Face lift and hair transplantation as a single procedure.

Frequently, when a face lift procedure is performed, several pieces of healthy scalp are discarded as waste unless a prehairline incision is used. In selected cases, such as patients with hair loss, these pieces of scalp may be used to create micrografts (grafts with 1 to 2 hairs) and minigrafts (grafts with 3 to 4 hairs) and transplanted to the areas of need in the same session. I have found particularly rewarding the combination of face lift and hair transplantation, because patients who need both procedures benefit immensely by doing them together. This way, the pieces of healthy scalp that normally would have gone to waste are recycled. In a preliminary fashion, a strip of retroauricular and occipital scalp that normally would be discarded is harvested from one side and handed to my assistants. Under magnification, they dissect it into micrografts and minigrafts as I do the face lift on that side. When I go to the second side of the face lift, I give them the other strip of scalp; again, as they dissect it into grafts, I continue with the face lift. Usually, we generate about 1000 micrografts and minigrafts from those strips that would have normally been discarded. If I want more grafts, I would (in a preliminary fashion) harvest the donor strip of the size required. As the face lift with or without eyelids is completed, we usually have the grafts ready for insertion. Today, we are able to transplant approximately 1000 grafts in about 1 hour. Therefore, combining the two procedures adds only about an hour to our surgical and anesthesia time.     

Latrogenic platelet dysfunction: an emerging peril.

Abnormal bleeding after a face lift was found to be due to a profound interference in platelet function caused by clofibrate and xylocaine acting synergistically. This did not appear to be an idiosyncratic reaction to either of the drugs, as it could be reproduced in vitro by using platelets from normal individuals. Clofibrate is a drug used commonly by persons in the age group requesting face lifts. Beware.     

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.     

Reinforced orbitotemporal lift: contribution to midface rejuvenation

The changes in the aging face occur from progressive ptosis of the skin, fat, and muscle, in conjunction with bone absorption and cartilage atrophy. In the orbital region, hollowness and compartmentalization occur. Conventional face lift procedures correct only the skin flaccidity, and superficial musculoaponeurotic system techniques reposition the skin and platysma without repositioning the middle third of the face, creating an artificial jawline. Subperiosteal rhytidectomy disrupts the anatomy of the periorbita, which gives the patient a certain scarecrow aspect. Composite rhytidectomy associated with brow lift and blepharoplasty may offer better results, with improvement in the malar and orbital regions. The reinforced orbitotemporal lift (ROTEL) is a new procedure in a face lift that allows the orbicularis oculi muscle and all the structures connected to it to be elevated and stretched and the orbitotemporal skin to be raised, repositioning these structures and ending orbital compartmentalization. The result is an impressive improvement in the malar-orbitotemporal region, resulting in a natural and youthful appearance.     

Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis

Deep venous thrombosis and pulmonary embolus are known risks of surgery. However, the incidence of these conditions in face lift is unknown. In this study, the incidence of deep venous thrombosis/pulmonary embolus after face lift is studied and factors associated with thromboembolic complications are evaluated. One-third of the active members of the American Society for Aesthetic Plastic Surgery were randomly selected. Participating surgeons completed a one-page survey providing information on face-lift procedures during a 12-month study period. A response rate of 80 percent was achieved, with 273 of the 342 surgeons responding to the survey. A total of 9937 face-lift procedures were reported in the 1-year study period. There were 35 patients with deep venous thrombosis (0.35 percent), 14 patients with pulmonary embolus (0.14 percent), and 1 patient death in the series. Although 43.5 percent of patients underwent face lift under general anesthesia, 83.7 percent of deep venous thrombosis/pulmonary embolus events occurred with general anesthesia. For prophylaxis for deep venous thrombosis/pulmonary embolus, 19.7 percent of the surgeons used intermittent compression devices, 19.6 percent used thromboembolic disease hose or Ace wraps, and 60.7 percent used no prophylaxis. Of patients developing deep venous thrombosis/pulmonary embolus, 4.1 percent were treated prophylactically with intermittent compression devices, 36.7 percent with thromboembolic disease hose/Ace wraps, and 59.2 percent with no prophylaxis. It was found that deep venous thrombosis/pulmonary embolus after face lift is a measurable complication experienced by one of nine surgeons surveyed. Deep venous thrombosis/pulmonary embolus is more likely to occur when the procedure is performed under general anesthesia. The majority of plastic surgeons surveyed used no prophylaxis for deep venous thrombosis when performing face-lift procedures. Intermittent compression devices were associated with significantly fewer thromboembolic complications, whereas Ace wrap/thromboembolic disease hose afforded no protection against deep venous thrombosis/pulmonary embolus when used alone. In conclusion, aesthetic surgeons should consider adopting intermittent compression devices when performing face lift under general anesthesia.     

