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Biomedical subjects

Bahman Guyuron

Publications and source records attributed to Bahman Guyuron.

At least 19 recordsLinked to original sources
PubMed2006

Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards.

BACKGROUND: The efficacy of endoscopic forehead rejuvenation has been questioned. However, many proponents of the technique are convinced that this procedure is indeed an optimal choice for the majority of patients desiring forehead rejuvenation and have found the means of preventing adversities. METHODS: The purpose of this article is to discuss the common features and reasons for suboptimal endoscopic forehead rejuvenation outcomes and avoidance of these flaws based on the author's experience with 372 procedures. RESULTS: These imperfections include inadequate muscle resection, under- or overelevation of the eyebrows, asymmetry, glabellar dimpling or depression, displeasing eyebrow arch, and excessive separation of the eyebrows. CONCLUSIONS: In this report, the details of these flawed outcomes are discussed, and the ways in which they can be avoided or corrected are reviewed to improve the learning curve for less-experienced surgeons and to aid in producing more predictable and pleasing results.

Endoscopy↗
PubMed2006

Endoscopic forehead rejuvenation: II. Long-term results.

BACKGROUND: The purpose of this study was to analyze the long-term objective and subjective outcomes in patients who have undergone endoscopic forehead rejuvenation. METHODS: Preoperative and postoperative photographs of 100 patients who underwent endoscopic forehead rejuvenation by one surgeon (B.G.) between 1993 and 2001 were objectively analyzed. Postoperative changes in left and right eyebrow position were assessed in each patient by counting the number of pixels in the digitalized photographs and by clinical measurements, and compared with preoperative values. In addition, subjective ratings of the surgical outcome obtained from both the patient and the evaluating surgeon were compared. All data were analyzed using the paired t test. RESULTS: The average postoperative follow-up was 44 months (range, 12 to 95 months). Statistically significant differences in brow position between the preoperative and postoperative periods were observed in the following categories: the average distance from the lower brow margin to the upper eyelid margin (p < 0.005), the average distance from the lateral brow margin to the medial canthus horizontal line (p < 0.001), elevation of the lateral canthus relative to the medial canthus (p < 0.001), and the distance between the medial margins of the eyebrows (p < 0.001). In addition, preoperatively, 74 percent of eyebrows were positioned below the superior orbital rim, whereas 97 percent were positioned at the rim or above postoperatively, with 82 percent positioned above the rim. The most common complications were some degree of persistent paresthesia (50 percent), itching (14 percent), and forehead dynamic imperfections and irregularity (10 percent). CONCLUSION: Endoscopic forehead rejuvenation improves brow position relative to the orbital rim, brow arch form, vertical frown lines, and horizontal frown lines of the forehead, with stable results many years after surgery.

Adult↗
PubMed2006

Septal cartilage defined: implications for nasal dynamics and rhinoplasty.

BACKGROUND: Although the septal cartilage is integral to structural nasal stability, it is routinely violated during septorhinoplasty. This occurs during dorsal hump reduction, caudal septal reduction, submucoperichondrial resection of a deviated septum, or harvesting of cartilage graft material. Despite such routine alteration and/or use, the characteristics of septal cartilage have not been adequately defined. METHODS: By measuring septal length, height, and cartilage thickness mapped out at 5-mm intervals over the entire nasal septum in 11 fresh cadaver specimens, the characteristics of septal cartilage were determined. RESULTS: Septal thickness measurements demonstrated significant differences along the nasal septum, with the greatest thickness along the septal base (2.7 +/- 0.1 mm), followed by intermediate thickness along the septal dorsum (2.0 +/- 0.2 mm) and the least thickness along the central portion (1.3 +/- 0.2 mm) and at the anterior septal angle (1.2 +/- 0.1 mm) (p < 0.001). CONCLUSIONS: These observations clarify several nuances regarding septal structural stability, septal deformities, and the effects of septal alteration during rhinoplasty. The findings of this study reinforce several principles, including recognition of factors contributing to the high propensity of acquired central septal perforations; preservation of a generous L-strut width, especially at the anterior septal angle, or if planning dorsal hump reduction, prudent allocation of harvested septal cartilage; and clarifying the proclivity for supratip deformity following rhinoplasty.

Aged↗
PubMed2005

Modified temporal incision for facial rhytidectomy: an 18-year experience.

