Archive for October, 2009
The upper eyelids and brow should be considered together for rejuvenation of the upper third of the face. The upper eyelid is one of the first areas of the face to show signs of aging, with excess skin. If left long enough, the redundant skin can obstruct a patient’s peripheral vision. Patients often complain of heaviness of the upper eyelid with outside observers commenting that the patient looks tired. Along with redundant skin, the upper eyelid can have bulging of the fat pads that surround the eye. The excess fat should be removed during upper eyelid blepharoplasty (eyelid lift).
The brow descends with age due to laxity in the supporting structures. The lateral, or outer portion of the brow, descends at an accelerated rate when compared to the central portion of the brow because of differences in attachment to the underlying soft tissue and bone. This results in a more rapid accumulation of redundant skin on the outer portion of the upper eyelid, which is termed “lateral hooding.” When determining the correct brow lift procedure, the surgeon should determine if the effects of aging on the brow include primarily the lateral brow or the more central portions of the brow. If there is a significant discrepancy in aging of the central and lateral brow, with the lateral brow primarily affected, a lateral temporal brow lift may be indicated. With this procedure an incision is placed in the hair overlying the temple and the brow is elevated in an upward and outward direction to restore its natural arch and youthfulness.
Often times patients do not seek consultation until the effects of aging are more advanced with the central brow having dropped significantly, as well. In this instance a total brow rejuvenation procedure should be performed, with several options currently being used. The most state-of-the-art brow lift procedure is the endoscopic brow lift whereby the brow is lifted using tiny incisions in the scalp and telescopes to release the brow and reposition it in an elevated position. There is controversy as to the effectiveness of this procedure. Over time, it has become apparent that in experienced hands it is an equally effective, less invasive procedure.
The trichophytic brow lift, an open technique, camouflages the incision by placing it in the hairline mirroring the entire length and carrying the incision down into the hair tuft over the temples. This is an effective technique that is still commonly used today by many surgeons. The primary consideration is whether the patient is willing to tolerate a much longer incision and more invasive procedure. Other types of brow lifts still used today, although less commonly, include: the coronal, direct, and midbrow lift with specific indications for each technique. The direct and midbrow lift place incisions in the forehead skin and are typically indicated for facial paralysis and older, male brow lifts respectively. The coronal brow lift approach places a large incision in the central scalp from ear to ear and is almost never indicated for rejuvenation procedures, but rather as an approach to facial trauma and head and neck procedures. The coronal brow lift incision may be indicated to reverse a previously over pulled brow procedure that has resulted in a “surprised look.”
When considering the upper eyelid and brow as a unit, one must restore brow position prior to removing upper eyelid skin to prevent “lagopthalmos,” or eyelid retraction, and dry eye. If the brow is at an appropriate height with a youthful arch, the upper eyelids may be addressed without a simultaneous brow lift. When a low brow position and redundant eyelid skin occur together, a brow lift should accompany an upper eyelid blepharoplasty with the brow lift performed first to prevent negative outcomes.
When patients present with primary concerns about their upper eyelids, the brow must be assessed at the same time in order to get optimal results. When a low brow is not corrected at the same time as the upper eyelid blepharoplasty, a future brow lift procedure can have a much higher complication rate and may preclude the procedure all together. Finding a surgeon who is familiar with the many brow lift techniques and assesses the brow and eyelids together as a complex, is important to avoid complications and deliver optimal results.
Post provided by: Blepharoplasty | Eyelid Lift Atlanta GA | Benjamin C. Stong MD
Loss of facial volume is part of the aging process, along with loss of elasticity and photoaging. Correction of facial volume with autologous fat transfers is not a substitute for surgery. Rather, it should be viewed as a complimentary procedure and should be planned with a global perspective on the individual facial aesthetics. Facial fat volumes peak in the late teenage years and then begin to diminish with time. Interestingly, many women feel the peak of beauty is around 30 years of age, after some facial volume has already been lost. Facial fat transfers can be used to either restore facial volumes or augment certain features the patient desires to accentuate.
The fat is harvested from easily accessible areas of excess fat including: the buttocks, thighs, and abdomen. It is then purified and injected in directed areas of the face to fill folds and shape the face. Areas of the face that are commonly treated with fat transfers are the cheeks and cheekbones, the troughs underneath the eyelids, the nasolabial fold (or laugh line), the lateral brow, and lips. Whenever there is free transfer of nonvascular tissue, only a certain percentage of that tissue survives. Variability in harvest and purification techniques and the amount of muscle movement in the recipient area, affect the survival of the fat transfers. In general, survivability is improved by using smaller suction cannulas to harvest, isolating individual fat cells, and injecting into areas of the face with less muscle motion. As such, the nasolabial fold area and lips are less likely to have a successful transfer, and the troughs under the eyelids have a higher success rate.
