative measures. Many of them are a matter of shape. Patients should be made aware of possible corrections in advance. Complications after surgery are much more frequent with a BMI above 35. Conclusions The plastic sur geon concludes the weight-reduction program by removing the last traces of the original obesity.

Three-Dimensional Circumferential Liposuction of the Overweight or Obese Upper Arm

Due to recent trends in liposuction, anatomic consideration of the body's fatty layers is essential. Based on this knowledge, a circumferential approach to achieving maximal aesthetic results is highlighted. In the upper arm, aspiration of fat from only the posterolateral region can result in skin flaccidity and disharmony of the overall balance of the upper arm contour. Different suction techniques were applied depending on the degree of fat accumulation. If necessary, the operation area was extended around the axillary and scapular regions to overcome the limitations of the traditional method and to achieve optimal effects. To maximize skin contracture and redraping, the authors developed three-dimensional circumferential liposuction (3D-CL) based on two concepts: circumferential aspiration of the upper arm, to which was applied different fluid infiltration and liposuction techniques in three anatomic compartments (anteromedial, anterolateral, and posterolateral), and extension of liposuction to the periaxillar and parascarpular areas. A total of 57 female patients underwent liposuction of their excess arm fat using this technique. The authors achieved their aesthetic goals of a straightened inferior brachial border and a more slender body contour. Complications occurred for five patients including irregularity, incision-site scar, and transient pigmentation. Through 3D-CL, the limitations of traditional upper arm liposuction were overcome, and a slender arm contour with a straightened inferior brachial border was produced. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at http://www.springer.com/00266.

Autologous Fibroblast Culture in the Repair of Aging Skin

Human cell cultures are being developed to replace various body tissues. To assess the safety and efficacy of dermal regeneration with the injection of young autologous fibroblasts obtained from culture containing serum from patients themselves. Dermal tissue from the groin of five patients was cultivated in M199 medium supplemented with 10% human serum. Four population doublings were obtained. The fibroblasts were injected intradermally into forehead wrinkles and periorbital and paranasal areas. At the fourth population doubling, a mean of 3.85 × 10(6) cells/mL was obtained; viability was 98%. Sixty days after completing treatment, with four injections given at 15-day intervals, periorbital tonicity had improved significantly, although the quantity of fibroblasts used resulted in little improvement to surface lines and no improvement at all in deeper wrinkles. After 6 months, no further changes were found beyond the initial results obtained. Injection of skin fibroblasts cultivated in medium supplemented with human serum is a viable technique and provokes no side effects. Four injections given at 15-day intervals containing a total of 6.4 × 10(6) fibroblasts/mL resulted in significant improvement in periorbital skin flaccidity. Further studies should be conducted with larger sample sizes.

The Deep Anchored Inner Thigh Lift

The medial thigh area remains a troublesome region for body contouring in patients with lipodystrophy and/or skin flaccidity. Liposuction has proven effective in patients who have excess fat deposits but do not have a significant degree of skin laxity. The skin in this area of the body is often thin and inelastic, and in most circumstances where skin laxity is present, liposuction alone fails to remodel and tighten the inner thigh. Thus, it is necessary to combine liposuction with skin excision to achieve acceptable cosmetic results. The purpose of this article is to present the authors' technique of inner thigh lift using a novel dermoadipose flap design, which allows an effective anchoring of the inferior flap of the inner thigh to the adductor major tendon at the pubic bone insertion site. This novel approach creates a strong and stable anchoring site for the inferior inner thigh flap. In the authors' experience this technique has proved safe and effective, has a decreased morbidity, and achieves excellent cosmetic results.

