Frank Zegarra 1, Walter Zegarra 1, Carmen R. Talavera 1, Antonio M. Quise 2,3 1 Clínica Zegarra, Lima, Peru; 2 Grupo de Investigación Biomédica Web Med Research, Lima, Peru; 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A. Facial and neck aging involves a progressive change of the facial volume and neck texture resulting from atrophy and deflation of the midface, increasing neck laxity and the descent of face soft tissue.1 Such process distorts the homogeneous topographical appearance and primary arcs of the young face creating the inverted heart shape that characterize aging.1 Plastic surgeons offer a variety of minimally invasive techniques for face and neck rejuvenation, but some of these techniques remain more controversial than others due to variable success rates and effect’s sustainability.2 Among them, there are three techniques that we believe we can combine, and if used in the right order, could help to achieve a more impactful face and neck rejuvenation. Each of these techniques are sound in evidence and includes YAG Nd laser-lift 3, thread-lifting 4, and genioplasty 5. Here, we present the outcomes of our first two cases using this novel technique. Procedure. Following standard surgical protocols, under general anesthesia, the procedure starts by using the laser face-lift technique with a pulsed 1064-nm Nd:YAG laser (Smart-Lipo; Deka, Italy). The laser is delivered via a 600-microm fiber encased in a 1-mm micro-cannula introduced through a 1-mm incision with the following parameters: 10-12 watts of average power; 0.3 msec pulse duration; 50-60 Hz frequency; and, by controlling the skin surface temperature below 42 °C with a handheld non-contact thermometer. This technique allowed us to achieve a well-distributed lipolysis together with a simultaneous skin retraction and immediate blood coagulation within local small blood vessels. Second, we use the thread-lift technique to avoid secondary skin flaccidness, which is a common side effect of the laser face-lift. Here, we can use either polypropylene (permanent) or polydioxanone (non-permanent) threads to sustain the skin (which can be anchored or loose), choosing the thread depending on the desired outcome. And third, we project the chin for an optimal definition of the neck by using the genioplasty technique. To do so we use an intraoral incision, take off the muscle subperiostically leaving a portion attached to the periosteum, and completely release the chin. Then we use a Nylon 3-0 to advance the muscles attached to the genial tubercle underneath the neck as well as to project the adipose tissue. Indirectly, by projecting the chin we also tighten the skin in the area of the lower lip, jowls, and marionette lines, helping to better define the mandibular contour and a better-defined neck. Finally, compressive dressings are used two days after the procedure (for the whole days), and for next three weeks during the night. Follow-up visit were scheduled at one month, three months and six months after the procedure. Case Reports. Patient 1 A 51-year-old man presented in August 2016 with severe neck skin laxity on his face and neck requesting rejuvenation surgery in order to restore his self-esteem. At subsequent assessments, spanning over two months, it was mutually agreed that standard face and neck rejuvenation procedures might not be sufficient to leverage his expectations, but surgical outcomes might improve significantly if we combine them. The patient fully consented and the risks of some postoperative scarring were clearly outlined to him. The procedure was performed in October 2016. His preoperative photographs demonstrated a severe skin laxity with excess skin in the jowls as well as in the upper and lower parts of the neck, which were the patient’s main aesthetic concern (Figures 1A and 1C). At the six-month follow-up the patient showed a marked improvement in the area of the cheek, nasolabial folds and neck, which led to complete satisfaction of the procedure outcomes (Figures 1B and 1D). Patient 2 A 46-year-old man presented in November 2016 with severe neck skin laxity and early aging face signs requesting rejuvenation surgery in order to reinstate his self-confidence. At subsequent assessments, spanning over three months, it was mutually agreed that separate face and neck rejuvenation procedures might not be sufficient to clout his expectancies, but surgical outcomes