Surgery Archive

The fat of injection sites

US Food and Drug Administration approval and widespread use of botulinum toxin A (Botox) for cosmetic facial applications has heralded a new era of nonsurgical office procedures. This injectable facial animation inhibitor, which is a valuable adjunct to surgical rejuvenation, is exceedingly effective and rapidly administered.

Because Botox requires percutaneous injection to reach desired muscle sites, patients may experience some pain and apprehension. Injections are frequently administered in the forehead and around the eyes, so some patients experience more sensitivity and anxiety than they do with injections in other facial or bodily areas. I evaluated the use of a topical anesthetic cream, Eutetic Mixture Local Anesthetics (EMLA) (Astra Pharmaceuticals, Westborough, MA), in reducing the discomfort of Botox injections.

Patient selection

Twenty patients who had been previously treated with Botox forehead injections were selected as study subjects. Previously treated patients were chosen because they were more likely to have lower anxiety levels and could better evaluate injection pain. Patients reviewed and signed consent for study participation.

Treatments

Ten glabellar injections to the procerus and corrugator muscles were administered in each patient in a standard pattern. Five injection sites on 1 side of the face were pretreated with EMLA cream; 5 injection sites on the other side of the face were pretreated with a similar-appearing nonanesthetic cream, Kinerase (ICN Pharmaceuticals, Costa Mesa, CA). Patients were not told which side was being treated with the anesthetic cream. The topical agents were applied in a simple “spot” method at injection sites without the use of an occlusive dressing (Figure). The creams were allowed to dry for 30 minutes (until clear) before injections were administered. A total of 0.05 mL of Botox (2.5 ?/0.1 mL) was instilled in each injection site.

A, Spot application of EMLA to injection sites. B, Absorption of EMLA after 30 minutes, with blanching of skin.

On the basis of the paired nature of the injections, patients were asked to not only grade each injection site (pain vs no pain) but also to grade which side of the matched pair was more painful. I conducted data analysis by first comparing paired injection sites on the basis of mean improvement and also by using a paired sign test to determine which side was less painful in each patient.

Results

Twenty patients receiving 200 injections were evaluated. On the left (control) side, 11 of 100 injections sites (11%; mean = 1.2, SD = .39) were rated as painless. On the right (experimental) side, 73 of 100 injection sites (73%; mean = 6.8, SD = .31) were rated as painless. When comparing the pain between the 2 sides (rather than at each injection site), all 20 patients (100%) reported a significant difference in pain control between the 2 sides, with the experimental side always better than the control side (P < .0001).

EMLA vs alternatives

EMLA is a well-accepted topical anesthetic cream that has been used for diverse skin applications, including venipuncture and superficial surgery. This eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (pH 9) produces cutaneous anesthesia through dermal penetration. The depth of the dermal anesthetic effect increases in accordance with how long the cream has been on the skin: After 60 minutes it is about 1 to 2 mm, and after 3 to 4 hours it may increase to 6 mm.

Although a longer wait after application may offer greater dermal anesthesia, I chose 30 minutes as a practical interval for office administration. This was also the amount of time in which the creams lost their visibility through absorption and evaporation. Applied with a spot-application technique, EMLA cream is effective in improving the discomfort of Botox injections. Its effectiveness has been previously demonstrated in eyelid injections, although the application method was different. Applying a dot of EMLA cream at the site of a skin injection is easy, convenient, and inexpensive. A 5-g tube will likely provide enough cream for more than 25 patients.

Many other methods of decreasing the pain of Botox injections have been proposed. Using the smallest-gauge needle is an obvious intervention that, combined with a small-volume syringe, also helps ensure accurate administration. Although EMLA is traditionally used with occlusion when administered in larger volumes, the findings of this study demonstrate that occlusion is not necessary, particularly in injections with small-gauge needles. Reconstitution with an isotonic mixing solution (preservative-containing saline solution) and lowering of skin temperature with the use of various cooling methods (eg, ice, aerosol sprays) have also been shown to decrease injection discomfort. However, ice, in particular, is inconvenient to apply, and the pain control it affords is only partially effective.

Conclusion

The use of EMLA cream is a rapid and effective method of decreasing pain during the percutaneous administration of Botox for aesthetic facial enhancement. Pain is reduced by more than 60% when EMLA is applied 30 minutes before treatment. Although injection pain is not eliminated, discomfort is clearly diminished. This finding will improve the acceptance of such intramuscular treatments, particularly in the apprehensive patient.

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Face liftand the Incision

Achieving natural-looking results without visible signs that surgery has been performed is the key goal of facial rejuvenation surgery.Nevertheless, one of the untoward outcomes of face lift surgery is the so-called face lift look. Conspicuous preauricular scars, earlobe malposition, distortion of the tragus, and high sideburns are responsible for most face lift stigmata. The “face lift look” does not occur if procedures are followed to properly place incisions, preserve ear contour, and maintain the sideburns in their normal position.

Preoperative planning, particularly with regard to observation of the ear contour and the location of the sideburns, is a fundamental requirement for achievement of satisfactory results in rhytidoplasty. The preauricular area and sideburns are sites where face lift stigmata are easily detected (Figure 1). In addition to proper evaluation of facial changes caused by aging, precise assessment of ear contour, sideburn location, and distance between the hairline and lateral canthus is mandatory to obtain a satisfactory outcome that preserves ear contour, tragal shape, earlobe location, and sideburn position ( Figure 2).

Stigmata of facial plastic surgery. A, Elevation of sideburns; B, destruction of the tragus.

Preoperative evaluation of the preauricular approach. A, The preauricular approach is appropriate in this 67-year-old patient with sideburns in a natural position and a nice ear contour. B, The retrotragal approach is appropriate in this patient, given the long earlobe and thin tragus

Incision planning

Placement of the incision above the ear may vary, depending on the position of the sideburns. If the sideburns are low, the incision should be made in the hair-bearing temporal area. If the sideburns are located in a higher position, the incision should contour the sideburns and extend farther into the hair-bearing zone. If the distance between the hairline and the lateral canthus of the eye is relatively long, the incision should enter the hair-bearing area at a higher site.