Closed Platysmotomy: A New Procedure for the Treatment of Platysma Bands Without Skin Dissection

Platysma muscular bands are present during the aging period, generally starting in the second half of the fourth decade of life in both sexes. One or two bands along the anterior segment of the neck are the most frequent, with varied extensions and appearances. The literature records different techniques for solving the problem of platysma bands. All the methods involve submental incision, cutaneous dissection, and various tactics for eliminating the action of the platysma bands. This report aims to describe a procedure for deactivating these bands using a percutaneous approach that eliminates the need for submental, cutaneous incision and dissection. This technique involves the use of a steel wire loop that encircles the platysma band and is connected to a device known as the platysmotome through two puncture holes in the skin. Three to six sections along each band eliminate the platysma band, leaving no visible marks on the skin. This method is indicated as an isolated procedure for patients with visible platysma bands and no skin flaccidity, patients with recurring bands after face-lifting and no cervical skin flaccidity, patients who have bands with little cervical skin flaccidity but do not care to undergo face-lifting, and patients who undergo face-lifts for platysma bands that include closed platysmotomy and tightening of the platysma by lateral suture. The described technique is a method specifically designed for deactivation of the platysma bands that can be used both in isolation and in conjunction with face-lifting. Because this method avoids submental, cervical incision and dissection, it is a less invasive technique for “deleting” the bands, whether applied alone or in association with face-lifting. From May 2008 to November 2009 (19 months), 61 patients underwent surgery for the correction of platysma bands via percutaneous myotomy. Among them, the first 11 patients received postoperative follow-up evaluation ranging from 8 to 17 months.

Eficácia da intervenção fonoaudiológica para atenuar o envelhecimento facial

TEMA: eficácia da intervenção fonoaudiológica na estética facial para atenuar os sinais de envelhecimento. PROCEDIMENTOS: análise fotográfica e descrição do raciocínio clínico utilizado em três casos clínicos de clientes do sexo feminino, com queixas referentes à estética facial, que se submeteram ao atendimento fonoaudiológico. Foram realizadas a entrevista inicial, a avaliação das funções estomatognáticas, a avaliação da movimentação dos músculos da mímica expressiva e a documentação fotográfica e em vídeo. Com base nessa avaliação e na queixa das clientes foram estabelecidas as metas terapêuticas. Em cada um dos casos foi proposto um raciocínio clínico especifico e individualizado, levando-se em consideração a sinergia muscular e a presença ou ausência de flacidez de pele. Durante doze sessões, com duração de 50 minutos, foram feitos exercícios musculares funcionais e massagens na face. As clientes foram orientadas a manter uma rotina diária de procedimentos em casa. RESULTADOS: após o atendimento fonoaudiológico pode-se observar que os sinais de envelhecimento foram atenuados, sendo esse resultado compatível às expectativas das clientes, que expressaram satisfação ao final do atendimento. CONCLUSÃO: constatou-se a eficácia da intervenção fonoaudiológica, por meio da documentação fotográfica, como resultado da aplicação de um raciocínio clínico individualizado, específico da área de motricidade orofacial com enfoque em estética.

Anetoderma of Prematurity

In 1996, a form of acquired anetoderma (flaccid skin resulting from lack of dermal elastic tissue) was described in extremely premature,

Cutaneous blisters as the presenting signs of recurrent thyroglossal duct cyst in a child

Conflict of interest: none declared. We report a 4‐year‐old boy who presented with a history of sudden onset of an asymptomatic mass, 25 mm in size, on the midline of the upper neck. High‐resolution ultrasonography (US) and magnetic resonance imaging could not confirm a precise diagnosis, but did indicate inflammation. Treatment with amoxicillin and clavulinic acid twice daily was started, but did not result in marked improvement. The mass was excised, and the histopathological findings were diagnostic for thyroglossal duct cyst associated with prominent inflammatory infiltrate. Serum levels of free thyroxine and thyroid‐stimulating hormone were normal. Three months later, two tense bullae, filled with a yellowish serum, developed at the scar site (Fig. 1a). The blisters burst several times after occasional trauma or during bathing, leaving a flaccid skin flap with the ostium of the fistula visible beneath it. The blisters rapidly refilled with serum, with a chronic course. Re‐excision of the whole lesion was carried out using the Sistrunk1 technique, i.e. including removal of the hyoid bone.