An 18-year experience with the senior author's temporal incision is expounded. First, the existing sideburn is outlined with a marking pen. A sideburn is designed approximately 2 cm wide and 2 cm long, regardless of the extent of the existing sideburn providing the minimum sideburn. The posterocaudal portions of the newly designed sideburn will correspond to that of the existing dense portion of the sideburn. After dissection and removal of excess skin, the entire vertical portion of the scar will remain within the hair-bearing skin, eliminating the potential for visibility unless preoperatively the sideburn is less that 2 cm wide. There are several advantages to this approach. First, the configuration of the sideburn remains essentially unaltered. Second, the length of distribution for the redundant redraped facial skin is increased in comparison with most other incisions, thus avoiding a dog-ear regardless of the extent of the excess facial skin. Rhytidectomy is more effective because the distance from the incision to the nasolabial crease and the oral commissure is reduced, thereby effectively transmitting the traction forces to these sites compared with the conventional temporal incision that is placed above the ear. In addition, exposure of the surgical field is significantly enhanced by the added ability to rotate the skin flap medially. The potential disadvantage is that the operative time is increased to accommodate meticulous repair of the temporal incision. A slight modification of this incision has been implemented over the past 18 years, placing the anterior vertical incision farther posterior compared with the original report. The horizontal and posterior vertical portions of the incision are positioned at the hairline, resulting in an inconspicuous scar. None of the 125 patients in this latter group required a scar revision compared with 37 (4.28 percent) of 865 patients before this modification. This technique effectively achieves the goal of facial rhytidectomy and maintains a natural appearance without discernible scars for most patients. Patient and surgeon satisfaction with this method has been very high, and consequently, it has been used for almost all patients in the senior author's (Guyuron's) practice.

Cicatrix↗
PubMed2005

The lesser and third occipital nerves and migraine headaches.

BACKGROUND: Reports of a correlation between relief of migraine headaches and resection of corrugator muscles or injection of botulinum A toxin have renewed interest in finding the cause of migraine headaches and identifying the trigger sites. Four trigger sites have been described. One of these is along the course of the greater occipital nerve. Recent anatomical studies of this nerve have defined its location with respect to external landmarks, leading to new studies with gratifying results. There is a subset of patients who undergo chemodenervation or surgical release of the greater occipital nerve and note improvement or elimination of the symptoms along the greater occipital nerve course but who experience an emergence of migraine headache symptoms laterally. The authors propose the lesser occipital nerve as the source of pain in those who experience headaches laterally and involvement of the third occipital nerve in those who notice residual symptoms in the midportion of the occipital region. METHODS: To test this hypothesis anatomically, 20 cadaver heads were dissected to trace the course of the lesser occipital nerve and third occipital nerve and define the location of these nerves with respect to external landmarks. The midline and a line drawn between the inferiormost points of the external auditory canals were used to obtain standardized measurements of these nerves. RESULTS: The location of emergence of the lesser occipital nerve was determined to be an area centered 65.4 +/- 11.6 mm from midline and 53.3 +/- 15.6 mm below the line between the external auditory canals. The third occipital nerve was found 13.2 +/- 5.3 mm from midline and 62.0 +/- 20.0 mm down from the line between the two external auditory canals. CONCLUSIONS: This information can be used to conduct clinical trials of chemodenervation of these nerves in an attempt to eliminate migraine symptoms in the subset of patients who continue to experience residual symptoms after surgical release of the greater occipital nerve.

Botulinum Toxins, Type A↗
PubMed2005

Components of the short nostril.

BACKGROUND: The short nostril, best visualized on the basilar view, is a multifaceted dysmorphology that requires evaluation beyond that of alar/columellar deformities. While the soft triangle is the key component in short nostril disharmony, the alar rim and cartilaginous structures that border the nostrils play a salient role as well. METHODS: A retrospective review of 200 consecutive rhinoplasties (primary and secondary) examined the specific role of soft triangle excision and other components in the short nostril deformity. Twenty-seven patients underwent soft triangle excision with or without alteration of the other structures influential on nostril length. Of these 27 patients, only three patients required soft triangle excision alone. RESULTS: The distance from the nostril apex to the caudal border of the alar dome was found to be the crucial element in defining the treatment approach for creating nostril length. When this distance was long, excision of the soft triangle lining and approximation of the alar rim to the lining under the dome elevated the nostril apex and elongated the nostril. When the distance between the nostril apex and overlying dome was ideal or short, soft triangle lining removal was not required, and an optimal nostril length was established by repositioning the other components. Raising the dome using transdomal sutures redirected the wide domal arch vertically, narrowing and lengthening the nostril, provided there was no redundancy in the soft triangle. In a similar fashion, interdomal sutures improved both nostril length and inclination. Placement of a columellar strut also elongated the nostril. An alar rim graft, used primarily to correct alar rim retraction and concavity, also elongated the short nostril. CONCLUSIONS: The most important factor in analysis and treatment of the short nostril is the extent of the soft triangle tissue present. Soft triangle lining removal is indicated when the distance from the nostril apex to the caudal dome is excessive. This allows the nostril apex to be pulled anteriorly, thus elongating the nostril. The short nostril often coexists with multiple other abnormalities of the nasal base and tip, mandating a comprehensive approach to address all the deformities encountered. Correction of alar retraction also effectively increases nostril length. Further improvement of asymmetric tips and nostrils can be achieved through unilateral soft triangle lining excision with dome equalization through tip suturing and a subdomal graft.