Correcting laxity in the facial tissues with lifting and tightening procedures should be performed prior to, or simultaneously with fat transfers to avoid overfilling the face. Procedures that should be considered prior to having a permanent facial augmentation material injected include: a face lift, midface lift, and brow lift. Rarely are facial fat transfers indicated as an isolated, sole, procedure. Often patients use non permanent facial fillers to fill in troughs and folds during times when the facial laxity is still fairly youthful. The next logical step in a patient’s mind may be to get a permanent filler to avoid the need for repeated injections. The difficulty with this idea, is that the facial soft tissues will continue to lose support and drop with age, necessitating further rejuvenation surgeries. Following surgery, the areas that may require fat transfers may be different than the areas that were injected during youth due to soft tissue repositioning.
Facial fat transfers are an art form, with the most important aspect being able to understand the global facial aesthetic perspective. Understanding the areas most likely to have a good outcome and the decision of when to inject is not always straight forward. In general it is a good idea to perform fat transfers either simultaneously with additional surgical procedures or secondarily as an adjunctive procedure to restore youthful facial volumes. Overfilling can look awkward, resulting in unhappy patients. There is a subgroup of people who are good candidates for isolated fat transfers at an early age or patients who decide they will never be interested in future surgical procedures and elect to use transfers as their primary rejuvenation procedure. These patients may undergo multiple transfers during their lifetime to try and retain a youthful appearance resulting in an “inflated look.” When considering fat transfers, one should find a surgeon who uses contemporary techniques and understands the impact of fat transfers on future surgeries and facial aesthetics.
Post provided by: Facial Fat Transfers Atlanta GA | Benjamin C. Stong MD
Skin cancer is the most common malignancy in humans, with the order of frequency in descending order: basal cell carcinoma, squamous cell carcinoma, and melanoma. Mohs micrographic surgery is used to remove basal and squamous cell carcinoma with frozen section tumor control and a subsequent closure of the defect that should follow essential reconstructive principles. The majority of the Mohs surgeries are performed by either fellowship trained or non fellowship trained dermatologists. Most simple closures are performed by the Mohs surgeon, often with good outcomes. Some patients request a referral to a facial plastic surgeon with significant experience if the lesion is on the face.
The options for reconstruction include: secondary intention, elliptical primary closure, local flap closure, regional flap closure and skin grafts. Uncommonly tissue expanders or free tissue transfer may be necessay with very large defects and is beyond the scope of this article and will be addressed in later posts. Cartilage grafts from the ear or rib can be used to strengthen nasal repairs preventing nasal obstruction or recontour ear defects, and infrequently, bone grafts from the skull may be needed to help rebuild total or near total nasal defects.
With primary closures, the defect should be converted into an ellipse with elevation of surrounding tissue and proper closure technique. Tissue eversion turns out the edges of the skin, puckering the incision to compensate for wound contraction, and is critical to create an imperceptible closure. Placing the incision parallel to relaxed skin tension lines is of primary importance in order to camouflage the incision, orienting it to the naturally occurring wrinkles that develop in the face. The incisions can be revised with either surgical removal and closure or skin resurfacing procedures, after healing for a minimum of 9 months to a year.
Local flap closures are used to repair larger defects that exceed the ability to perform an elliptical primary closure. Geometric patterns are created in the adjacent tissue of the face and flaps of muscle and skin or skin only are rotated into the defect. Consideration of blood supply is essential when designing these flaps of tissue to insure their survival and optimal wound healing. When transposing tissue from the surrounding area it is very important to understand how the direction of pull these flaps generate will affect important surrounding structures such as the eyelid, brow, lip, and hairline. If the flap is placed in the wrong orientation, there can be significant distortion of these structures resulting in patient dissatisfaction.
Regional flaps use tissue from other areas of the face and move it into the defect area. The workhorse regional flaps in Mohs reconstruction are the paramedian forehead flap and cheek interpolation flap. The donor areas come from the central forehead and cheek skin respectively. There is a pedicle with an arterial supply to the end of the flap that is preserved crossing over an intervening area of normal skin while the flap develops a native circulation. The blood supply to the tissue is conducted through the bridge of tissue that is left attached to its origin and arterial supply for at least three weeks. Because the survival of the flap is dependent on leaving it attached, a second stage is required to remove the bridge of tissue and finish the reconstruction of the defect area as well as restoring the donor site. These types of flaps are usually reserved for larger defects of the eyelid, nose, and ear.