Sad Umbilicus: Prevention and Treatment

Although the navel is a functionless depressed scar, it represents an important and pleasing landmark. Any degree of umbilical protrusion and horizontal orientation or distorted shape signifies deviation from the ideal female umbilicus [1]. One of the most common and difficult problems with the abdomen is treatment of the supraumbilical wrinkling that may develop in the linea alba after pregnancies or due to aging, flaccid skin, or excessive fat aspiration, provoking a defect called ‘‘sad umbilicus.’’ (Fig. 1). Various techniques have been used to resolve this deformity. Toledo [2] tried resecting the wrinkled skin above the umbilicus through a circular periumbilical incision and with a horseshoe-shaped incision, leaving the lower pedicle of the umbilicus untouched. The results of this technique have not been gratifying. In the past, liposuction has been used because the wrinkling skin over the umbilicus can sometimes be misinterpreted as excess fat, resulting in an iatrogenic deformity [3]. Fat grafting of this area also has been done, but the results are not consistent [3]. Although the ideal shape of the umbilicus has been debated, recent studies have shown that the young thin female with an attractive abdomen tends to have a small, vertically oriented umbilicus [4]. We are proposing a new technique for prevention and correction of the sad umbilicus. Minimum undermining through a small incision in the superior part of the umbilicus using a 4-mm liposuction cannula in the midline of the upper abdomen creates a minimal superior sulcus. Interaponeurotic sutures are performed using 4-0 nylon. These sutures pull superiorly and tighten the supraumbilical skin by fixing the level of the superficial fascia to the musculoaponeurotic fascia (Fig. 2). The fixation point on the musculoaponeurotic fascia is 2 to 3 cm superiorly compared with the suture point of the superficial fascia. Two to three sutures, depending on the severity of the case, are needed. For prevention of sad umbilicus after performance of liposuction via an umbilical incision, one to two Fig. 1 Preoperative view of a 34-year-old patient with ‘‘sad umbilicus’’ deformity

Treatment of Iatrogenic Abdominal Contour Irregularities

In many countries, liposuction is the most frequently performed aesthetic procedure. The procedure is promoted as a safe, easy-to-learn, outpatient procedure. The increasing number of liposuction procedures, often performed by inadequately trained physicians, has led to a growing number of iatrogenic postliposuction contour deformities and skin irregularities. This report describes a treatment protocol for iatrogenic abdominal contouring deformities. For patients who present with contour deformities but no skin flaccidity, the type 1 treatment plan (syringe-assisted lipectomy and lipografting) is the suggested approach. In cases of contour deformities and infraumbilical skin flaccidity, the type 2 treatment plan (mini-lipoabdominoplasty and lipografting procedures) is used. Finally, in the case of contour deformities as well as supra- and infraumbilical flaccidity, the type 3 treatment plan (lipoabdominoplasty and lipografting procedures) is indicated.

Quantifying Augmentation Gluteoplasty Outcomes: A Comparison of Three Instruments Used to Measure Gluteal Projection

Gluteal augmentation is increasingly common. However, few studies have quantitatively reported postoperative gluteal projection. This study compared three different standardized instruments (i.e., radiographic, sonographic, and anthropometric) for quantifying gluteal projection after lumbar-hip dermal fat rotational flap to identify a simple, cost-efficient valid instrument. A total of 10 women ages 35 to 68 years (mean, 47.3 years) with skin flaccidity and gluteal ptosis underwent bilateral lumbar-hip dermal fat rotation flap gluteal augmentation (20 procedures). Gluteal projection was measured 1 week preoperatively and 8 months postoperatively using computerized axial tomography (CAT) scan, ultrasound, and anthropometry. The CAT scan measured 1.40 cm of projection on the left (p < 0.001) and 1.43 cm on the right (p = 0.001). Ultrasound measured 2.16 cm of projection on the left (p < 0.001) and 1.88 cm on the right (p = 0.001). Anthropometry measured 1.75 cm of projection on the left (p < 0.01) and 1.35 cm on the right (p < 0.05). Repeated measures analysis of variance (ANOVA) comparing the CAT scan, ultrasound, and anthropometry demonstrated statistically similar results on the left (p = 0.43) and right (p = 0.62). All three instruments were sufficiently sensitive to measure a statistically significant increase in postoperative gluteal projection. Moreover, all three instruments were statistically similar in accuracy of measurement. Therefore, the authors conclude that ultrasound or anthropometry are satisfactory, inexpensive instruments for accurately quantifying postoperative gluteal projection.