might improve significantly by combining them. The procedure risks, including postoperative scarring and residual pain, were clearly outlined to the patient and he fully consented. The procedure was performed in February 2017. His preoperative photographs demonstrated a severe skin laxity in the neck with a poor definition of the facial contour and neck, which were the patient’s main aesthetic concern (Figures 2A and 2C). At the six-month follow-up the patient showed a marked improvement in the definition of the jowl, cheeks, and neck, which led to complete satisfaction of the procedure outcomes (Figures 2B and 2D). The surgical outcomes also helped the patient to improve his overall quality of life and to perform better socially and professionally. Discussion The cases shows that the combination of the techniques YAG Nd laser-lift, thread-lift, and genioplasty might allow us to fully satisfy patients that require face and neck rejuvenation by obtaining excellent cosmetic results with little recovery time. This procedure overall offers an effect that is more that the sum of the individual effects of each technique, through synergy and opportunity. Such innovation could represent a breakthrough discovery in the scope of face and neck rejuvenation procedures, but certainly we would need to confirm that by carrying on the necessary randomized controlled trials. In the absence of such evidence what we can say is that by combining these three techniques we really are addressing the main cosmetic disruption of aging, which are skin laxity and the lost of the primary arcs of the young face. The advantages of complement laser-lift with thread-lift are clear in the sense that skin laxity is highly sensitive to both procedures, but thread-lift reduces the likelihood of skin flaccidness secondary to laser face-lift and reinforce both effect for synergy and sustainability. And if we add the effects that genioplasty can offer to address the skin laxity at the upper and bottom neck, we certainly can offer a more impactful face and neck rejuvenation similar to the two cases we describe here. Patient Consent The patients provided written consent for the use of their images. Conflict of interest The authors declare that they have no conflicts of interest.
Purpose: The aim of this study is to evaluate the use of resected orbicularis muscle as an autogenous graft for palpebral suspension to the frontalis muscle in the treatment of blepharospasm. Methods: Case report Female patient, aged 70, treated with botulinum toxin injections (XEOMIN) since 2010 every month. Given the ineffectiveness of the course of treatment, a myomectomy of the orbicularis muscle associated with a palpebral suspension to the frontalis muscle is considered. Methods: Technique Sub ciliary incision. Anterior lamella dissection. Lower orbicularis muscle dissection. Resection of the lower orbicularis muscle (to treat the spasm). Employment of the resected orbicularis muscle to achieve palpebral suspension. Incision in the upper palpebral fold. Anterior lamella dissection and tarsal exposure. Fixation of the resected orbicularis muscle to the tarsus with three 6.0 Vicryl sutures. Frontal incision above eyebrow. Passage of the orbicularis muscle suspension. Reformation of the upper palpebral fold with 6.0 Vicryl. Fixation of the orbicularis to the frontalis muscle. Closure. Results: 13 months after the operation the patient is satisfied with the treatment. The clinical examination indicates an improvement in her blepharospasm syndrome (even without botulinum toxin treatment) and an appropriately positioned upper eyelid. Discussion: The authors have reviewed the results of the international literature. Numerous studies have been made on the different techniques and materials used in frontalis suspension surgeries. In this study we will focus our discussion on the advantages and disadvantages of the employment of silicone (synthetic graft material), orbicularis muscle, temporal muscle aponeurosis and fascia lata (autologous graft materials). The main advantages of synthetic graft materials are the simplicity of the procedure and the pliability of the eyelid. The disadvantages of these methods are, on the one hand, the risk of extrusion and breakage and, on the other hand, the cost and the limited durability. The main advantages of autologous methods are that they are well tolerated, strong and lasting in