The preauricular incision must follow an imaginary line dividing the auricle and face (Figure 3, A). The markings should follow the natural curves of the ear. The incision should not be a straight line; incisions may be placed in front, on, or behind the tragus. Whatever your choice, the shape of the tragus should never be changed. Sutures should be placed without any tension ( Figure 3, B and C). In most patients, there is a crease in front of the tragus where the incision can be made. Whenever possible, I prefer to use the pretragal incision.

A, The incision is made along an imaginary line that divides ear and face. B, Intraoperative appearance immediately after the incision. C, Intraoperative placement of the final sutures. Sutures should be placed without any tension

When performed with careful surgical technique, the preauricular incision is rarely noticeable after surgery. It can result in a very natural-looking appearance, without distortion or alteration of the ear contour, and with sideburns that are correctly located (Figure 4 and Figure 5). In some patients, scarring from previous procedures (performed elsewhere) is improved ( Figure 6).

A, Preoperative view of a 49-year-old woman.B-D, Evolution of the preauricular scar at 4 days, 45 days, and 1 year, respectively, after face lift.

A, Preoperative view of a 54-year-old woman. B, Postoperative view 1 year after face lift. Note the position of the sideburns.

A, Preoperative view of a 62-year-old patient who presented with scarring of the preauricular area and earlobe contour distortion after surgery. B, Postoperative appearance 6 months after reoperation shows improvement.

If the tragus is thin and the anterior crease is not perceptible, I recommend a retrotragal incision. When this incision is used, proper defatting of the flap is also necessary (Figure 7).

A, Defatting of the tissue in front of the ear. B, Intraoperative appearance before the final suture.

Conclusion

Sophisticated maneuvers in rhytidoplasty are counterproductive if they result in conspicuous scars or other visible signs of surgery. Careful technique with regard to incision placement is mandatory for optimal results. Frequent causes of the face lift look include ear distortion, tension of the flaps, improper direction of the flaps, excessive distance between the hairline and lateral canthus, and elevation of the sideburns. The patient should be able to wear any kind of hairstyle after undergoing rhytidoplasty.

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Inframammary fold and the Inframammary

My patients in Sweden always request that I create as little scarring as possible on the aesthetic unit of the breast when I perform breast surgery. In fact, they appear to be more concerned about their scars than any other aspect of the surgery. With increased media exposure, general public sophistication about breast augmentation has become widespread. Today most people know that when a woman has 2 symmetrical scars, either around the areola or in the inframammary fold, she has undergone breast augmentation. I have seen patients with such scars who were as distressed about these obvious signs of surgery as they were about the preoperative appearance of their breasts.

I have heard colleagues say that the inframammary scar is placed in the fold and, as a result, is inconspicuous. However, in my hands, few scars placed on the body, except for those above the neck, become inconspicuous; most can be seen with the naked eye from 10 feet. I also find it difficult to place the scar in the future inframammary fold with precision because most augmentations will lower the inframammary fold. It is hard to know exactly where the future inframammary fold will be, and therefore placement of the incision is difficult.

Desire on the part of the patient for a short convalescence, allowing her to return to work sooner, is a current trend in aesthetic surgery. One of the major disadvantages of submuscular breast augmentation is the postoperative pain that patients frequently experience because of evulsions of the muscle fiber origins from the sternal and costal ribs. The blunt dissection of the pocket frequently causes microbleeding in the periosteum of the involved muscle origins. However, if these muscle fiber attachments are released with electrocautery instead of blunt dissection, postoperative pain is reduced to almost none.

Submuscular breast augmentation with electrocautery dissection was first performed through the inframammary approach with a lighted retractor. When performing this procedure from a transaxillary approach, you have to use an endoscope. My experience with the transaxillary approach, using an endoscope, has shown that most patients experience little pain and can return to office work within a couple of days. Patients who do heavier work, including lifting, are usually advised to stay out of work for 2 weeks. Other advantages with this technique, compared with conventional blunt dissection: Intraoperative bleeding is reduced to an absolute minimum, and the pocket can be created with greater precision. Because bleeding is thought to be one of the causes of capsular contraction, electrocautery dissection should prove an advantage in this respect. But long-term follow-up is necessary to learn whether this holds true.

Increased precision, provided by this technique, in the creation of the pocket will also provide a better inframammary fold shape. In some patients, when performing a blunt submuscular dissection from the axilla, I have encountered a ligament in the inframammary fold (earlier described by Barnett), which can be quite difficult to break. If this ligament is not broken, it usually results in a very obtuse and ill-defined inframammary fold, or ‘double bubble’ deformity. This can be avoided with electrocautery dissection and the use of an endoscope.

When one is dealing with a capsule through the axillary incision, the endoscope is the ideal instrument to use with regard to access and visibility, compared with earlier techniques involving lighted retractors and specially designed knives.

Surgical technique

Place the patient in a sitting position while you mark the lateral and medial extents of the pocket, as well as the current and future inframammary folds. In most patients, I find that I lower the inframammary fold at least 2 to 4 cm. Mark the axilla incision with the patient’s arms raised. I prefer to place the incision along the natural folds, 3 cm under the middle of the axilla (Figure 1). Inject the axilla incision with local anesthesia with epinephrine. I also usually inject this solution into the areas of anticipated dissection between the old and the new inframammary folds because this is the only area in which I plan to cut through the muscle. In all other areas I use the cleavage plane between the pectoralis major and minor muscles.

Patient with an axillary incision is marked with the current and proposed inframammary folds.

Start the procedure by identifying the lateral border of the pectoralis major muscle through the axillary incision. Then separate the pectoralis major from the pectoralis minor muscle. Create a small pocket with your finger, being careful to remain between the 2 muscles in the cleavage plane to avoid any bleeding. When introducing the endoscope, I stand above the patient’s arm to get direct access to the pocket and to maneuver easily (Figure 2). Use the electrocautery in coagulation mode with a high-power setting; this will cut and coagulate at the same time without too much burning. In the event of a bleeder, it is practical to be able to switch from coagulation mode to spray mode.

The breast tissue is retracted with a curved blade retractor, and the endoscope is in place.