Considerations in Body Contouring: Brachioplasty

Following massive weight loss, the upper arms take on a characteristic appearance that includes sagging, flaccid skin. The term used by laypersons to describe this is “bat wings.” Brachioplasty is the surgical technique used to correct this undesirable consequence of weight loss. This article discusses the brachioplasty procedure, preparation, postoperative care, and potential complications.

Bilateral Lumbar Hip Dermal Fat Rotation Flaps: A Novel Technique for Autologous Augmentation Gluteoplasty

The present study reports a novel technique for augmentation and/or correction of deformities in the gluteal region. This technique is applicable to patients with skin excess, skin flaccidity, and/or ptosis, and for redundant skin folds in the lower back region, that often occur following the surgical treatment of morbid obesity. In a retrospective review, nine female patients, aged 27 to 64 years, underwent the bilateral lumbar hip dermal fat rotation flaps procedure for gluteal augmentation. The patients were observed over a period of 3 months to 4 years. Gluteal projection was measured with a standardized computed tomographic scan in two patients. Complications were analyzed. The postoperative photographs and the measurements taken by computed tomographic scan proved that the gluteal projection had been increased satisfactorily with this innovative procedure. Three complications were observed, the major one being a hematoma that required reoperation. Bilateral lumbar hip dermal fat rotation flaps is an ultimate technique that should be performed in selected patients to create a harmonic autologous augmentation of the buttocks region. Although the complication rate of this technique was high, it was similar to that in some authors' reports for belt lipectomy.

Chirurgie faciale de rajeunissement

Aging brings about anatomical changes that are undesirable. Senescence is consequently one of the most powerful stimuli for aesthetic surgery. The face, responsible for the myriad expressions of human experience, is constantly subject to exposure and also suffers from the perennial action of environmental factors and gravity. Frequently, the face is the main focus of anxiety in individuals who have attained a certain age, presenting skin flaccidity and loss of tone, marked lines of expression and fat deposits. Expectations of both the patient and the surgeon, regarding facial aesthetic surgery, have increased considerably over the last two decades with the advent of newer procedures and equipment. While experience allows the surgeon a better selection of techniques, at the same time he must be knowledgeable in details of different surgical approaches and variations to attain the best result for each individual case. The anatomy of the aging face should be examined carefully for a personalized treatment plan. Currently, a satisfactory result of an aesthetic facial procedure is obtained when signs of an operation are undetectable and no anatomical landmarks have been altered. The bond created between the patient and surgeon will be frustrated if there remain signs that reveal the "secret" that surgery was performed.

Augmentation Mammaplasty with Anatomic Soft, Cohesive Silicone Implant Using the Transaxillary Approach at a Subfascial Level with Endoscopic Assistance

Many augmentation mammaplasty techniques have been developed paying special attention to incision location and pocket plane to achieve more natural-looking breasts. The authors' technique of choice in patients with mammary hypoplasia, empty breasts following a diet program, or more than one lactation episode causing skin flaccidity without ptosis is the placement of an anatomical implant using a transaxillary approach in a subfascial plane with endoscopic assistance. Thus, ideal patients are those presenting mammary hypoplasia, empty breasts following two or more lactation episodes, and breast skin flaccidity without ptosis, with the nipple-areola complex placed above the inframammary fold. The technique and its indications are presented thoroughly. Forty-five patients were operated on using this technique from May of 2001 to October of 2003. One-year follow-up results showed highly rated patient satisfaction. One patient underwent an implant exchange because of implant size dissatisfaction. The authors prefer subfascial plane implants to submuscular ones. Possible rotation of anatomic implants and the subsequent asymmetry when contracting the pectoral muscle are avoided. Pectoral muscle is not detached from its insertions, resulting in less postoperative pain. Likewise, the authors prefer a subfascial to subglandular pocket since the weight of the subglandular pocket and the glandular weight itself are borne by the skin envelope leading to breast ptosis development over time. On the other hand, fascia provides additional support to the subfascial implant, thus eliminating ptosis development and achieving good filling of the upper pole similar to the filling provided by subglandular implants.

