Browplasty and browpexy: an adjunct to blepharoplasty

Surgical approaches to the eyelids and eyebrows have been refined by application of their anatomy and appreciation of their pathophysiology. Sexual variations in eyebrow appearance can be attributed in part to the eyebrow fat pad. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is flatter and at the level of the supraorbital rim. The eyebrow fat pad is more prominent in the male, producing a fuller appearance in the lateral brow area. Many women are concerned about the flatter, full lateral brow, which assumes a masculine quality. The authors describe a surgical technique that permits identification of the brow fat pad and then the ability to debulk the eyebrow (browplasty). In addition, the brow can be elevated by internal plication suture to physically elevate the eyebrow (browpexy). This procedure is designed to utilize an eyelid crease incision, and it reduces the indications for more involved procedures to eliminate brow ptosis, such as midforehead or coronal approaches.     

Extended upper blepharoplasty for lateral hooding of the upper eyelid using a scalpel-shaped excision: a 13-year experience

Excess skin of the upper lids is often accompanied by lateral overlap of skin with crow's feet because of the absence of fixation to the tarsal plate, giving the eye a sad, heavy look that often disturbs the lateral visual field. The accepted crescent-shaped blepharoplasty is somewhat convex, which is widest at the center of the lid with or without a lateral extension. However, in patients who have normal brow position or minimal eyebrow ptosis and whose main concern is the excess upper eyelid skin and lateral hooding, such a crescent excision may not suffice. A scalpel-shaped excision that is widest laterally and that tapers to a point medially will extirpate the maximal skin where it is most needed and overcome the skin excess in the lateral aspect of the upper lid. Between 1990 and 2002, 301 white patients (275 women and 26 men) between the ages of 33 and 79 years were operated on using the extended scalpel-shaped upper blepharoplasty technique. The follow-up period was more than 1 year. The lower margin of the incision is along the supratarsal crease, about 10 mm above the ciliary line. It begins medially about 1 cm above and lateral to the medial canthus. Above the lateral canthus, the skin marking is gently curved upward and outward, often within a natural skin crease or crow's feet to reach a little below and slightly beyond the lateral extremity of the eyebrow. The upper border of the incision joins the two extremities of the skin outline in a gentle convex curve. The general outline of the incision takes on the shape of a number 20 scalpel blade in which the maximal width is located laterally. Following excision of the excess skin and removal of protuberant fat pads if needed, suturing is executed from lateral to medial. The final suture line is in the form of an oblique flattened lazy S. Following the removal of the stitches on the fifth postoperative day, no wound dehiscence was noticed at the lateral scar zone. In the older individuals, due to the lax skin, the scar becomes scarcely noticeable with time and often falls within a pre-existent crow's feet crease. Elimination of some of the crow's feet was also demonstrated. In patients with visual field impairment, significant functional and visual improvement was achieved. Most patients mentioned a pleasing postoperative open "Oriental" look of the eyes. The extended scalpel-shaped upper blepharoplasty adequately deals with the hooding of the skin laterally. This technique overcomes the excess of skin in both vertical and horizontal directions, since in suturing the lateral part of the skin defect in an oblique plane, slack skin is taken up transversely, and the technique provides some indirect upward support to the lateral eyebrow. In the absence of crow's feet in the younger person, this technique is not recommended because the lateral part of this suture line is visible, especially if the scar widens.     

Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique

Scarring eyebrow loss is usually repaired with a hair-bearing island scalp flap or scalp strip grafting technique. The results, however, are usually not desirable with regard to appearance. In this article, a one- or two-hair graft with a dense-packing technique was developed for cicatricial eyebrow reconstruction. It was carried out by harvesting a scalp strip close to the hairline of the back, then dividing it into a series of one- or two-hair grafts, and finally implanting the grafts into the prepared recipient holes of the eyebrow with a desired hair direction. With the authors' experience in treating 96 patients (154 eyebrows) in cases of burn, skin grafting, traumatic scarring, and chemical peeling scar after tattoo removal, the eyebrows could be restored in only one session. In general, 150 to 200 grafts with 200 to 250 hairs were needed for a complete male eyebrow reconstruction and 100 to 150 grafts with 150 to 200 hairs were needed for a complete female eyebrow reconstruction. The maximal hair density was 91.5 hairs/cm per session. Over a 6-month follow-up period, the mean graft survival rate reached 98.1 percent. All of the patients achieved satisfactory results, with a very natural appearance. These results indicate that the above-mentioned technique could be a practical, effective, and probably ideal method for cicatricial eyebrow reconstruction.     