It is important to dissect from the medial to the lateral side in wide, sweeping motions to avoid ending up with a small hole (Figure 3 and Figure 4). In the event of bleeding, vision in a small hole is quickly obscured. While you are dissecting, it is important that your assistant follow your progress by observing the patient’s skin surface to guide you as you approach your markings. When 2 cm remains to be dissected above the future inframammary fold, I usually cut through the muscle to better define the new inframammary fold. I cut through the muscle fibers, but only until I see the subcutaneous fat shining through, not more ( Figure 5).

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Fat grafts and Fat

In my ongoing search for a reliable off-the-shelf material for use in lip augmentation, I began using AlloDerm (Lifecell Corp., The Woodlands, TX) several years ago. AlloDerm is freeze-dried human tissue that has been decellularized to eliminate the risk of inflammation and rejection. It is said to retain vital elements of tissue structure (collagen, elastin, proteoglycans), and to have a shelf life as long as 2 years.

Alloderm application

Intrigued by how easily AlloDerm can be used, I began to examine the longevity of the material when it is implanted in lips. After performing this procedure, I observed that graft absorption was variable. Most patients experienced at least 60% graft absorption in 6 months. Many, however, still demonstrated palpable material after 1 year.

Here is my method for implanting AlloDerm in the lips:

1. Reconstitute the material in accordance with the manufacturer’s suggestions. The graft size I find most useful is 3.5 by 7 cm. This size is sufficient for both the upper and lower lips; frequently some material is discarded.

2. With the patient under general anesthesia, or oral sedation and regional nerve blocks, infiltrate the oral commissures and dry vermilion with 1% lidocaine with 1:100,000 epinephrine to effect hydrodissection and to provide hemostasis. I believe that the presence of blood in the pocket substantially affects both autologous and allogenic graft survival.

3. Make a 3-mm transverse incision in both oral commissures and dissect a submucosal tunnel with blunt-tip tenotomy scissors or a Freer periosteal elevator (Padgett Instruments, Kansas City, KS).

4. Pass the graft with a curved graft retriever (Byron Medical, Inc., Tucson, AZ) The graft should be palpable at the vermilion cutaneous border but not above. Close the incisions with chromic catgut.

5. Use routine perioperative antibiotic coverage, local wound care, and diet advancement.

I have expanded my clinical application of Alloderm to include skeletal augmentation of the malar, infraorbital, and mental areas, as well as correction of asymmetries and contour deformities of the nasal dorsum and sidewall. I found substantial improvement in graft survival with minimal absorption. I attribute this improved survival to my placing the grafts in areas of virtually no mobility. Another application I have used with success is the placement of large sheets of Alloderm between a breast implant and its surrounding capsule to camouflage wrinkling.

Alternative materials and methods

My preferred material for lip augmentation is autologous tissue, when it is available (combined SMAS/fat grafts). However in some patients there may not be sufficient tissue to supply the necessary volume. I have used injectable fat grafts and found their survival in the lips unpredictable. I also tried Softform implants (McGhan Medical, Santa Barbara, CA), which resulted in my removing almost as many as I inserted. They felt unnatural and were always palpable. If not positioned perfectly, they also appeared unnatural.

The introduction of Cymetra (Lifecell Corp.) appeared to answer the need for a reliable injectable soft tissue filler material with a survival rate exceeding that of injectable collagen. However, my experience with this material was not favorable. Cymetra was rapidly absorbed, and patients were disappointed. I no longer use this material.

In a recent article, Duncan provides a novel method of lip and perioral rejuvenation in which she divides the acellular graft into small particulate grafts, permitting augmentation by means of injection. This may be a better alternative than Cymetra.

The European, Canadian, and South American experience with Restylane (Qmed AB, Uppsala, Sweden) and Perlane (Qmed AB) offers hope for another user-friendly soft tissue filler.

Conclusion

Alloderm is user-friendly, with variable absorption, depending on tissue handling and the recipient area Particulate Alloderm seems to be a reasonable alternative when the use of injectable material is indicated. Autologous material is preferred when available without added morbidity and when expected survival exceeds that of acellular allogenic grafts.

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Hgh of Fat

In Tolkien’s classic tale The Lord of the Rings, at one point the creature Gollum falls off a cliff trying to go too fast, all the while telling himself, “Less haste, more speed.” It is to be hoped that we are not as possessed by the possibilities of human growth hormone (HGH) as Gollum was by visions of the One Ring. Nevertheless, in dealing with this controversial issue, it is worth noting that a degree of caution is advisable to get us where we need to go.

More than 30 years ago, growth hormone from human pituitary extract was used to treat children of short stature with congenital growth hormone (GH) deficiency. In a study of 12 patients treated with GH compared with 9 untreated controls, conducted in a veterans’ hospital in Milwaukee, WI, in 1990, Rudman demonstrated that many dramatic, positive physiologic changes occurred in normal, elderly patients. He stated, “the effects of six months of human growth hormone on lean body mass and adipose-tissue mass were equivalent in magnitude to the changes incurred during 10 to 20 years of aging.” In a subsequent paper he concluded, “The overall deterioration of the body that comes with growing old is not inevitable. We now realize that some aspects of it can be prevented or reversed.” Since then, the use of HGH has accelerated beyond its classic indication for the treatment of hypothalamic pituitary disease in children and adults with GH deficiency to encompass administration to normal, healthy, aging adults as part of the evolving field of antiaging medicine.

The term antiaging has itself become a source of controversy Some take it to mean reversing aging, some interpret it as slowing aging, and others consider it a synonym for wasted effort. Aging has been defined as longevity in conjunction with survival (minimal heart, lung, and brain function); wellness (being able to participate in activities of daily living and self-care); physical fitness (push-ups, sit-ups, reaction time, visual acuity, running, etc); cell function (accumulation of lipid waste products in the brain, mitochondrial function), and myriad other categories. As outlined in the essay “No Truth to the Fountain of Youth,” biologists accurately argue that aging and degeneration of cells occur fundamentally at the cellular level in spite of any medical, hormonal, vitamin, supplement, or other macroscopic therapy.In spite of eager optimism on the part of some practitioners, we simply don’t have a mechanism to characterize, much less modulate, aging at the cellular level.