Surgical correction of the “small” postpartum ptotic breast

Background In our experience, most women seeking correction of the “small” ptotic breast have a history of previous pregnancies and breastfeeding. Objective We propose a classification of postpartum ptosis into 4 groups and describe the appropriate surgical treatment for each category of ptosis. Methods We defined categories of ptosis on the basis of the remnant mammary gland, skin condition, position of the nipple-areolar complex (NAC), and distance from the NAC to the inframammary fold (IMF). Patients in group 1 (n = 15), with the NAC in good position, were treated with the use of simple subglandular augmentation mammaplasty. Patients in group 2 (n = 8), with grade I ptosis in which the nipple required elevation of no more than 3 cm and the distance from the inferior border of the areola to the IMF was less than 4 cm, were treated with the use of crescent-moon mastopexy. Patients in group 3 (n = 20), who demonstrated a higher degree of skin flaccidity and grade I or II ptosis and in whom the distance from the NAC inferior border to the IMF was between 4 and 6 cm, were treated with the use of circumareolar mastopexy. Patients in group 4 (n = 24), with moderate to severe skin flaccidity and ptosis in whom the distance from the NAC to the IMF was more than 4 cm, were treated with the use of modified vertical mastopexy. Results Eight-five percent of patients were satisfied with their results. Unfavorable results were related to dissatisfaction with breast shape and postoperative scarring; such results occurred most often in group 4 patients. Complications were within reasonable limits, including 2 cases of hematoma and 3 cases of decreased NAC sensibility in group 3 patients and minor dehiscence in 3 patients in group 4. Conclusions Careful patient evaluation and choice of technique, as determined by the classification proposed in this paper, enabled us to achieve high rates of patient satisfaction with low rates of complications and revision.

Noninvasive lower eyelid blepharoplasty: a new technique using nonablative radiofrequency on periorbital skin.

Laxity and rhytids of the lower eyelids are common cosmetic concerns. Historically, correction has either been surgical through either transcutaneous or transconjunctival blepharoplasty or ablative through laser resurfacing or chemical peeling. Therapeutic options usually require significant postoperative healing and have the potential risk of scarring ectropion or pigmentary loss. To report the use of a new technique that uses nonablative radiofrequency (NARF) to tighten noninvasively and nonsurgically the flaccid skin of the lower eyelids by treating the periorbital area to produce cosmetic improvement. Nine patients with skin flaccidity of the lower eyelids had a single treatment session with NARF in a small area of skin in the periorbital region, specifically the zygomatic and/or temporal areas. All patients were treated with topical anesthesia only. The treatment lasted approximately 10 minutes. No postoperative care was required. All of the nine patients in the study achieved cosmetic improvement of the eyelids ostensibly through skin contraction. All patients were able to return to their normal routines immediately. Although the results were gradual, patient satisfaction was remarkable. No complications were seen in this study. This new procedure using NARF was successful in providing a safe, noninvasive, cosmetic improvement in these patients with excessive skin laxity of the lower eyelids. Postoperative morbidity, including down time and complications, was not seen.

Anetoderma and its prothrombotic abnormalities

Background Anetoderma is characterized by circumscribed areas of flaccid skin due to the loss of elastic tissue in the dermis. It may be primary or secondary to various dermatoses. The primary form has been reported in association with autoimmune diseases and recently with antiphospholipid antibodies. Its etiology remains unknown. Objectives To analyze clinical and laboratory data from a series of patients with anetoderma referred in our university reference center for connective tissue disorders. Patients and methods All the consecutive patients with histologically confirmed anetoderma followed in our clinic from 1996 to 2001 were enrolled in this study. Laboratory investigations included the screening for prothrombotic abnormalities and classical immunological investigations for systemic lupus erythematosus. Clinical and laboratory data were analyzed retrospectively. Results Anetoderma was primary in 9 cases and secondary to lupus profundus in 2 cases. Prothrombotic abnormalities were detected in 10 patients (9/9 with primary and 1/2 with secondary anetoderma). Antiphospholipid antibodies were detected in 9 patients. Only 4 patients fulfilled criteria for definite antiphospholipid syndrome which was primary for 3 and associated with systemic lupus erythematosus in the other. Conclusion Patients with anetoderma should be evaluated for the possible presence of a prothrombotic state and warned of its potential risks when present..