the long term. With regards to the temporal muscle aponeurosis and fascia lata, the disadvantages of these materials are, on the one hand, the scar on the donor site and, on the other hand, the length of the operative procedure. When harvesting fascia lata an additional surgical field must be provided. With regards to the resected orbicularis muscle, the main disadvantage is that results must be analyzed in the long term as this is the first patient treated by this technique. Conclusions: The use of resected orbicularis muscle as an autogenous graft for palpebral suspension to the frontalis muscle in the treatment of blepharospasm has proven to be a simple, aesthetic and effective alternative technique. Bibliography: J. W. Henderson Essential Blepharospasm, Transactions of the American ophtalmological society, 1956 J.S. Elston Botulinum A Toxin for ocular muscle disorders. Lancet, 1986 D. Dressler at al. Frontalis suspension surgery to treat patients with blepahrospasm and eyelid opening apraxia: long term results; J Neural Trans, 2017 F Viterbo at al. Aesthetic and Non-aesthetic Indications for Orbicularis Oculi Myectomy. Aesth Plast Surg, 2016 T.J. Broadbent et al. A survey of current blepharospasm treatment patterns among oculoplastic surgeons; OPRS 2016
TIPS ON THICK SKIN RHINOPLASTY Jamal Jomah, MD, FRCSC, FRCSEd, ABHRS, FACS Triple Board (USA, Canada, UK) Consultant Plastic Surgeon General Manager - Med Art & Ajmal Clinics Governor - American College of Surgeons - KSA Director - ATLS Course INTRODUCTION The thick skin is a challenge in Rhinoplasty as it obscures the fine details obtained while sculpting the nasal structures. Traditionally, it was thought that Rhinoplasty on thick skin is played with unsatisfactory results due to the development of polly beak deformity or due to lack of definition and even possible scarring. New technical developments and tips have been introduced to modify the standard rhinoplasty. PURPOSE / AIM The aim of this paper is to describe the latest technical tips and demonstrate it by video. METHOD A literature review is conducted to define the patients’ thick skin both in clinical features and radiological measurements and the comparison was highlighted between thick and thin skin. The literature was reviewed for all the technical pre, intra, and post-operative tips that can be used in such patients. RESULTS and DISCUSSION It appears that there is no standard definition of thick skin. The literature is based on some clinical findings but there are no objective measurements to determine this. Radiological measurements were performed in this case and then one of the papers reported in the literature and this has shown for the first time that thick skin can be measured by CT scan. CONCLUSION The presentation has demonstrated that thick skin rhinoplasty can be performed with a very good results provided that the surgeon is aware of the technical refinements that should be considered during the procedure.
Title : Acquired Deep Superior Sulcus: Treatment with Hyaluronic Acid. Case Report. Authors: Thierry Malet , Barbara Villanustre. Centre d’Ophtalmologie Monticelli Paradis, Marseille, France Purpose: This study aims to evaluate the effectiveness of hyaluronic acid fillers as a nonsurgical alternative in the management of acquired deep superior sulcus Materials and Methods: Case Report Female patient, 32 years old referred for evaluation because of aesthetic concern on left upper eyelid. The patient has noticed the current cause of consultation 3 years ago and has never been treated for this condition. No history of trauma or other accompanying illnesses. No past ocular history. Upon physical examination, asymmetric supratarsal crease, with abnormally deep left superior sulcus. Left eye enophtalmos revealed by Hertel exophtalmometry readings of 15mm in the right aye and 14mm in the left eye. Vision 10/10. Rest of eye examination is normal. Our concern about the orbital and sulcus asymmetry prompted us to review an old CT scan which revealed evidence of maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls consistent with silent sinus syndrome Treatment options were discussed with the patient: orbital floor augmentation surgery; lipofilling; hyaluronic acid fillers. Course of treatment was decided with injection of 1 ml of cross-linked and non cross-linked hyaluronic acid 15 mg/ml with 0,3% lidocaine in the left superior