Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.     

新型强脉冲光治疗雀斑临床疗效观察

目的:观察新型强脉冲光治疗雀斑的疗效。方法:采用飞顿辉煌激光360嫩肤系统(以色列飞顿公司),波长570～950nm,光斑面积10mm×30mm,脉宽10、12、15ms,能量14～19J/cm~2。治疗40例雀斑患者,每三周一次,共治疗5次,末次治疗后评价患者雀斑的疗效。结查:40例患者经过治疗后,18例(45%)基本完全消退,14例(35%)明显消退,8例(20%)好转,总有效率为100%。所有患者面部治疗区域皮肤质地较以前更光滑、细腻,无严重不良反应出现。结论:采用新型强脉冲光治疗雀斑疗效显著、安全,副作用少。     

强脉冲光光子美容技术的回顾与进展

强脉冲光(intense pulsed light,WL)是一种高强度的,多光谱的,非相干的光源,它的波长范围在500nm～1200nm,这些特性使强脉冲光在以皮肤组织对不同波长的光具有选择性吸收并产生光热解效应的原理为基础的无损伤性皮肤美容治疗中具有较广泛的应用。同时,与传统的治疗皮肤光损伤与光老化的方法比较,强脉冲光光子美容技术具有治疗效果好以及病人恢复时问较快等优点。文中回顾了强光光子嫩肤技术的产生及近年来的研究进展,说明强脉冲光光子美容技术是一种新颖的、有效的、非损伤性的治疗皮肤光损伤、光老化的方法,具有良好的美容医疗应用前景。     

Applications of the classic dermal fat graft in primary and secondary facial rejuvenation

Volumetric facial aging occurs primarily as a descent of facial soft tissues, followed by their secondary atrophy. Proper volumetric facial rejuvenation, therefore, demands effective superior redistribution of fallen soft tissues, for which the author prefers malar imbrication. Only then do augmentative adjustments become appropriate, including solid facial protheses, "soft-tissue" fillers, dermal fat grafts, free-fat micrografts, and Erol's "tissue-cocktail." Of these, the author prefers the time-honored dermal fat graft for all primary volumetric augmentations within the surgical field, reserving free-fat micrografts for adjustments outside the field and those performed secondarily. Dermal fat grafts are added to the face in three categories: "camouflage" grafts from the anterior face lift discard specimen to correct contour irregularities in the sculpted subcutaneous cheek in half of patients; "transition" grafts from the suprapubic abdomen to the zone between the midface and lower face in 5 percent of patients with an emaciated quality to their aging; and "secondary" grafts from the abdomen in occasional patients with volumetric deformities following inexpert face lift and other forms of trauma. All grafts were harvested, prepared, and placed according to 10 straightforward technical principles. The grafts were highly effective and predictable in their ability to augment contour; none of 283 total grafts were regarded as a treatment failure. The use of such grafts was extremely safe, with complications limited to cyst formation in 1.5 percent of grafts, all of which were treated nonoperatively. The use of the dermal fat graft is seen as safe, effective, and convenient when the subcutaneous plane of the face is exposed during facial rejuvenation. The majority of grafts were derived from the face lift discard specimen. Although those that came from outside the head and neck presented extra inconvenience and operative time, their use was limited to occasional and challenging circumstances that justified extra investment.     

Treatment of poikiloderma of Civatte on the neck with an intense pulsed light source

Effective treatment of poikiloderma of Civatte is difficult. The ideal treatment combines elimination of both the vascular and pigmented components simultaneously. Treatment with a broad-spectrum noncoherent intense pulsed light source delivers multiple wavelengths with software-controlled pulse durations and sequencing that permit treatment of both vascular and pigmented lesions simultaneously. The objective of this study was to determine the response and side effects of treating this condition with intense pulsed light. In the study, 66 patients with typical changes of poikiloderma of Civatte on the neck were treated with intense pulsed light at various settings every 4 weeks until the desired improvement occurred. A 50 to 75 percent improvement in the extent of telangiectasias and hyperpigmentation was observed after an average of 2.8 treatments. The incidence of hypopigmentation was 5 percent. It was concluded that intense pulsed light is an effective mode of therapy for poikiloderma of Civatte. It seems to offer a reduction in both pigmentation and telangiectasia-associated erythema, with minimal side effects.     

Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts

Tumescent infiltration has been widely used in body-contouring surgery to facilitate dissection and reduce blood loss. Although its use in facial surgery has been suggested, there are presently no comparative studies of its efficacy. The aim of this study was to investigate the long-term outcome in a large series of consecutive face lifts performed with and without tumescence. During a 6-year period, 678 consecutive face lifts were performed: 449 without tumescence and 229 with tumescent infiltration using 200 ml on each side of the face. The spectrum of techniques included the extended superficial musculoaponeurotic system (SMAS) procedure, the lateral SMASectomy, the extended supraplatysmal plane lift, and the cutaneous face lift. Complications, such as hematoma, skin necrosis, alopecia, and scar quality, were compared between groups using Fisher's exact test. The use of tumescent infiltration facilitated dissection, particularly in the neck. Postoperative swelling and bruising were reduced in the tumescent group. In comparisons of major complications between groups, no difference was seen in hematoma rate (p > 0.5), although the incidence of other complications was significantly reduced by tumescent infiltration. Significant reduction was observed in the rate of skin necrosis (p = 0.03), alopecia (p = 0.006), hypertrophic scarring (p = 0.001), stretched scarring (p = 0.003), and scar revision (p < 0.001). This is the first comparative study of tumescent infiltration in facial rejuvenation surgery. Tumescence made dissection easier and significantly reduced the incidence of troublesome complications. The surgical technique and aesthetic implications for rejuvenation surgery are discussed.     

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.     

Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining

In the past 8 years, short-scar cervicofacial rhytidectomy has been used with great success and a high level of patient satisfaction. The operation involves limited incisions in the sideburn and preauricular areas, extending just around the fold of the ear lobule. Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed mainly at this level. Skin undermining is kept to a minimum, eliminating the need for extended incisions to reduce dog-ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making such an operation practical and is the reason why the skin incisions can be kept short. Dissection of large areas of skin and separation of the skin from the underlying SMAS necessitate larger incisions. The operation is safe, speedy, less traumatic, and well tolerated among patients at high risk, such as smokers. The risks of complications are also reduced with this operation.     

Is the treatment of axillary osmidrosis with liposuction better than open surgery?

Axillary osmidrosis is an annoying, although not life-threatening, problem that includes unpleasant odor and the occasional staining of clothing. Suction-assisted lipectomy has been tested as a treatment for axillary osmidrosis with variable success. The authors retrospectively reviewed 134 patients who underwent superficial liposuction for bilateral axillary osmidrosis in their division between June of 1998 and June of 2002. The surgical complications and results were compared with those reported in their previous report of 343 patients (102 available for postoperative result evaluation) who received open surgical treatment with partial excision of axillary skin and subcutaneous tissue. The overall complication rate was 3.73 percent, significantly lower than the 11.08 percent complication rate seen with open surgical treatment. Of their 134 patients, 114 were available for long-term follow-up. Thirteen patients (11.40 percent) had very good results, 79 patients (69.30 percent) had good results, and 22 patients (19.30 percent) had poor results. Significant differences were found between those who underwent superficial liposuction and those who underwent open surgery. The number of patients with very good and good results decreased significantly from 91.18 percent (open surgery) to 80.70 percent (liposuction), and those with little or no improvement increased from 8.82 percent (open surgery) to 19.29 percent (liposuction). Compared with open surgery for the treatment of osmidrosis, liposuction produces significantly fewer complications but is less effective. Of the patients who underwent liposuction for osmidrosis, 80 percent were satisfied with the result. Further study is needed to determine whether liposuction for osmidrosis can be improved.     

Harvesting fat from the infratemporal fossa

As part of forehead rejuvenation and surgical treatment of migraine headaches, the mass of the corrugator supercilii, the procerus, and the depressor supercilii muscles is replaced with fat for optimal aesthetic contouring of this region and to help prevent recurrence of the glabellar lines. The authors propose a new fat graft donor site that is convenient and safe and that adds only minutes to the total operating time. This fat is located between the deep layer of deep temporal fascia and the temporalis muscle as it approaches the zygomatic arch. The temporal musculofascial anatomy as it relates to the available fat donor sites is described. This source has been used on 74 occasions at 128 sites, from July 1, 2002, to December 31, 2002, with no complications attributable to the technique.     

The use of skin grafts in postburn contracture release: a 10-year review

Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.     

Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication

The rejuvenation technique of malar imbrication, which avoids dissection in the plane of the seventh cranial nerve, is presented to address the author's altered priorities in midfacial rejuvenation. These priorities target volumetric over tension-based goals in a manner that is simpler, safer, and more sculpturally effective than existing techniques. Volumetric manipulations in the subperiosteal and subcutaneous planes also bring substantial rejuvenation to the periorbital and perioral regions, without lip or lower lid incisions. Fourteen of the 172 patients (8 percent) who underwent consecutive procedures for primary facial rejuvenation suffered temporary upper lip paresis. Other complications were infrequent and limited. One patient underwent reoperation for asymmetry. Increased postoperative swelling and recovery are a necessary consequence of the subperiosteal component, just as increased operative time attends the wide undermining of the subcutaneous component. Despite these liabilities, the author recommends adding volumetric resculpture to the existing conventional tools of soft-tissue displacement under tension and topical resurfacing in pursuit of safer, more effective, and more natural rejuvenation of the aging face.     

强脉冲光治疗鲜红斑痣的血管能量分布模拟

根据鲜红斑痣的病理特点,建立分层模型中包含分立血管的皮肤模型,以血管为主要研究对象,用蒙特卡罗的模拟方法模拟在强脉冲光系统治疗鲜红斑痣中,血管中光能量密度的分布规律.结果显示与单波长激光相比,强脉冲光照射下血管中光能量的分布更加均匀,在光束传输方向上能量梯度更平坦;且血管中能量极大值更小.     

Intraoperative tissue expansion in rhytidectomy revisited

Intraoperative tissue expansion is an adjunct that has been used during rhytidectomy to rejuvenate the face and neck. This technique has been thought to allow for additional skin resection and, thus, increased skin tightening during rhytidectomy. The stretch of the skin by expansion should allow for additional skin resection before closure. Also, when the force of the underlying expander is removed, the expanded skin would recoil and the advancement of the flap should become tighter, with improved results. The technique achieved some popularity a few years ago but has received little recent attention. In this study, the authors attempted to compare face-lift results of adjunctive intraoperative tissue expansion during rhytidectomy with similar techniques without intraoperative expansion. The results of 50 female patients who underwent rhytidectomy for midface rejuvenation by a single operating surgeon composed the study group. Twenty-five of the patients had undergone rhytidectomy that addressed the cheek, chin, and neck areas without expansion (nonexpanded rhytidectomy group). The other 25 patients (expanded rhytidectomy group) had adjunctive intraoperative tissue expansion performed with the rhytidectomy. A tissue expander was temporarily placed beneath the rhytidectomy flaps on each side and expanded in a standard manner before final skin resection and closure. Frontal and lateral photographs were evaluated by 54 examiners. Preoperative and postoperative photographs of the 50 patients were viewed side-by-side by the examiners. The patients were presented in blind fashion and random order. The examiners graded the results of each patient on a scale of improvement from 1 to 10, with 10 being the maximum level of improvement. The scores were recorded and statistically evaluated by using the two-sample test. Evaluation of the examiners' scores showed that the mean rating given to patients in the expanded rhytidectomy group was 5.07 (SD = 1.12). The mean rating for the nonexpanded rhytidectomy group was 5.27 (SD = 1.57). When the two groups were compared using the two-sample test, the difference between the two was not statistically significant (p = 0.6127). Intraoperative tissue expansion as an adjunct to rhytidectomy did not result in improved facial rejuvenation in this patient series. The authors' impression is that the benefits of tissue expansion do not justify the added expense, time, and risks associated with using tissue expansion during rhytidectomy.     

Pulsed and scanned carbon dioxide laser resurfacing 2 years after treatment: comparison by means of scanning electron microscopy