Humans↗
PubMed2005

Calibrated lateral crus stabilizer.

BACKGROUND: Fundamental shortcomings of the currently available instrumentation prompted the need for a device that facilitates stabilization of the lateral crus while at the same time allowing for precise measurement of the retained cartilage fragment along the anatomic axis of the lateral crus. METHODS: This article presents a new instrument, the calibrated lateral crus stabilizer, and highlights its unique features, which facilitate the precise and symmetric excision of the lateral crural cartilage. RESULTS: A lateral crus stabilizer with a calibration mechanism is introduced that provides the means for precise removal of the excess portion of the lower lateral cartilage during rhinoplasty. CONCLUSIONS: There was a need for improved instrumentation to stabilize the alar cartilage than what is currently available. New instrumentation is presented that answers that need.

Calibration↗
PubMed2005

Stability after endoscopic forehead surgery using single-point fascia fixation.

BACKGROUND: With endoscopic forehead rejuvenation, most surgeons use at least two points of fixation for each eyebrow, often including some type of bone fixation, to achieve the aesthetic goal of lasting repositioning of the eyebrows and elimination of frown lines. In this prospective study, short-term and 1-year postoperative changes in the position of the eyebrows following extensive release of eyebrow-retaining ligaments and use of single-point fascial suture (without bone fixation) were objectively evaluated. METHODS: Front-view, life-size photographs of 48 patients undergoing endoscopic forehead surgery for treatment of migraine headaches were analyzed preoperatively and 1 and 12 months postoperatively. The distance of the caudal portion of each eyebrow from a horizontal line passing through the medial canthi was measured at three levels: (1) the lateral canthus, (2) midpupil on a straight gaze, and (3) medial canthus. RESULTS: Statistical analysis revealed a significant elevation of the eyebrows at each of these three reference points when preoperative and 1-month postoperative data were compared (p = 0.001). Twelve months postoperatively, the eyebrows remained significantly elevated at each of the three reference points on both the left (p = 0.001) and right (p = 0.001) sides. Comparison of data at 1 and 12 months postoperatively did not show any statistically significant difference (p = 0.1 to 0.9 at the three levels), indicating that the eyebrow elevation was maintained. CONCLUSIONS: The authors conclude that wide release of the eyebrow-retaining ligaments with single-point fascial fixation is an effective method for elevation of the eyebrows, and that bone fixation should be used when an alteration of eyebrow arch form or correction of eyebrow asymmetry is indicated.

Adult↗
PubMed2005

Comprehensive surgical treatment of migraine headaches.

The purpose of this study was to investigate the efficacy of surgical deactivation of migraine headache trigger sites. Of 125 patients diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls, with 4:1 allocation. Patients in the treatment group were injected with botulinum toxin A for identification of trigger sites. Eighty-nine patients who noted improvement in their migraine headaches for 4 weeks underwent surgery. Eighty-two of the 89 patients (92 percent) in the treatment group who completed the study demonstrated at least 50 percent reduction in migraine headache frequency, duration, or intensity compared with the baseline data; 31 (35 percent) reported elimination and 51 (57 percent) experienced improvement over a mean follow-up period of 396 days. In comparison, three of 19 control patients (15.8 percent) recorded reduction in migraine headaches during the 1-year follow-up (p < 0.001), and no patients observed elimination. All variables for the treatment group improved significantly when compared with the baseline data and the control group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey. The mean annualized cost of migraine care for the treatment group (925 dollars) was reduced significantly compared with the baseline expense (7612 dollars) and the control group (5530 dollars) (p < 0.001). The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4) (p = 0.003). The common adverse effects related to injection of botulinum toxin A included discomfort at the injection site in 27 patients after 227 injections (12 percent), temple hollowing in 19 of 82 patients (23 percent), neck weakness in 15 of 55 patients (27 percent), and eyelid ptosis in nine patients (10 percent). The common complications of surgical treatment were temporary dryness of the nose in 12 of 62 patients who underwent septum and turbinate surgery (19.4 percent), rhinorrhea in 11 (17.7 percent), intense scalp itching in seven of 80 patients who underwent forehead surgery (8.8 percent), and minor hair loss in five (6.3 percent). Surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms. Additional studies are necessary to clarify the mechanism of action and to determine the long-term results.

Absenteeism↗
PubMed2005

The zygomaticotemporal branch of the trigeminal nerve: an anatomical study.