Reconstruction of facial defects with superficial temporal artery island flaps: a donor site with various alternatives

Color and texture match is crucial in reconstruction of facial tissue defects. Between March of 1997 and July of 2000, island flaps based on the parietal, anterofrontal, centrofrontal, posterofrontal, and superior auricular branches of the superficial temporal artery were used in the reconstruction of tissue defects localized on different regions of the face in 28 patients. According to the size and the location of the defect, the flap was selected. There were 15 male patients and 13 female patients, with ages ranging between 19 and 74 years. In six of the flaps, venous congestion was observed. Because of the elevation of the eyebrow on the flap side, three patients required a sling to the opposite eyebrow. Excellent color and tissue match and transfer of hair-bearing tissue to the eyebrow and beard areas were achieved with no other complications. Satisfactory aesthetic results were gained.     

Septal crossbar graft for the correction of the crooked nose

Surgical management of the crooked nose still constitutes a problem that is difficult to solve because of the possibility of recurrence and the risk of weakening the supporting structures. The authors propose an innovative surgical technique for the correction of this deformity that takes into account both aspects of the problem. The technique combines septoplasty by means of staggered intracartilaginous incisions with the original positioning of a unilateral spreader graft. Once realignment of the deviated cartilages is achieved, this cartilaginous stent, referred to as a "crossbar graft," makes it possible to keep the mobilized axis firmly in the correct position over time. This graft is also quite effective from a functional point of view in restoring the correct angle of the internal nasal valve. Moreover, the technique allows for the harmonization of the aesthetic line from the eyebrow to the tip-defining point on the concave side with the same line on the other side.     

Verifying surgical results and risk factors of the lateral thoracodorsal flap

In 1986, the combined use of the lateral thoracodorsal flap and an implant was introduced as an alternative method of delayed reconstruction of small to medium-size breasts for postmastectomy patients who are reluctant or unable to consider reconstruction by tissue expansion or by more extensive autologous tissue transplantation. So far, the technique has only been proven reproducible in Sweden. Postmastectomy radiotherapy has been proven to increase the risk of wound-healing complications after lateral thoracodorsal transplantation, and additional risk factors such as advanced age, obesity, smoking, and some general health characteristics have been indicated. The authors initiated a prospective study to assess the reproducibility of this technique outside Sweden and to confirm the proven risk factor, prove or refute the alleged ones, and possibly identify additional factors. Additionally, they applied the technique for immediate breast reconstruction and tried to expand the indications and applications of the lateral thoracodorsal flap even further. The authors report on their initial experience with 60 lateral thoracodorsal flaps and conclude that the use of this flap is a well-reproducible technique for breast reconstruction, with few complications leading to failure. Using the lateral thoracodorsal flap in combination with tissue expanders allows for reconstruction of breasts of larger than medium size. Moreover, the authors successfully applied fully deepithelialized lateral thoracodorsal flaps for additional indications. The statistical significance of postmastectomy radiotherapy as a risk factor could not be confirmed, but some general health characteristics were found to be significant patient-related risk factors. Out of five procedure-related characteristics, only increased flap length was proven to negatively influence the outcome of the procedure.     

Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers

Although the gluteal V-Y advancement flap has been recognized as the most reliable method for management of sacral pressure ulcers, its limited mobility has been a challenging problem. The authors present a new modification of the V-Y advancement flap to overcome the problem. After débridement, a large triangle is designed to create a V-Yadvancement flap on the unilateral buttock and the medial half is elevated as a fasciocutaneous flap, preserving the distal perforators in the muscular attachment. Then an arc-shaped incision is made in the gluteus maximus muscle along with the lateral edge of the triangular flap. The split muscle is elevated at a depth above the deeper fascia until sufficient advancement of the flap is obtained. This full-thickness elevation of the gluteus maximus muscle from the distal (lateral) side avoids the impairment of perforators or their mother vessels and achieves great advancement. Thirty-one patients with sacral pressure defects larger than 8 cm in diameter were treated using this surgical procedure. Overall, 93.5 percent of the flaps (29 of 31) healed primarily. The largest defect that was closed with a unilateral flap was 16 cm in diameter. The present technique accomplishes remarkable excursion of the unilateral V-Y fasciocutaneous flap, with high flap reliability and preservation of the contralateral buttock as well as gluteus maximus muscle function.     