sulcus and orbital rim in the sub orbicularis plane with a retrograde injection bolus technique. The same process was repeated 1 month later with 1 ml of the same product in the left superior sulcus and orbital rim and 0.5 ml in the right superior sulcus and orbital rim. Results: The patient was satisfied with the cosmetic improvement after hyaluronic acid injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 2,5 years. Discussion: The authors reviewed the results of international literature. Many studies have been made on the employment of hyaluronic acid fillers as a nonsurgical alternative in the management of periorbital hollows. Compared to lipofilling and orbital floor augmentation surgery we find that the main advantages of hyaluronic acid fillers are that they are simple to employ, have no “recovery time” and procedures can be repeated; while their main disadvantages are that they are absorbable and the risk of granulomas and late edemas. This study confirms literature data. Conclusion: Hyaluronic acid has proven to be a simple, aesthetic and effective nonsurgical alternative in the management of acquired deep superior sulcus Bibliography Bardot J, Fogli A, Malet T, Saboye J. Les cernes. In Chirurgie esthétiques des paupières. Chapitre 5; 63-74. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg 2006;22(5): 335-41. Illner A, Davidson HC, Harnsberger HR, Hoffman J. The Silent Sinus Syndrome: Clinical and Radiographic Finidings; American Journal of Roentgenology, February 2002 Mavrikakis I, Detorakis ET, Yiotakis I, Kandiloros D. Nonsurgical management of silent sinus syndrome with hyaluronic acid gel. Ophtal Plast Reconstr Surg. 2012; 28 (1): e6-
Le traitement de la cellulite est une demande extrêmement fréquente de nos patientes pour laquelle les solutions chirurgicales sont souvent inadaptées ou décevantes . Il existe certes la liposuccion superficielle ou la lipolyse laser mais la qualité des résultats obtenus ( risque d’irrégularités) et / ou la longueur du processus ( lipolyse laser) nous font souvent hésiter à proposer ces techniques. La cellulite adipeuse peut être définie comme un amas graisseux superficiel dont l’épaisseur non homogène est responsable du phénomène de peau d’orange de l’aspect matelassé de la peau D’un point de vue anatomique la cellulite associe à des degrés variables , excès graisseux superficiel , capitons graisseux et relâchement cutané La meilleure connaissance de la structure de la cellulite a permis le développement de techniques non chirurgicales adaptées à chaque type de lésion . Parmi ces nouvelles techniques deux ont particulièrement retenues mon attention : 1°) l’association radiofréquence monopolaire / ultrasons pour traiter l’excès graisseux superficiel et le relâchement cutané : il s’agit d’un procédé thermique qui couplé aux ultrasons va permettre une diminution homogène de l’épaisseur de graisse superficielle et un remodelage cutané 2°) la subcision procédé mécanique , technique micro invasive qui va permettre une section des septa pour traiter les capitons et obtenir un relissage cutané Au cours de cette communication , après une brève présentation de ces procédés , je vous présenterai les résultats obtenus après 7 mois d’utilisation et l’intérêt de l’association de ces techniques . Ces nouvelles techniques permettent de répondre à une demande pour laquelle nous n’avions pas ou tres peu de solutions et ainsi de garder notre patientelle captive.
les professionnels de santé et les médecins en particulier sont de plus en plus touchés par la publication en ligne d’avis de leurs patients. Lorsqu’ils sont bons on n’y prête généralement pas attention. Mais lorsqu’ils sont mauvais et dénigrants ils peuvent engendrer des conséquences préjudiciables. Un avis factuellement avéré est donc finalement plutôt rare . Lorsque celui-ci est négatif, il peut porter atteinte à notre réputation et à notre probité avec à terme un impact sur notre activité. Dés lors comment se prémunir face à un avis négatif ? C'est la question à laquelle nous essayerons de répondre à travers l'avis et l'exemple de différents experts venus de différents horizons ( médecins , webmaster , avocats , assureurs ). Nous vous présenterons également un modèle de réponse simple qui pourrait être une première défense en cas de mise en cause . Cette session se veut interactive et une large place sera laissée pour un débat avec l'assemblée .