There is no doubt of the physiologic effects of HGH. Innumerable studies of the last decade have demonstrated unequivocally that a person’s clinical function can be improved to mirror that of someone years younger. Moreover, guarded optimism is appropriate with respect to any association between HGH administration and cancer; at least to date, there are no data to suggest an increased incidence of cancer resulting from long-term HGH treatment.However, in the evaluation of the healthy patient for HGH administration, the efficacy of treatment remains highly problematic. Controlled clinical trials are the gold standard in the medical literature and should be applied to assess the results of HGH treatment. The study of several hundred patients over a few years in a controlled trial may be required to delineate more precisely the benefits of HGH therapy. In the years to come, understanding of the human genome will guide us in our tracking of outcome at the cellular level. [9] All studies conducted thus far have been longitudinal, without appropriate matched controls, and have been largely based on clinical, not cellular, evaluations. Longitudinal studies lack the power of controlled trials and require many more participants over a much longer period to obtain meaningful data. The data produced are neither strong nor cogent for changes at the cellular level. The widespread off-label use of HGH and the pecuniary temptations for physicians managing large clinics for an aging baby-boomer population hungry to stay young make its judicious clinical use in the face of patient demands extremely difficult, if not impracticable. The cost of hundreds of millions of dollars to achieve a new Food and Drug Administration clinical indication for the use of a drug and the expiration of patent protection within the next several years make the expenditure of research dollars by the pharmaceutical industry highly unlikely.

In the disease approach to health care, a drug has specific clinical indications for its use, such as systolic blood pressure or white blood cell count. In the wellness approach to health care, the indication may simply be “improvement” of a clinical assessment. Demonstrated indications for HGH include improvement with respect to visceral body fat, percentage of body fat, muscle mass, strength, bone density, cardiac output, sense of well-being, cholesterol levels, and improvements in many other health or fitness characteristics of a certain biodemographic age group. These may be used as biomarkers of fitness, and are subject to intervention through diet, exercise, nutrition, supplements, and sleep, as well as HGH. They are not specifically markers of aging. Good medical practice dictates implementation of less invasive, safer, and better understood interventions as first-line therapy. If these treatments fail, second-line, less understood therapies, such as HGH, may be indicated.

Should HGH therapy be continued lifelong in the healthy, 6 days on and 1 day off per week? The measurement of parameters is relatively straightforward, but identifying specific endpoints, clinical outcomes, or goals is more problematic. The list of clinical factors could include many of the following: hitting a golf ball farther, being able to stand in the operating room for increased hours with better concentration, having more energy to participate in family life and community affairs, enjoying a better sex life, losing weight and gaining muscle mass, improving memory, and avoiding future fractures. Are these goals sufficient to warrant a more aggressive and invasive (and expensive) intervention over the safe, effective, less costly conservative ones, given that the delay of old age and longer life through HGH therapy are unproven and, with current technology, unlikely, if not unattainable?.

Although there are many anecdotal reports of HGH abuse in competitive athletes, no responsible physician wisely argues for the “pharmacologic” or superphysiologic replacement of HGH to many times the natural levels produced by a healthy 25-year-old. We do not have an appropriate set of goals or endpoints other than the physiologic replacement of HGH levels to the upper quartile of the natural levels produced in the healthy 25-year-old. This is an important and acceptable first step. However, it is essential that we develop a comprehensive set of goals for patients in controlled clinical trials and measure them prospectively. Only then will we be able to identify suitable patients on the basis of specific biomarkers and measure efficacy in the wellness approach to health care. Researchers may have definitive answers for us in a few years; we have reason to be highly cautious in our approach but optimistic about our ability to find the answer.

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The patient of Fat grafts

In the course of 30 years of aesthetic surgery practice, I have gradually evolved a facial rhytidectomy technique that in my hands produces consistent results while minimizing complications. During my training, wide skin undermining and preauricular skin incisions were routine. Little consideration was given to hairline disturbance, and in many patients the aesthetic improvement was unpredictable and inconsistent. In 1972, Bruce Connell visited the Manhattan Eye, Ear and Throat Hospital and, using one of my clinic face lift patients, demonstrated a submental approach to treating the medial platysma cords. The next year, Sam Hamra borrowed one of my clinic patients to demonstrate the SMAS technique he learned while in practice with Mark Lemmon. To the best of my knowledge, these demonstrations represented the first time either of those techniques was performed in New York City. From these early observations, I learned it is always necessary to be analytical and that aesthetic surgery technique is continually evolving.

In my practice, I continued to evolve a rhytidectomy technique based on my experiences and ongoing education. No single technique best suits all patients, and ancillary procedures are frequently needed to optimize results.

In the past 8 years I have performed hundreds of facial rhytidectomies using a particular technique, the “anterior vertical SMAS lift,” or variations of it, to provide patients with predictable and pleasing aesthetic results. My diagnostic process involves identifying the key facial elements that must be addressed and customizing the surgical plan to achieve maximal improvement. Although I incorporate elements from the work of Sam Hamra, and Dan Baker, I offer significant differences that provide excellent results while minimizing the possibility of complications. I do not recommend this technique for the novice surgeon; execution requires comfort with sub-SMAS dissection and an excellent knowledge of surgical facial anatomy.

Analysis of key facial elements

I begin analyzing key facial areas in each patient to determine how best to achieve aesthetically pleasing results (Figure 1). A preauricular incision is less troublesome and time consuming than a peritragal or retrotragal incision, and in about one-third of rhytidectomies, I am able to use this approach. A mature man or woman generally has a well-defined crease in which the incision can be discreetly placed. However, in younger patients, or if the patient frequently wears her hair back or in a short style that exposes the preauricular area, a peritragal approach is preferable, just as it is when no well defined preauricular crease exists.