Suction lipectomy of the neck

Suction lipectomy of the neck has been advocated in other reports. However, because of skin laxity, a simultaneous face/neck lift has been performed usually. In this series of 49 patients, ages 18 to 73, removal of submandibular fat was performed by suction lipectomy. A simultaneous face/neck lift was not done. In addition, no skin was excised. On the contrary, the apparent excess skin was found to be required for contouring. Approximately one-third of the patients had a simultaneous chin implant. Others had different aesthetic surgical procedures performed during the same operation. The removal of neck fat by suction has proven to be more efficacious than excisional methods of lipectomy. The risks of operation have been found comparable to suction lipectomy performed in other anatomic locations.     

SMAS-platysma face lift

Correction of laxity in the submental area and of hypertrophic neck cords has been enhanced with the SMAS-platysma face life over that which was achieved with a standard skin face lift. Evaluation of a 6-year experience with the SMAS-platysma face lift reveals that the operation can be safely performed with an acceptably low incidence of complications. The incidence of hematoma and associated complications is less than that which occurs when cervical and submental defatting is performed in conjunction with a skin face lift.     

Multiplane face lift with the subperiosteal dissection for orientals

A subperiosteal face lift rejuvenates the midface and periorbital region by restoring facial muscle tone. Since 1993, the authors have performed this procedure on Oriental patients who have their own distinct facial contours: the brachycephalic cranium and a prominent zygoma and mandibular angle. Although it was thought that these protuberances might disturb the subperiosteal procedure, especially in the anterior midface, the procedure could be performed easily by adopting the ancillary upper buccovestibular and subciliary incisions; the authors found that the protuberances actually act as fulcrums to keep up the lifting vectors reliably. For older patients, the procedure was combined with a deep subcutaneous dissection. A simple lift of the periosteum would not improve a severe nasolabial fold deformity and prominent wrinkles adequately because of "lag-lifting" of the superficial layer. It was concluded that the multiplane face lift, consisting of the subperiosteal and the deep subcutaneous approaches, achieves a natural-appearing rejuvenation of the Oriental aging face.     

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.     

Normalized lift: an energy interpretation of the lift coefficient simplifies comparisons of the lifting ability of rotating and flapping surfaces

For a century, researchers have used the standard lift coefficient C(L) to evaluate the lift, L, generated by fixed wings over an area S against dynamic pressure, ?ρv(2), where v is the effective velocity of the wing. Because the lift coefficient was developed initially for fixed wings in steady flow, its application to other lifting systems requires either simplifying assumptions or complex adjustments as is the case for flapping wings and rotating cylinders.This paper interprets the standard lift coefficient of a fixed wing slightly differently, as the work exerted by the wing on the surrounding flow field (L/ρ·S), compared against the total kinetic energy required for generating said lift, ?v(2). This reinterpreted coefficient, the normalized lift, is derived from the work-energy theorem and compares the lifting capabilities of dissimilar lift systems on a similar energy footing. The normalized lift is the same as the standard lift coefficient for fixed wings, but differs for wings with more complex motions; it also accounts for such complex motions explicitly and without complex modifications or adjustments. We compare the normalized lift with the previously-reported values of lift coefficient for a rotating cylinder in Magnus effect, a bat during hovering and forward flight, and a hovering dipteran.The maximum standard lift coefficient for a fixed wing without flaps in steady flow is around 1.5, yet for a rotating cylinder it may exceed 9.0, a value that implies that a rotating cylinder generates nearly 6 times the maximum lift of a wing. The maximum normalized lift for a rotating cylinder is 1.5. We suggest that the normalized lift can be used to evaluate propellers, rotors, flapping wings of animals and micro air vehicles, and underwater thrust-generating fins in the same way the lift coefficient is currently used to evaluate fixed wings.     

Combined rhytidectomy and full-face laser resurfacing

A series of patients undergoing a combined face lifting procedure with simultaneous laser resurfacing is described. Although resurfacing is accepted as safe for deep-plane face lifts and forehead lifts, there are reports of preauricular skin loss with a standard face lift. In this series, 26 consecutive cases are described. A superficial musculoaponeurotic system (SMAS) face lift technique was used. A skin flap was developed no more than 3.0 cm from the preauricular area, and most of that was excised. Full-face laser resurfacing was done with the SilkTouch laser. An 8-mm square pattern was used at 16 to 18 W. Three to four passes were done. Care was taken, however, to do very superficial lasering of the periphery, especially over the small amount of undermined skin that remained. There was no preauricular skin loss. This series demonstrates the safety of combining laser resurfacing with the SMAS technique face lift in regard to preauricular skin loss.     

The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation.