Facial rejuvenation using subcutaneous nanofat injections : an innovative technique. Dr Sophie Menkes We aimed to access wether our novel nanofat grafting procedure improves skin quality, while yielding a regenerative effect, and wether this novel technique can also achieve a lifting effect. Methods : Patients who requested for non-surgical facial rejuvenetion were enrolled between january 2017 and June 2017. Fat was aspirated from inner face of the knee, or medial thigh, or lower abdomen regions. Following aspiration and flushing, microfat was obtained after washing with saline. This microfat was emulsified to obtain nanofat suspension, wich was injected using a 25 G cannula into the subcutaneous layer at all parts of the face. Images were obtained before and at 1,3, and 6 months. Patients were also administered a survey concerning facial appearance. Results : Fifty patients were included (2 men and 48 women ; mean age, 35-65 years ; mean follow-up, 9 months). The clinical results were apparent between 2 and 4 weeks after injection, and improvements were continuously observed until 6 months postoperatively. All patients confirmed an improvement in texture, elasticity, glowing, firmness, fine wrinkles, and skin hydration, along with a regenarative effect. Patients also exhibited considerable improvements in skin glow/regularity, and 80% exhibited considerable improvements in facial shape with a lifting effect. Only minor complications were noted, including redness and edema between 2 and 4 days, and some bruises and pain in donor site. Conclusion : Facial rejuvenation with subcutaneous nanofat injections at all parts of the face appears to be an effectice method, although additional studies are necessary.
Microfat, Nanofat grafting in genital rejuvenation Dr Sophie Menkes Introduction : Genital restoration is growing in recent years. It can improve vaginal dryness, mucosa trophicity, genito-urinary symptoms of menaupose (GSM) and lost of elasticity and volume of external genitalia. Objectives : Our goal is to show that microfat, nanofat grafting can be effective in this indication. This study aims to present our technique, analyzing effectiveness, patient satisfaction, and complications. Methods : Patients presenting vaginal trophic disorders, atrophy of labia majora, and GSM were included. After abdominal fat harvesting (or inner face of the knees, or thighs) and fat graft preparation, a microfat and nanofat grafting was performed in the genital area. 8 ml of microfat was injected in the labia majora and 6 ml of nanofat in the vestibul and the first 3 centimeters of the vagina wall (posterior and lateral) pH, Fridmann score and Female Sexual Distress Scale (FSD) were used to evaluate the results, the effectiveness and tolerance of the treatment. Results : 10 patients benefited from this technique. A significative improvment of the Fridmann score, pH, and FSD scale was found for all patients, with particular benefit on dryness, pH and dyspareunia. No complication were found in our study. Conclusion : This study demonstrate that functional disorders of intimate sphere can be treated by micofat, nanofat. This autologous procedure is able to provide a very good rejuvenation of genital area. This method was effective in all patients, and required a single session.
Dr Nora Nugent discusses her approach to labiaplasty and how she has modified her practice to optimise the results for her patients and improve the patient journey. Worldwide labiaplasty is the fastest growing aesthetic procedure in terms of numbers undertaken over the last five years and Dr Nugent sees many women requesting labiaplasty in her practice. In her presentation, she shares her tips for the preoperative consultation, counselling and preparation of the patient along with her preferences in surgical technique and for postoperative care.
Comment faire un «beau» lifting de fesse? Quelques règles simples permettent d’évaluer la tension à apporter sur les sutures sans qu’elles se désunissent, tout en conservant une bonne efficacité sur les excédents cutanés. En accordant attention et précision à cette opération, elle peut sortir du cadre réparateur pour être proposée à titre esthétique. 1-Lockwood TE. Lower-body lift. Aesthet Surg J. 2001 Jul;21:355–70. 2-Le Louarn C, Pascal JF. Autologous gluteal augmentation after massive weight loss. Plast. Reconstr. Surg. 2008 Apr;121:1515–1516; author reply 1516–1517. 3-Pascal J-F. French creativity in body contouring surgery. Ann Chir Plast Esthet. 2010 Oct;55:397–412. 4-Vico PG, De Vooght A, Nokerman B. Circumferential body contouring in bariatric and non-bariatric patient. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010;63:814–9. 5-De Runz A, Brix M, Gisquet H, Pujo J, Minetti C, Colson T, Sorin T, Agrinier N, Simon E. Satisfaction and complications after lower body lift with autologous gluteal augmentation by island fat flap: 55 case series over 3 years. J Plast Reconstr Aesthet Surg. 2015 Mar;68(3):410-8.