To optimize the aesthetic outcome of a face lift, first consider key elements of the face and neck. Hairline height is marked against a fixed point (the ear) and should never be raised more than 1.5 cm above this point. If there is no preauricular crease, use a retrotragal incision. If the malar region is flat, and there is a triangular “hollow” just inferior and lateral, as well as a “bunching up” of subcutaneous tissue cephalad to the nasolabial crease, an anterior vertical SMAS lift is indicated. Consider fat injections or the use of alternate biologic fillers if the nasolabial crease is particularly deep. The jowls will substantially improve with the lift but may also benefit from lipoplasty for further contouring. Correction of microgenia dramatically improves the profile and improves definition of the submental area. I usually suction the submental region. If there is an arch-like appearance to the medial cords (ie, their vertical expanse is separated but the cords meet in the submental region), I will open this area and suture the medial cords. Posterior and superior rotation of the lower SMAS will change the jawline. Open suctioning along this plane may also be necessary. I do not resect a prominent submandibular gland; I personally believe that the possibility of nerve injury is too great. I point it out to the patient preoperatively and explain that it will be present after the procedure. The sternomandibular trough requires careful analysis. While a blunted trough is consistent with a round or heavy face, a deeper trough will enhance an angular or thin face.

The relationship of sideburn to ear position must also be considered. I draw a line from the lowest portion of the sideburn across the ear at this same level; with vertical repositioning of the facial skin, the hairline should not be elevated more than 1.5 cm above this line. To prevent too much elevation, I plan for an additional transverse incision at the lower sideburn and then excise the dog-ear at this level. I have never found it necessary to continue the pretrichial incision superiorly along the anterior hairline.

I frequently perform submental suction lipectomy but rarely use a submental incision to address the cords, preferring a posterior approach to the platysma muscle. However, if there is a visible “arch” when the patient is viewed frontally, I believe this requires a submental incision and suturing of the medial plastysmal cords. When considering the relationship between chin, nose, and jawline, I do not hesitate to recommend a chin implant if I feel it will enhance the aesthetic result.

The sternomandibular trough is an important aesthetic unit delineated by the anterior sternomastoid muscle, the jawline, and a horizontal line from the angle of the jaw intersecting the sternomastoid muscle. It is described as a trough rather than a triangle to emphasize its depth or dimensionality. A deep, well-defined trough enhances the appearance of a well-defined jawline, as long as it is consistent with other facial features.

I have found the anterior vertical SMAS lift to be most effective in dealing with nasolabial folds in patients undergoing facial rejuvenation surgery. I frequently perform fat injections along the nasolabial fold, at the time the rhytidectomy is performed, to further enhance results. However, I do not find biologic fillers effective for treating the nasolabial line without a simultaneous face lift. To analyze this area, I examine the region between the malar prominence and the mound of tissue just cephalad to the fold. I assess whether the intervening area is flat or hollow and digital elevation of the mound improves the malar region and minimizes the fold. The anterior vertical SMAS lift specifically addresses these problems. Additionally, improvement of the marionette lines, if present, and contouring of the jowls and jawline are achieved.

I recently conducted an informal survey regarding the submandibular gland. I sent a brief questionnaire to 11 plastic surgeons across the United States who I believe perform the largest volume of face lifts yearly. One of the questions I asked was how they treat the submandibular gland. Interestingly, not one of them resects the gland. This is consistent with my own experience; I personally believe that the possibility of nerve injury is too great. I make certain the patient understands that the fullness under the jawline may not be substantially improved.

The jawline between the chin and sternomandibular trough is usually improved with the technique described. Some suctioning with a flat blunt cannula under direct vision may also be helpful in defining this area.

Surgical technique

Mark the anatomic landmarks with the patient sitting; include the malar prominence, angle of the jaw, the jowls, the medial platysmal cords, and the extent of submental fat. Administer appropriate anesthesia, then mark preauricular or peritragal incisions. Mark the inferior transverse extent of the sideburn in red and carry this mark onto the ear so that a fixed reference point is visible.

Infiltrate the entire surgical site with epinephrine containing local anesthetic, and prepare and drape the patient. Begin with a punctate incision in the submental crease. Here, insert a blunt 3-mm Mercedes-type cannula and carefully contour this area using suction. If I am dissatified with the result, I extend the incision for further defatting under direct vision.

On the first (infiltrated) side of the face, use a #15 blade to incise along the marked areas. If you marked a retrotragal incision, carefully dissect the skin from the underlying cartilage with nasal tip scissors. Dissection anteriorly and inferiorly superficial to the SMAS is accomplished in a few minutes with Mayo scissors and finger dissection. In the face, the dissection is carried only just beyond the line drawn between the malar eminence and the angle of the jaw (Figure 2 and Figure 3).

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Fat and Fat grafts

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High profile of the implant

Round saline implants remain the most popular choice for breast augmentation, with 86% of women who undergo augmentation receiving round rather than shaped implants. The advantages of round implants include the creation of a “teardrop” profile in the upright position that rounds out in the supine position, mimicking the behavior of a natural breast [2. RS Hamas, The comparative dimensions of round and anatomical saline-filled breast implants. Aesthetic Surg J 20 (2000), pp. 281–290. Abstract | PDF (261 K) | View Record in Scopus | Cited By in Scopus (10) ease of placement through a variety of approaches; and the choice of a smooth or textured surface. However, an important limitation of the standard profile round implants is that the implant size desired by the patient may not have a diameter that corresponds to the base diameter of the breast. If the implant diameter exceeds the base width of the breast, the implant may be circumferentially constricted, resulting in accentuation of rippling ( Figure 1). Such rippling can be especially conspicuous in the thin patient with little breast tissue because of the easier palpability and greater visibility of the implant. These are often the very patients who desire an implant with a relatively larger volume for their respective size.

The effect of circumferential constriction around a saline implant is demonstrated with a tape measure.

Constricted implants may also be more subject to crease folding, possibly contributing secondarily to higher deflation rates. Attempts to expand the implant pocket to accommodate the larger implant may result in overdissection, which in turn can contribute to symmastia on the medial aspect and to trauma to sensory nerves as they course into the breast laterally. Avoidance of overly wide breast implants minimizes tissue trauma from pocket dissection beyond the breast base. It seems reasonable to conclude that the augmented breast with an implant whose diameter comfortably coincides with the anatomical base diameter is theoretically at lower risk for both aesthetic and physical compromise.