Studies have reported short-term and long-term (1-year) findings for laser skin resurfacing. Two of the most popular systems used for this procedure, the continuous-wave Sharplan 40C SilkTouch system and the pulsed Coherent 5000C UltraPulse system with a computer pattern generator, were previously compared for a range of follow-up times up to 1 year, using light microscopy and transmission electron microscopy. This study analyzed the 2-year morphological differences using scanning electron microscopy. Tissue samples were obtained from 10 patients (age range, 50 to 72 years; skin types II and III) who had undergone laser resurfacing 2 years previously. One half of the face of each patient had been treated with the continuous-wave system and the other half with the pulsed system. The samples were subjected to scanning electron microscopy. On the continuous-wave-treated side, significantly better dermal collagen organization was observed at 2 years, with plump-appearing fibers that were closely knit to form a compact structure. On the side treated with the pulsed system, the collagen fibers in the papillary dermis were more loosely arranged and appeared drier. In both the continuous-wave-treated and pulsed-treated areas, the epidermis appeared healthy and exhibited some signs of age-related deterioration, with slightly flatter plaques and somewhat more flaking keratin on the pulsed-treated side. Probably because of the greater degree of residual thermal damage associated with the continuous-wave system, at 2 years after treatment there was more prolific synthesis and better orientation of collagen fibers, which were maintained for longer times, compared with the pulsed-treated specimens.     

The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases

The use of conscious sedation is rapidly gaining acceptance and popularity in plastic surgery. At the present time, many procedures are performed using intravenous sedation and local anesthesia. The purpose of this article was to examine the safety and outcome of full abdominoplasties performed under conscious sedation at the authors' institution. Over a 6-year period from 1997 to 2002, 266 abdominoplasties were performed by the two senior authors. One hundred thirteen of these (42 percent) were performed under a general or regional anesthetic because a concurrent procedure was performed that precluded the use of conscious sedation (64 hysterectomies, 18 hernia repairs, six urogynecologic procedures, 10 breast reductions, and one laparoscopic cholecystectomy) or because of patient and surgeon preference (14 cases). One hundred fifty-three abdominoplasties (58 percent) were performed under conscious sedation using intravenous midazolam and fentanyl along with a local anesthetic. No patients had an unplanned conversion to deep sedation or general anesthesia. Eighty percent of these cases were performed with a concurrent procedure (80 liposuctions, 19 breast augmentations, 20 mastopexies, three capsulotomies, and 13 varied facial aesthetic procedures). In addition, 12 patients had concurrent hernia repairs (five ventral and seven umbilical) under conscious sedation. Mean follow-up was 10 months (range, 1 to 56 months). There were no intraoperative complications and no major postoperative complications. The minor complication rate was 11.1 percent (10 seromas requiring needle aspiration in the office, three superficial wound infections, two cases of marginal skin necrosis, one stitch abscess, and one pseudobursa requiring reexcision). Seven revisions were performed for suboptimal scars (5 percent). The results of this study demonstrate that abdominoplasties can be performed under conscious sedation in a safe and cost-effective manner for almost all patients. This type of procedure is well tolerated, has a low complication rate, and has high patient satisfaction. Increasing experience and small modifications in local anesthesia and surgical technique have strengthened the authors' conviction that conscious sedation is the preferred method of anesthesia for most patients undergoing abdominoplasty.     

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps.Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.     

Treatment of midfacial defects using prostheses supported by ITI dental implants

The purpose of this study was to evaluate retrospectively the use of ITI dental implants used for anchoring facial prostheses in the restorative treatment of midface defects. The authors analyzed the clinical data of 26 patients with orbital defects (n = 11), orbitonasal defects (n = 4), orbitonasomaxillary defects (n = 3), and nasal defects (n = 8). Data included age, sex, primary disease, implant position, implant length, implant failure, prosthetic attachment, radiation therapy, and peri-implant skin reactions. Follow-up was at 1, 3, 6, and 12 months and then on a yearly basis. The authors noted the status of healing and complications, if any. In total, 62 implants were placed as follows: 27 (43.5 percent) for orbital prostheses, 12 (19.4 percent) for orbitonasal prostheses, 14 (22.6 percent) for orbitonasomaxillary prostheses, and nine (14.5 percent) for nasal prostheses. Thirty-eight implants (61.3 percent) were placed in previously irradiated areas in 18 patients (69.2 percent). Mild skin reactions together with mild accumulation of sebaceous crusting around implants were recorded in 14.2 percent of the skin observations. No patient experienced severe inflammation requiring administration of systemic antibiotics or surgical revision. Implant success was 100 percent in both irradiated and nonirradiated patients. In conclusion, ITI dental implants result in a high rate of success in retaining midface prostheses and offer good stability and aesthetic satisfaction.     

Aesthetic eyelid ptosis correction: a review of technique and cases

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.     

Anterolateral thigh flap donor-site complications and morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.