The subperiosteal face lift described by Psillakis has been criticized for not showing a more dramatic improvement over conventional brow/face lift procedures. His approach also has a significantly high incidence of nerve injury. This study reports our anatomic findings and surgical modifications, which have permitted a significant improvement in the safety of execution and clinical results using the subperiosteal face lift concept. Pertinent points of applied local anatomy and dissection techniques are as follows: First, we use extensive interconnected subperiosteal dissection that includes the entire zygomatic arch. This allows better repositioning of the deep soft tissues of the entire upper face, most of the midface, and indirectly, key structures of the lower face. Second, the upward pull of the muscles of the cheek and mouth will produce an elevation of the corner of the mouth, affecting positively the smiling mechanism, the oral frowning, and the jowls. Third, the dissection deep to both layers of the temporal fascia decreases the risk of injury to the frontalis nerve. Fourth, the temporal fascia is used as a lifter and anchoring element of the entire cheek-perioral soft tissues as opposed to the periorbital fibrofatty tissues. This will decrease the risk of injuring the frontal and zygomatic branches of the facial nerve. These modifications have been used in 28 patients. Our rate of patient satisfaction has been high, and no complications with regard to nerve injury have been observed. This compares favorably with our initial 60 patients, in whom the Psillakis or Tessier approach was used. In these patients, there was an 11 and 20 percent rate of nerve injury, respectively.     

Measurement of Force Produced by an Insect-Mimicking Flapping-Wing System

We present a new version of a compact insect-mimicking flapping-wing system driven by a small motor, and suggest two testing approaches to measure the thrust or lift generated by a flapping-wing system. Flapping performance tests show the proposed flapping-wing system, which is powered by an onboard battery (lithium, 3.7 V, 180 mAh), could flap at flapping frequency of 25 Hz, and produce an average thrust or lift of about 3 g. In a wired-flight test under constrained conditions, the flapping-wing system could fly at an average forward velocity of 700 mm·s^?1. For measuring the average thrust or lift produced by the flapping-wing system, we propose two testing approaches of wired-flight test and swing test with the aid of a high-speed camera and they are compared with a load cell measurement. The average thrust or lift values from the two proposed approaches agree well with the average thrust or lift values measured by a load cell.     

Personal experiences and algorithm of endoscopically assisted subperiosteal face lift in orientals for 5 years.

Orientals are anatomically distinct from Caucasians and are characterized by a thick dermis, a Mongoloid slant of the palpebral fissure, a relatively prominent zygoma and mandible angle, and a relatively flat nose. Given these characteristics, it was believed that the subperiosteal face lift was not suitable for Orientals. However, at our institution, endoscopically assisted subperiosteal face lifts were performed from May of 1994 to October of 1998 on 236 patients; variable pitfalls, as well as satisfying results, were reported. Patient ages ranged from 29 to 66 years (mean age, 55.2 years), and follow-up ranged from 6 to 44 months (mean follow-up, 23 months). All forehead and brow lifts were performed using an endoscopic guide, and routine corrugator resections and procerus myotomies were performed. Three slanted cortical tunnels were made at the corresponding locations on the outer table of the calvarium, and 1-0 nylon or screw suspension and fixation were performed after a 1-cm to 2-cm lift. Midface lifts were performed through lower blepharoplasty incisions and vertical temporal incisions instead of through conventional preauricular and postauricular incisions. Dissections were made subperiosteally and over the deep layers of deep temporal fascia. Malar fat pads were suspended with 1-0 nylon and affixed to deep temporal fascia.Most patients have been satisfied with their postoperative results, but unfavorable results and complications have been reported. Complications were classified as early or late complications or unfavorable results on the basis of the 3-week postoperative evaluation. There were 28 early complications (11.9 percent), consisting of ecchymosis with edema (persisting for up to 4 weeks), paresthesia, lagophthalmos, accentuated Mongoloid slant, small dimpling on the scalp, and scalp fold formation on the fixation site. There were 13 late complications/unfavorable results (5.5 percent), consisting of insufficient lift, exaggeration of sunken upper eyelids, intermittent headaches, itching sensations, and paresthesia on the scalp. The unfavorable results occurred in the patients who had previously undergone blepharoplasty and in those who had a history of foreign body injections into the face, fatty and thick faces, sunken upper eyelids, Mongoloid slants, and asymmetric facial expressions. Through understanding the anatomic characteristics of the Oriental face (i.e., thick dermis, Mongoloid slant of palpebral fissure, prominent zygoma and mandible angle, and flat nose), satisfying results were achieved by appropriate application of the modified procedures.     