The high-profile saline implants introduced in 2002 by Mentor (style 3000; Mentor Corp., Santa Barbara, CA) and Inamed (McGhan style 68HP; Inamed Corp., Santa Barbara, CA) provide a useful option for breast augmentation. With the choice of different profiles in terms of diameter-to-volume ratios, the patient and surgeon can choose the desired implant volume first and then select the implant profile that best matches the patient’s breast base diameter (a low-profile implant is also available).

High-profile implants may also be beneficial in cases of periareolar mastopexy. The geometry of the periareolar mastopexy may result in central flattening of the breast. The greater projection afforded by the high-profile design helps counteract this tendency.

Measurements and implant selection

The external breast base diameter was measured with the use of calipers. Other important dimensions that were measured included the distance from the areolar margin to the inframammary fold and the distance from the nipple to the sternal notch. The aesthetic goal is to center the implant behind the nipple-areolar complex. A simple pinch test will yield an indication of the thickness of the soft tissue envelope. The ideal implant diameter is the external breast diameter minus the soft tissue thickness. Because some degree of periprosthetic soft tissue thinning is to be expected, the surgeon has a reasonable degree of flexibility in determining the implant dimensions, as long as the base diameter of the implant does not exceed that of the breast. An implant with an excessively narrow base will result in an undesirable space between the breasts and unnatural “cleavage.” My preference is to have the patient select the implant size before surgery through the use of trial implants placed in a bra of the desired cup size. Although this process does not translate perfectly into postoperative results, if the patient is adequately informed about the limitations of the process, a good selection can be made. It must be noted that implants tend to appear smaller than expected after implantation. The type of implant is not important in size selection as long as it will conform to the bra because it is used only to determine the desired volume. Once the size is chosen, the implant with the best match to breast base diameter is determined. The typical indication for the use of high-profile implants is a patient with a narrow chest who wants relatively large implants.

The high-profile implants from Mentor and Inamed differ in the ratio of breast base diameter to projection. Calculations from catalog data show that the Mentor style 3000 implants have a ratio of approximately 2.0 to 2.1 at the midrange of fill volumes, compared with 2.1 to 2.2 at midrange for the McGhan style 68HP from Inamed. The Mentor product provides a greater volume at a given breast base diameter but also yields a correspondingly sharper angle of transition from the chest wall to the breast. High-profile implants may not settle into a teardrop profile in the upright position as well as standard profile round implants (Figure 2).

Oblique and lateral views show the different profiles of standard and high-profile implants. A-C, Preoperative views of a 21-year-old woman. D-F, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68 (standard, round) implants, 330 cc filled to 350 cc. G-I, Preoperative views of a 27-year-old woman. J-L, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68HP (high-profile) implants, subpectoral, 320 cc filled to 330 cc. Note that this patient’s chest is narrower than that of the patient depicted in parts A-F, whose chest wall is wider and flatter.

Surgical technique

Preoperative markings were made to facilitate pocket dissection corresponding to the diameter of the implants. Correct positioning of the implants was important in centering the implant behind the nipple-areolar complex. Subpectoral placement may have particular advantages in helping create a more natural transition and compensating for the steeper profile. A closed fill system was always used.

Results

Under the criteria outlined above, 67 of a total of 164 saline breast augmentation patients were selected to receive high-profile implants over a 14-month period. The tendency toward rippling appeared to be diminished, although this parameter is difficult to quantify. Representative results of primary augmentation are shown in Figure 2; results of augmentation with periareolar mastopexy are depicted in Figure 3.

Figure 3. A, C, E, Preoperative views of a 33-year-old woman with postlactational involution and ptosis. B, D, F, Postoperative views 3 months after periareolar mastopexy and augmentation with McGhan style 68HP (high-profile) saline implants, 350 cc filled to 380 cc.

Cases

Three cases are presented to illustrate patient selection for high-profile versus smooth, round implant styles.

Case 1

A 21-year-old woman requested augmentation with 330- to 350-cc implants after trying sample implants in a C-cup bra. She was noted to have a relatively wide and flat chest wall and a breast base diameter of 13.5 cm, with a pinch test finding of 1.5 cm. A 330-cc McGhan style 68 (standard, round) implant with a fill volume of 350 cc and a base diameter of approximately 12.3 cm was selected (Figure 2, A-F).

Case 2

A 27-year-old woman also selected 330- to 350-cc implants. Her chest wall was somewhat narrower than that of the patient described in case 1, with a breast base diameter of 12 cm and a pinch test finding of 1 cm. A 320-cc McGhan style 68HP (high-profile) implant with a fill volume of 330 cc and a base diameter of approximately11.1 cm was selected (Figure 2, G-L).

Case 3

A 33-year-old woman with postlactational involution and ptosis requested implants of 350 to 380 cc. A periareolar mastopexy was recommended, and McGhan style 68HP implants, 350 cc filled to 380 cc, were selected to match the patient’s breast base diameter. The high-profile shape was observed to provide some benefit with respect to central projection.

Discussion

The increasing range of options for breast augmentation with saline implants permits greater customization to suit the patient’s anatomy and preferred implant size. Before the introduction of high-profile designs, a trade-off between volume and base diameter was common. Avoidance of circumferential constriction of the implant through selection of an implant whose diameter is comfortably circumscribed by the breast may help minimize rippling, a common complaint among patients who undergo augmentation with saline implants. Disadvantages of the high-profile design include less mobility of the implant and a less obtuse transition from the chest to the upper breast — in other words, less of a teardrop shape compared with standard round implants.

Conclusion

High-profile saline breast implants offer a useful option for women seeking breast augmentation, particularly women with a narrow chest and little breast tissue. They also offer greater projection to patients who undergo periareolar mastopexy. Disadvantages include the possibility of decreased implant mobility and a sharper angle of transition from the chest wall to the breast.