Skin grafts are usually reserved for patients who cannot undergo local and regional flaps for either medical of personal reasons. The skin is usually donated from around the ear or the neck and placed into the defect. Because there is no direct blood supply to the tissue, it usually takes longer to heal. Typically, there are more unsatisfactory results due to the longer healing process and the mismatch of skin, but they are convenient for both patient and physician because the procedure is a single stage.
Mohs reconstruction is challenging and requires an experienced surgeon who understands the decision process that goes into closing a defect. Most of the reconstructions can be performed in the office on the same day as the removal. Steroid injections and massage are used to hasten the healing process and improve outcomes if needed. When considering having a Mohs reconstructive procedure it is important to find an experienced surgeon, who understands the challenges and pitfalls of the surgeries and has experience with all the types of reconstructive techniques to achieve optimal outcomes.
Post provided by: MOHS Micrograpic Surgery Atlanta GA | Benjamin C. Stong MD
The lower eyelids and midface are structures that should be considered together when planning rejuvenation procedures. There is a youthful transition from the lower eyelid that is lost with age resulting in a bulging lower eyelid and a trough, “a double contour deformity.” Proper restoration procedures must consider reconstructive principles when developing and perfecting techniques. Contemporary trends have moved away from making incisions just below the lash line in blepharoplasty to using incisions on the inside of the eyelid with fat removal and skin pinch excisions. The natural course of aging on the face results in a loss of facial fat volume and hollowing. The removal of fat from the lower eyelid can result in a sunken appearance. Contemporary techniques are now trending towards fat preservation and repositioning to conserve facial fat thus creating a natural transition between the lower eyelid and midface.
The aging process of the lower eyelid and midface is complex. The tear trough deformity is characterized by a fold that occurs between the bulging of the lower eyelid and upper cheek. Correction of this deformity requires a keen understanding of midface and lower eyelid anatomy. In the near future lower eyelid blepharoplasty will trend toward fat repositioning procedures to translocate the fat the bulges from the lower eyelid and orbit into the groove to create a natural youthful transition to the upper cheek. This can only be achieved through the incision below the lash line.
The nasolabial fold lies between the base of the nostril and the corner of the lip. It deepens with age due to dropping of facial fat pads. It is also one of the most difficult areas to correct. Because there are many procedures that attempt to address the issue, there is no perfect procedure. To date the two most effective procedures to lift the midface fat pads and smooth the nasolabial folds are the deep plane face lift and the transtemporal subperiosteal extended midface lift. The medical literature supports the idea that the effect of the deep plane face lift on the nasolabial fold is short when compared to its effect on the lower cheeks and neck. The extended transtemporal subperiosteal midface lift offers an anatomically advantageous procedure to effectively lift the central cheek area to reposition the facial fat pads to a more youthful position creating a more natural transition between the cheek and lower eyelid through very small incisions that are well camouflaged in the temporal hair. Many other attempts to perform midface lift surgery use the same access points but either ignore or inadequately release the soft tissues of the cheek, temple, and nasolabial folds leading to sub optimal results and early failure.
Others perform a midface lift through an incision in the lower eyelid and effectively release the tissues of the central midface, cheek, and nasolabial fold, but they uniformly fail to release the outer portions of the cheek and temple that results in tethering during repositioning and early decent to its original position with an unacceptably high rate of lower eyelid malposition. Expecting the lower eyelid, which should be considered a non load bearing structure, to support the weight of the midface can result in pulling the lower eyelid down, an unusual appearance, and problems with watery, dry eyes.
Optimal rejuvenation of the midface usually requires a lower eyelid blepharoplasty with fat preservation and repositioning with an extended transtemporal subperiosteal midface lift. Addressing the midface through traditional face lift incisions has been reported, but is not as effective at achieving maximal long term repositioning. There are several surgeries that are relevant to total midface rejuvenation. Except in younger people, rarely is the midface lift indicated as an isolated procedure. It can be performed in conjunction with a traditional face lift or brow lift procedure to avoid multiple surgeries and healing times. Performing safe effective midface surgery is challenging to even the most experienced surgeons. When considering a surgeon, understanding the procedure and how it will address a patient’s specific concerns is of paramount importance to meet expectations.
Post provided by: Midface Lift Surgery Atlanta GA | Benjamin C. Stong MD