Subperiosteal brow lifts without fixation

Most surgeons today advocate an endoscopic subperiosteal brow lift for surgical correction of the upper third of the face. At the author's clinic, this operation has been performed since 1994 and the subgaleal bicoronal brow lift is no longer used. In earlier investigations, the author showed that the subperiosteal approach (n = 60) gives a better result than the subgaleal method (n = 60) when compared 1 year after surgery. In the literature, however, there are no published data regarding the long-term results of subperiosteal brow lifts. The author took material from his earlier investigations and looked at the same patients 5 years postoperatively. He compared the subperiosteal approach (n = 30) with the subgaleal brow lift (n = 15) and found that after 5 years the brows of the subgaleal patients were on the same level as they were before surgery, but in the group of subperiosteal brow lifts, almost all of the brows were higher 5 years after surgery than they were 1 year after surgery, with a mean increase in height of 2.5 mm. These findings led the author to the question whether scalp fixation was necessary at all when performing a subperiosteal brow lift. He performed 20 subperiosteal endoscopic brow lifts where scalp fixation was not used at all, relying only on changing the balance of muscle vectors around the eyebrows. Using a computerized instrument, measurements were made of the distance between the medial canthus and the top of the eyebrow, the midpupil and the top of the eyebrow, and the lateral canthus and the top of the eyebrow. All patients were measured before and 1 year after surgery. The author found an increase of the vertical height from the midpupil to the top of the brow, with an average increase of 3.9 mm. There were no differences between patients who had only a brow lift and those who had a brow lift and an upper blepharoplasty at the same time. The author concludes that for most cases where an increased vertical height of the brows of more than 4 mm is not needed, it is not necessary to use scalp fixation to achieve a natural result.     

Depth of the facial nerve in face lift dissections

Facial nerve depth was measured in 12 cadaver face halves after bilateral face lift dissections. The main nerve trunk emerged anterior to the midearlobe and was 20.1 +/- 3.1 mm deep. Nerve exit from the parotid edge also was deep, averaging 9.1 +/- 2.8 mm for temporal, 9.2 +/- 2.2 mm for zygomatic, 9.6 +/- 2.0 mm for buccal, and 10.6 +/- 2.7 mm for mandibular branches. Distal to the parotid gland, danger areas where nerve branches became superficial were distal temporal, lower buccal, and upper mandibular branches over the masseter muscle and marginal mandibular as it crossed the facial artery. Some protection in these danger areas was provided by fascia, especially superficial temporal and masseteric, while platysma provided some protection for the mandibular branch. Fascial and muscle protection was less in thin cadavers. Face lift dissection can be rapid in areas where facial nerve branches are deep or absent, such as postauricular, inferior to the zygomatic prominence, and near the earlobe.     

Unsatisfactory forehead scar following face lift

The W-plasty scar revision technique has been found to be effective in the repair of the difficult and cosmetically unsatisfactory hairline scar following the ill-advised face lift technique that excises forehead skin.     

The Role of Elytra in Beetle Flight: I. Generation of Quasi-Static Aerodynamic Forces

We conducted a comprehensive study to investigate the aerodynamic characteristics and force generation of the elytra of abeetle,Allomyrina dichotoma.Our analysis included wind tunnel experiments and three-dimensional computational fluiddynamics simulations using ANSYS-CFX software.Our first approach was a quasi-static study that considered the effect ofinduced flapping flow due to the flapping motion of the fore-wings (elytra) at a frequency of around 30 Hz to 40 Hz.The dihedralangle was varied to represent flapping motion during the upstroke and downstroke.We found that an elytron producespositive lift at 0° geometric angle of attack,negative lift during the upstroke,and always produces drag during both the upstrokeand downstroke.We also found that the lift coefficient of an elytron does not drop even at a very high geometric angle of attack.For a beetle with a body weight of 5 g,based on the quasi-static method,the fore-wings (elytra) can produce lift of less than 1%of its body weight.     

Mechanics of scars

When a wound heals, as everyone has observed, it contracts, thickens and wrinkles the neighbouring skin, forming a scar. The morphology of the scar depends on the type of wound; an urgent tracheotomy leads to a very different scar than a carefully planned face lift. The surgical challenges of intrusive procedures such as removal of skin lesions, skin transplantation or grafting, and scar removal are complicated by the complex geometry and stress states in different parts of the body. We show that, for relatively general conditions, the nature of the localisation of the scar is determined by the background tension of the skin which can arrest the formation of wrinkles around a scar. Our physical experiments to simulate this procedure indicate that the region deformed by the defect has a characteristic length scale r* approximately 1 square root of tau, where tau is the natural tension of the skin.     

Stretching and tissue expansion for rhytidectomy: an improved approach

Intraoperative expansion of the skin of the face supplies additional tissue that permits closure of the face lift incision with minimal tension. This paper presents the findings in rhytidectomy patients over the last 3 years using both intraoperative stretching and intraoperative stretching combined with tissue expansion utilizing the Man face lift expander. Sixty-seven patients underwent rhytidectomy surgery, of whom 50 were treated with stretching techniques alone and 17 were treated with the combined stretching and expansion method. The patients' ages ranged from 28 to 78 years. Results indicate that the patients treated with combined stretching and expansion had significantly more skin removed. This new technique appears to offer significant clinical advantages over usual face lifts.