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The implant of High profile

Round saline implants remain the most popular choice for breast augmentation, with 86% of women who undergo augmentation receiving round rather than shaped implants. The advantages of round implants include the creation of a “teardrop” profile in the upright position that rounds out in the supine position, mimicking the behavior of a natural breast ; ease of placement through a variety of approaches; and the choice of a smooth or textured surface. However, an important limitation of the standard profile round implants is that the implant size desired by the patient may not have a diameter that corresponds to the base diameter of the breast. If the implant diameter exceeds the base width of the breast, the implant may be circumferentially constricted, resulting in accentuation of rippling ( Figure 1). Such rippling can be especially conspicuous in the thin patient with little breast tissue because of the easier palpability and greater visibility of the implant. These are often the very patients who desire an implant with a relatively larger volume for their respective size.

The effect of circumferential constriction around a saline implant is demonstrated with a tape measure.

Constricted implants may also be more subject to crease folding, possibly contributing secondarily to higher deflation rates. Attempts to expand the implant pocket to accommodate the larger implant may result in overdissection, which in turn can contribute to symmastia on the medial aspect and to trauma to sensory nerves as they course into the breast laterally. Avoidance of overly wide breast implants minimizes tissue trauma from pocket dissection beyond the breast base. It seems reasonable to conclude that the augmented breast with an implant whose diameter comfortably coincides with the anatomical base diameter is theoretically at lower risk for both aesthetic and physical compromise.

The high-profile saline implants introduced in 2002 by Mentor (style 3000; Mentor Corp., Santa Barbara, CA) and Inamed (McGhan style 68HP; Inamed Corp., Santa Barbara, CA) provide a useful option for breast augmentation. With the choice of different profiles in terms of diameter-to-volume ratios, the patient and surgeon can choose the desired implant volume first and then select the implant profile that best matches the patient’s breast base diameter (a low-profile implant is also available).

High-profile implants may also be beneficial in cases of periareolar mastopexy. The geometry of the periareolar mastopexy may result in central flattening of the breast. The greater projection afforded by the high-profile design helps counteract this tendency.

Measurements and implant selection

The external breast base diameter was measured with the use of calipers. Other important dimensions that were measured included the distance from the areolar margin to the inframammary fold and the distance from the nipple to the sternal notch. The aesthetic goal is to center the implant behind the nipple-areolar complex. A simple pinch test will yield an indication of the thickness of the soft tissue envelope. The ideal implant diameter is the external breast diameter minus the soft tissue thickness. Because some degree of periprosthetic soft tissue thinning is to be expected, the surgeon has a reasonable degree of flexibility in determining the implant dimensions, as long as the base diameter of the implant does not exceed that of the breast. An implant with an excessively narrow base will result in an undesirable space between the breasts and unnatural “cleavage.” My preference is to have the patient select the implant size before surgery through the use of trial implants placed in a bra of the desired cup size. Although this process does not translate perfectly into postoperative results, if the patient is adequately informed about the limitations of the process, a good selection can be made. It must be noted that implants tend to appear smaller than expected after implantation. The type of implant is not important in size selection as long as it will conform to the bra because it is used only to determine the desired volume. Once the size is chosen, the implant with the best match to breast base diameter is determined. The typical indication for the use of high-profile implants is a patient with a narrow chest who wants relatively large implants.

The high-profile implants from Mentor and Inamed differ in the ratio of breast base diameter to projection. Calculations from catalog data show that the Mentor style 3000 implants have a ratio of approximately 2.0 to 2.1 at the midrange of fill volumes, compared with 2.1 to 2.2 at midrange for the McGhan style 68HP from Inamed. The Mentor product provides a greater volume at a given breast base diameter but also yields a correspondingly sharper angle of transition from the chest wall to the breast. High-profile implants may not settle into a teardrop profile in the upright position as well as standard profile round implants (Figure 2).

Oblique and lateral views show the different profiles of standard and high-profile implants. A-C, Preoperative views of a 21-year-old woman. D-F, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68 (standard, round) implants, 330 cc filled to 350 cc. G-I, Preoperative views of a 27-year-old woman. J-L, Postoperative views 6 weeks after augmentation with subpectoral McGhan style 68HP (high-profile) implants, subpectoral, 320 cc filled to 330 cc. Note that this patient’s chest is narrower than that of the patient depicted in parts A-F, whose chest wall is wider and flatter.

Surgical technique

Preoperative markings were made to facilitate pocket dissection corresponding to the diameter of the implants. Correct positioning of the implants was important in centering the implant behind the nipple-areolar complex. Subpectoral placement may have particular advantages in helping create a more natural transition and compensating for the steeper profile. A closed fill system was always used.

Results

Under the criteria outlined above, 67 of a total of 164 saline breast augmentation patients were selected to receive high-profile implants over a 14-month period. The tendency toward rippling appeared to be diminished, although this parameter is difficult to quantify. Representative results of primary augmentation are shown in Figure 2; results of augmentation with periareolar mastopexy are depicted in Figure 3.

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Stem cells and Adult stem

Identification of multipotential mesenchymal stem cells (MSCs) derived from adult human tissues has led to exciting prospects for cell-based tissue engineering and regeneration. Ongoing research in regenerative medicine may enable us to use living cells and their signaling mediators to repair and rejuvenate tissue. In aesthetic surgery, these therapeutic strategies may be used in the future not only to treat physical signs of aging but also to prevent them.

Several strategies are under investigation. Stem cells can be processed and implanted directly or modified ex vivo before implantation. They can also be combined with biomaterials that provide structural support and growth factors. In addition, endogenous stem cells may be activated by the administration of signaling factors.

Characteristics of adult MSCs

A stem cell is a cell from the embryo, fetus, or adult that can undergo extensive proliferation before senescence and can be differentiated to specialized cells of body tissues and organs. These cells remain in their undifferentiated state through suppression by some intrinsic or extrinsic factor until stimulated. As stem cells self-renew in vivo, their progeny include both new stem cells and committed progenitors with a more restricted differentiation potential. These progenitors, in turn, give rise to differentiated cell types.

The quintessential pluripotent cell is the embryonic stem cell (ESC), which has the ability to differentiate into all bodily tissues. This cell type has been isolated and cultured from 2 sources: (1) the inner cell mass of human embryos at the blastocyst stage, and (2) fetal tissue from terminated pregnancies. During embryonic development, the pluripotency of the ESC is narrowed to tissue-specific determined stem cells. The determined stem cells differentiate into committed progenitor cells that retain a limited capacity to replicate. Despite the pluripotency of ESCs, legal and moral controversies concerning their therapeutic and clinical application have prompted examination of adult MSCs.