Anthropometric measurements of the endoscopic eyebrow lift in the treatment of facial paralysis

Endoscopic eyebrow lift was performed on 51 patients presenting with eyebrow ptosis due to facial paralysis. The resulting anthropometric measurements of eyebrow position were analyzed statistically to evaluate the effectiveness of this method. When preoperative eyebrow differences between the paralyzed and nonparalyzed sides were measured, the average difference at midpoint was 4.4 mm, and at the highest point, 4.6 mm. When the same points were measured postoperatively, the average difference at midpoint was 2.4 mm, and at the highest point, 2.3 mm. The difference in eyebrow height between the paralyzed and nonparalyzed sides correlated positively with age, both preoperatively and postoperatively. However, differences between preoperative and postoperative eyebrow height (which reflects the effectiveness of endoscopic eyebrow lift) at the highest point did not correlate with age and at the midpoint displayed a slightly negative correlation with age. These results suggest that endoscopic eyebrow lift is effective among young patients whose eyebrow ptosis is minor and is relatively ineffective among elderly patients whose eyebrow ptosis is severe. The conventional method of juxta-brow excision is indicated for elderly patients, for whom the operative scar is almost inconspicuous.     

Muscles that act on glabellar skin: a closer look

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

医学文眉深浅探讨

本文认为医学文眉是古代文身术与近代医学的结合,是永久性画眉。详细地介绍了医学文眉的材料,方法与适应证。首次将文眉分为追求自然型与润色修饰型。正常求美者和眉型不足者都适合于文眉。鉴于目前除皮肤切除术外,尚无彻底消除文眉痕迹的方法,本文还分析了文眉术后的近期、远期效果,及文眉效果不满意时的补救措施,强调高水平的文眉。讨论了选色深浅、针刺深浅及皮肤深浅与文眉的关系,各深浅的优缺点,并提议文眉时针刺的深度以浅为妙。文中所介绍和讨论的方法。同样适用于文身术。     

Male perineogenital anatomy and clinical applications in genital reconstructions and male-to-female sex reassignment surgery

To determine the possibility of providing alternative surgical techniques for male genital reconstruction and for male-to-female sex reassignment surgery, the authors undertook an anatomic investigation of the perineogenital region in male cadavers. Anatomic dissection was performed on 14 male adult human cadavers (fresh and formalin-preserved) studying the main afferent vessels to the anterior perineal region and their mean internal diameters: deep external pudendal artery (0.60 mm), superficial perineal artery (0.50 mm), and funicular artery (0.37 mm). We established their exact topography, together with vascular anatomic variations, main vascular anastomosis circuits (base of the penis, scrotal septum, and perineal fat and lateral spermatic-scrotal fascia), angiosomes, anatomy of the rectovesical septum cavity, and their "critical" key points of dissection. The authors discuss the clinical possibility of elevation of a "tree" of previously described paragenital-genital flaps including mainly those based on the terminal branches of the internal pudendal vascular system, the erectile tissue pedicled flaps, and finally, flaps of the external pudendal system. The authors indicate the concrete vascularization system for each flap.     

The superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy

Most patients who undergo facial cosmetic surgery procedures that could cause lower eyelid retraction or ectropion should have an additional surgical procedure to support the lower eyelid and lateral canthus. The lower eyelid should be supported when performing laser planing of the eyelid; midface elevation through a lower eyelid incision approach; or conventional blepharoplasty, in patients with lower eyelid laxity. Suspending the lateral canthus by surgically altering the lateral canthal tendon is a proven technique that can provide support for the lower eyelid. However, a technique of this complexity may be unnecessary for most cosmetic surgery patients. To increase understanding of the fascial support system of the lateral canthus, four fresh cadaver dissections were performed to investigate the attachments of the lateral canthus to the lateral orbital rim. The most commonly appreciated attachment between the eyelids and the lateral orbital rim is the lateral canthal tendon (the lateral canthal raphe). However, the lateral canthus also is attached to the orbital rim at a more superficial level through the septum orbitale. This superficial fascial plane may be modified and used as a structure to stabilize or suspend the lateral canthus. This structure is defined in this article as the "superficial lateral canthal tendon."     

Bilateral cleft lip and nasal repair

SUMMARY: The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.     

Adaptation of scapula lateral rotation after reverse anatomy shoulder replacement

Scapula motion is significant for support of the arm and stability of the shoulder. The effect of the humeral elevation on scapular kinematics has been well investigated for normal subjects, but there are limited published studies investigating adaptations after shoulder arthroplasty. Scapula kinematics was measured on 10 shoulders (eight subjects) with a reverse total joint replacement. The measurements were performed using an instrumented palpating technique. Every subject performed three simple tasks: abduction, elevation in scapula plane and forward flexion. Results indicate that, lateral scapula rotation was significantly increased (average of 24.42% over the normal rhythm) but the change was variable. Despite the variability, there is a clear trend correlating humeral performance with increased rotation (R2 0.829). There is clearly an adaptation in lateral scapula rotation in patients with shoulder joint replacement. The reason for this is unclear and may be related to joint pathology or to muscle adaptation following arthroplasty.     

Reconstruction of the eyebrow in the pediatric burn patient

We have reviewed our experience with reconstruction of eyebrow alopecia secondary to thermal injury in the pediatric patient. Reconstruction was performed with free composite strip grafts or vascularized island pedicle flaps. The complication rates for eyebrows reconstructed with vascularized island pedicles with respect to loss of a significant portion of the flaps (30.8 percent) and malalignment of the grafts (23.1 percent) were significantly greater (p less than 0.001) than the significant tissue loss (10.6 percent) or graft malalignment (7.9 percent) observed for free composite grafts. Hair density was more predictably restored with the free composite graft technique (p = 0.0004). The patients reconstructed with composite grafts had 89.4 percent acceptable results in contrast to 38.5 percent acceptable results obtained with the island pedicle technique. Based on these findings, we reserve the use of the vascularized island pedicle technique for male patients with unilateral alopecia and heavy hair density in the remaining eyebrow and in cases where free composite grafts have failed. The remaining patients are initially treated with free composite grafts with acceptable results in the overwhelming majority of cases.     

The thin latissimus dorsi perforator-based free flap for resurfacing

The authors present their experience with "thin" latissimus dorsi perforator-based free flaps for resurfacing defects. Perforator-based free flaps have been used for various kinds of reconstruction by presenting important donor structures. The thin latissimus dorsi perforatorbased free flap included only the skin and superficial adipose layer to reduce its bulkiness by dissection through the superficial fascial plane. This flap was used in 12 clinical cases, without flap necrosis or other serious postoperative complications. All of the patients were examined by preoperative power Doppler ultrasound in the spectral Doppler mode to search for the most reliable perforator. This noninvasive ultrasound technique determines the exact location and course of and ensures the reliable flow of the perforators; therefore, it greatly assists microsurgeons in saving operation time and in selecting the most suitable design for perforator flap reconstruction. We used perforators that were identified several centimeters from the lateral border of the latissimus dorsi muscle. The thin flap dimensions could be safely designed for flaps measuring up to 20 cm in length and 8 cm in width for primary closure of the donor site. Generally, a long pedicle is not required for resurfacing reconstructions, where small recipient arteries in the bed are acceptable for anastomosis with pedicles. However, pedicle dissection to the proximal vessels through the latissimus dorsi muscle was required when it was necessary to match the recipient vein for anastomosis. The authors conclude that this thin latissimus dorsi perforator-based free flap has great potential for resurfacing because of its constant thickness, easy elevation with the help of power Doppler ultrasound information, and proper flap size for moderate defects caused by scar contracture release, superficial tumor ablation, and so on.     