This study was conducted to determine the site of emergence of the zygomaticotemporal branch of the trigeminal nerve from the temporalis muscle and to identify the number of its accessory branches and their locations. A pilot study, conducted on the same number of patients, concluded that the main zygomaticotemporal branch emerges from the deep temporal fascia at a point on average 17 mm lateral and 6 mm cephalad to the lateral palpebral commissure, commonly referred to as the lateral canthus. These measurements, however, were obtained after dissection of the temporal area, rendering the findings less reliable. The current study included 20 consecutive patients, 19 women and one man, between the ages of 26 and 85 years, with an average age of 47.6 years. Those who had a history of previous trauma or surgery in the temple area were excluded. Before the start of the endoscopic forehead procedure, the likely topographic site of the zygomaticotemporal branch was marked 17 mm lateral and 6 mm cephalad to the lateral orbital commissure on the basis of the information extrapolated from the pilot study. The surface mark was then transferred to the deeper layers using a 25-gauge needle stained with brilliant green. After endoscopic exposure of the marked site, the distance between the main branch of the trigeminal nerve or its accessory branches and the tattoo mark was measured in posterolateral and cephalocaudal directions. In addition, the number and locations of the accessory branches of the trigeminal nerve were recorded. On the left side, the average distance of the emergence site of the main zygomaticotemporal branch of the trigeminal nerve from the palpebral fissure was 16.8 mm (range, 12 to 31 mm) in the posterolateral direction and an average of 6.4 mm (range, 4 to 11 mm) in the cephalad direction. On the right side, the average measurements for the main branch were 17.1 mm (range, 15 to 21 mm) in the lateral direction and 6.65 mm (range, 5 to 11 mm) in the cephalic direction. Three types of accessory branches were found in relation to the main branch: (1) accessory branch cephalad, (2) accessory branch lateral, and (3) accessory branches in the immediate vicinity of the main branch. This anatomical information has proven colossally helpful in injection of botulinum toxin A in the temporalis muscle to eliminate the trigger sites in the parietotemporal region and surgical management of migraine headaches triggered from this zone.

Adult↗
PubMed2004

The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches.

An interest in pursuing new theories of the underlying etiology of migraine headaches has been sparked by previously published reports of an association between amelioration of migraine headache symptoms and corrugator resection during endoscopic brow lift. This theory has further been reinforced by recent publications documenting improvement in migraine headaches following injection of botulinum A toxin. There are thought to be four major "trigger points" along the course of several peripheral nerves that may cause migraine headaches. Among these peripheral nerves is the greater occipital nerve. For this reason, the authors have undertaken an anatomic study of this nerve to determine its usual course, potential anatomic variations, and possible points of potential entrapment or compression. The results of this anatomic study have enhanced further development of techniques designed to address these points of entrapment/compression and potentially lead to relief of migraine headaches caused by this mechanism. Twenty cadaver heads from patients with an unknown history of migraine headaches were dissected to trace the normal course of the greater occipital nerve from the semispinalis muscle penetration to the superior nuchal line. Standardized measurements were performed on 14 specimens to determine the location of the emergence of the nerve using the midline and occipital protuberance as landmarks. On the basis of this information, the location of emergence was determined to be at a point centered approximately 3 cm below the occipital protuberance and 1.5 cm lateral to the midline. This location can, in turn, be used to guide the practitioner performing chemodenervation of the semispinalis capitis muscle in an attempt to provide migraine symptom relief.

Humans↗
PubMed2004

Harvesting fat from the infratemporal fossa.

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

Adipose Tissue↗
PubMed2004

Hourglass deformity after botulinum toxin type A injection.

BACKGROUND: Complications, such as eyelid ptosis, have been attributed to botulinum toxin type A. An "hourglass" deformity, which is the consequence of temporalis muscle atrophy, has not been reported previously. OBJECTIVE: To report a transient muscle deformity of the temporalis muscle caused by botulinum toxin type A. METHODS: Patients who underwent injection of 25 units of botulinum toxin type A into the temporal muscle, in a fan-shaped fashion, during an ongoing study for treatment of migraine were noted to develop temporary depression of the temples. Preinjection and postinjection photographs were taken. Patients were also sent questionnaires to verify the observed information. RESULTS: Only 26 of 92 patients who underwent injection of botulinum toxin type A into the temporalis muscle subsequently reported depression of the muscle. When examined, all 92 patients exhibited this deformity ranging from minimal to significant. Patients who seemed to have less deformity were those who had excessive soft tissue overlying the muscle due to excess weight. CONCLUSION: A newly recognized deformity is reported subsequent to the injection of botulinum toxin type A into the temporalis muscle. Informing patients of this transient deformity may minimize concern following treatment.

Botulinum Toxins, Type A↗
PubMed2003

Nasal tip sutures part I: the evolution.

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today's rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.

Humans↗
PubMed2003

Nasal tip sutures part II: the interplays.

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.

Humans↗