Most cells in adult organs are composed of differentiated cells with specific phenotypic and genotypic characteristics. In the past decade, undifferentiated stem cells with varying capacity to develop into different mature tissues have been identified in mesenchymal tissues of adult humans. These quiescent adult stem or progenitor cells have been isolated from many anatomic sites, including brain, pancreas, liver, skin, fat, muscle, blood, bone marrow, lung, and tooth pulp. Adult stem cells may be activated for tissue regeneration during the natural processes of cell turnover and wound healing. As direct precursor cells for mature tissue, adult MSCs differentiate to several lineages, including chondrocytes, adipocytes, lymphocytes, fibroblasts, marrow stroma, osteocytes, myoblasts, cardiomyoblasts, and astrocytes. MSCs not only have the capacity to make specialized cells for the immediate repair or replacement of tissue, but also retain a high regenerative potential to guarantee correct function and cell turnover over time, possibly for a lifetime.

Adult MSCs were thought to develop into a narrow range of cell types that reflected the tissue composition from which they were isolated. However, in recent laboratory experimentation, adult stem cells have exhibited unexpected flexibility, differentiating into many tissue types. The term transdifferentiation is being used to describe this capacity. The plasticity of adult stem cells is thought to be similar to that of ESCs, creating new hope for their use in cell-based therapiesIn addition, MSCs demonstrate a high capacity for replication, with about 38 ± 4 population doublings before senescence.This replication would allow a small population of harvested cells to be expanded in culture before use.

Currently there is no unifying definition of MSCs or list of specific markers that define cell types characterized as MSCs. Instead they are currently defined by their ability to differentiate along specific mesenchymal lineages when induced. MSC potential is routinely determined with the colony-forming–unit fibroblast assay, and MSCs are identified by their expression of Thy-1 (CD90) vascular cell adhesion molecule-1 (CD106), and hyaluronate receptor (CD44).Although antibodies to several cell surface antigens can be used to recognize MSCs, specific molecular probes do not exist to unequivocally identify these cells in situ. Consequently, it is difficult to quantify their actual numbers or identify their precise locations. Moreover, it is speculated that MSCs are a heterogenous population containing cells with varying capacities for lineage-specific differentiation.

Stem cell procurement

Bone marrow aspirate is considered the most enriched source of MSCs. Given the wide distribution of MSC sources, the bone marrow stroma may be the source of a common pool of multipotent cells that access various tissues by way of the circulation, subsequently adopting characteristics that meet the requirements of maintenance and repair of a specific tissue type. This hypothesis is supported by the finding that liver cells with a donor genotype can be found in the bone marrow of transplant recipients.

To be practical, MSC harvest would have to carry a very low morbidity. Although bone marrow aspiration is not a high-risk procedure, pain at the donor site can be considerable. The ideal source of MSCs for aesthetic use would be tissue that is easily accessible and readily expendable. Zuk and associates have shown that adipose tissue, especially lipoplasty aspirate, is a source of MSCs with the potential for differentiation of adipose-derived stem cells into myogenic, osteogenic, chondrocytic, and adipocytic cells. Moreover, lipoaspirate can be easily processed to yield large numbers of stem cells.

Aesthetic applications

There are several possible strategies for using adult stem cells for aesthetic applications. Although large-scale clinical trials using stem cells for aesthetic indications have not yet begun, current research is under way in many laboratories, laying the foundation for this work in the near future.

One approach is to harness the replicative capacity and plasticity of adult stem cells to engineer autologous grafts for soft tissue and facial skeletal augmentation. Skin substitutes engineered from human cells are already in clinical use (eg, Apligraf [Organogenesis, Canton, MA]) and have generated great enthusiasm for the use of in vitro–engineered cells to generate cartilage, muscle, soft tissue, and bone. For example, adult stem cells could be harvested from lipoplasty aspirate and induced to differentiate (in vitro) to osteocytes. These new cells could then be seeded onto a biodegradable scaffold containing osteogenic growth factors and implanted back into the patient as a malar onlay graft. Once in place, the implant assumes the structure of autologous bone. A similar approach can be used for soft tissue augmentation. Adipose-derived adult stem cells may be extracted and stimulated to differentiate in vitro to an adipocyte lineage. The cells would be suspended in a hydrogel and injected with precision as an autologous graft. The problem of variable fat resorption (with standard lipoaugmentation of harvested fat) may be avoided because the newly generated adipocytes demonstrate near-complete engraftment and growth.

A second strategy is to simply deliver undifferentiated adult stem cells in high concentrations to a specific anatomic site. A “critical mass” of transplanted stem cells may serve to initiate a cascade of angiogenesis and repair in local tissues. A growing body of literature indicates that the number of MSCs decreases with age and/or systemic disease and that their relative presence can control the outcome of reparative events of skeletal tissues. Simply increasing the concentration of MSCs in the facial soft tissue at regular intervals during the aging process has the potential to maintain volume and elasticity of the treated structures. Furthermore, adult stem cells can serve as gene-delivery systems; harvested stem cells can be transfected with genes, coding for a range of vital growth factors before implantation. The transfected cells would actively secrete these agents into the surrounding microenvironment.

A third approach involves activating and manipulating endogenous adult stem cells in situ. Administering growth factors, cytokines, and other signaling agents would activate local MSCs and induce migration of distant MSCs, such as bone marrow, to a specific region. Encapsulating these agents in biodegradable polymers would create a sustained-delivery system capable of releasing different signals during key steps in the process of cell differentiation. This strategy could be used for the prevention and treatment of the stigmata of facial aging. Clearly the in vivo management of MSCs will require a more detailed understanding of the molecular steps of each differentiation pathway and the regulatory mechanisms that inhibit such differentiation in quiescent cells.

Conclusion

Manipulation of adult stem cells may play an important role in future aesthetic surgery. Ongoing research to define the cellular and molecular fingerprints of MSCs and to elucidate their role in normal and abnormal tissue functions will lay the groundwork for clinical trials involving the treatment and prevention of aesthetic deformities.

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