Flow-through anterior thigh flaps with a short pedicle for reconstruction of lower leg and foot defects

New flow-through perforator flaps with a large, short vascular pedicle are proposed because of their clinical significance and a high success rate for reconstruction of the lower legs. Of 13 consecutive cases, the authors describe two cases of successful transfer of a new short-pedicle anterolateral or anteromedial thigh flow-through flap for coverage of soft-tissue defects in the legs. This new flap has a thin fatty layer and a small fascial component, and is vascularized with a perforator originating from a short segment of the descending branch of the lateral circumflex femoral system. The advantages of this flap are as follows: flow-through anastomosis ensures a high success rate for free flaps and preserves the recipient arterial flow; there is no need for dissecting throughout the lateral circumflex femoral system as the pedicle vessel; minimal time is required for flap elevation; there is minimal donor-site morbidity; and the flap is obtained from a thin portion of the thigh. Even in obese patients, thinning of the flap with primary defatting is possible, and the donor scar is concealed. This flap is suitable for coverage of defects in legs where a single arterial flow remains. It is also suitable for chronic lower leg ulcers, osteomyelitis, and plantar coverage.     

Simplifying the vertical reduction mammaplasty

The vertical reduction mammaplasty is an evolving technique. Its proponents report significantly decreased scarring, better breast shape, and more stable results compared with the standard inverted-T method, but the learning curve is long and cosmetic outcomes can be inconsistent. Many surgeons have experimented with the vertical closure before returning to methods more familiar to them. The authors present their modifications to the vertical reduction mammaplasty. Their changes simplify the preoperative markings and the intraoperative technique to shorten the learning curve while maintaining reliable aesthetic results. With the patient standing, only four preoperative marks are made: (1) the inframammary fold; (2) the breast axis; (3) the apex of the new nipple-areola complex; and (4) the medial and lateral limbs of the vertical incision. In the operating room, a medial or a superomedial pedicle is developed. Excess breast skin is resected with the inferior and lateral parenchyma as a C-shaped wedge. The lateral skin-adipose flap is redraped inferomedially and sutured to the chest wall. The inferior aspect of the breast is aggressively debulked and a gathering subcuticular stitch is started 2 cm below the nadir of the nipple-areola complex. Finally, a 38-mm to 42-mm nipple-areola complex marker is used to create a circular defect that is offset 0.5 cm medial to the vertical axis of the breast. In their series, 56 patients were treated and no major complications were noted. The median follow-up period was 17 months. The average reduction was 554.5 g per breast; however, the reduction was greater than 1000 g per breast in eight patients. The authors found that (1) chest wall anchoring improves lateral contour and minimizes axillary fullness; (2) aggressive debulking inferiorly avoids the persistent inferior bulge; and (3) starting the subcuticular gathering suture 2 cm below the nipple-areola complex followed by placement of a nipple-areola complex marker at the conclusion of the case prevents lateral deviation and corrects the nipple-areola complex teardrop deformity. These innovations accelerate the learning curve by simplifying the preoperative markings and lead to more consistent postoperative results and an improved cosmetic outcome. In conclusion, these modifications yield a simple, easily learned vertical reduction mammaplasty with aesthetically reliable results.     

Reappraisal of island modifications of lateral calcaneal artery skin flap

Reconstruction of soft-tissue defects of the calcaneal region and the heel is very demanding and necessitates, as a rule, a sensate and thin flap. The ideal characteristics of a sensate and thin layer of flap should be combined with a reliable blood supply and minimal morbidity at the donor site. The authors report an updated review of their experience with the use of island modifications of the lateral calcaneal artery skin flap-the lateral calcaneal island flap, the lateral calcaneal V-Y advancement flap, and the bilobed-shaped lateral calcaneal island advancement flap-for the reconstruction of small and medium-sized tissue defects over the exposed calcaneal tendons and calcaneal bones of 18 patients. All of the procedures were performed under spinal or epidural anesthesia. There were no problems associated with flap viability, but the authors have seen necrosis of undermined skin between the lateral malleolus and calcaneal tendon in two cases and a partial loss of skin graft in one case. In this article, the authors discuss some advantages and disadvantages of the use of a lateral calcaneal island flap and its modifications.