Brow modifications are discussed with respect to their role as aids in achieving certain aesthetic effects when rhinoplasty is being performed. If a deep nasofrontal angle should not be brought forward, reduction of the brow may be indicated. If the nasofrontal angle should not be retrodisplaced to deepen a shallow angle, brow augmentation may prove helpful in separating the nose from the forehead or in making the nose appear shorter in the vertical dimension. Augmentation and reduction browplastic techniques are discussed, and selected methods are illustrated. Some involve additional resection of frontal bone or procerus muscle at the time of nasal-hump removal. Others employ grafts of bone and/or cartilage removed from the nose at the time of septorhinoplasty. The versatile aesthetic surgeon should be capable of changing all structures adjacent to the nose. Certain difficult cosmetic problems are best treated by directing appropriate attention to these structures and to the nose rather than by concentrating on the nose alone. That the brow is one of these important abutting landmarks is demonstrated.

Bone Transplantation↗

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Importance of the columellar-labial junction in rhinoplasty.

Concentration on tip positioning may draw a surgeon's attention away from modifying positions of the nasofrontal angle and of the columellar-labial junction. All three landmarks are, however, vital to the establishment of desirable profiles. This article emphasizes that changes in the positioning of the columellar-labial junction may (1) eliminate certain hazards involved in changing tip position, (2) make it possible to produce aesthetic effects that cannot be achieved with tip positioning alone, and (3) make rhinoplasty safer and more predictable in certain difficult cases. Also presented are techniques that have been found to work most satisfactorily in changing angle and position. A few patients selected from among several thousand rhinoplastic cases are analyzed to underscore the significance of this area in rhinoplastic planning. Follow-up varied from several months to several years.

Esthetics↗

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Face lift, part I: Extent of undermining of skin flaps.

One theory in cheek-neck lifting is that it is necessary to undermine skin flaps widely to achieve adequate short and long term results. We have proven that extensive undermining allows no more skin to be excised than is permitted by more conservative undermining when snug skin closures are used. Another part of the theory is that a sheet of scar tissue ("favorable fibrosis") forms and that the larger sheet of scar from more extensive undermining maintains the improvement from the lift longer than would a smaller sheet from less undermining. Controlled studies presented here cast doubt on this part of the theory. Many years ago we ran a series on patients in whom one side had essentially twice as much undermining as did the other. Equal amounts of skin were removed on both sides. Short and long term results were essentially the same on the two sides.

Cicatrix↗

PubMedDate not supplied

Face lift, part 2: Etiology of platysma cording and its relationship to treatment.

Based on examination of many necks and observations at surgery and on cadavers, we believe that "platysma cords"' or cervical folds are normal when the muscles are being contracted. In the aged, they do not disappear when the muscle is relaxed. We believe that they are caused by a stretching and loss of contractility of skin and fat overlying the anterior platysma muscles from aging and from the many contractions of these muscles which selectively stretch the overyling tissues. In addition, we believe that the superficial musculoaponeurotic system (SMAS), which in youth holds the muscle strongly and closely to the confines of the concavity of the neck, stretches so that the muscle webs more easily out of the concavity when contracted and is returned less completely into it upon relaxation. Treatment and prevention should be directed toward tightening the skin and the SMAS and supporting the muscle in its retrodisplaced, more youthful position.

Adolescent↗

PubMedDate not supplied

Face lift, Part 3: Plication of the superficial musculoaponeurotic system.

It is thought that plicating or folding the superficial musculoaponeurotic system (SMAS) upon itself near the ear with permanent sutures will improve and help maintain the results of cheek-neck lifting of the skin layer alone. Getting proof of this conjecture with controlled studies is difficult in the existing medicolegal climate. However, many years ago, we did carry out a limited study in a few patients in whom plication was performed on one side only. We found that plication does have some relatively long-lasting effects, particularly in improvement of platysma cording and in elevation and deepening of the cervical angle. Plication is not a substitute for adequate skin and/or fat resection. Because the early improvement in cases with platysma cording was so marked in contrast to the unplicated side, we had to limit the series stringently. As time went by, the differences on the two sides lessened.

Face↗

PubMedDate not supplied

Face lift, Part 4: Use of superficial musculoaponeurotic system suspending sutures.

We describe nonabsorbable sutures running from one or more sites in the superficial musculoaponeurotic system (SMAS), to other sites at a distance, or to fixed sites beyond or deep to SMAS for the purpose of pulling on or suspending the distal selected SMAS sites or changing contours between the suture ends. Our reasons for abandoning some sutures and continuing with others are stated. In face lifting, we still often employ sutures running from the anterior part of the platysma and SMAS back to the sternocleidomastoid fascia. These sutures help prevent platysma "cording" and are useful in the restoration and preservation of a more youthful profile in the neck. Examples and controls are demonstrated. These sutures and the long-term results of their use have never been shown before. Problems encountered in using suspending sutures are described.

Face↗

PubMedDate not supplied

Face lift, part 5: suspending sutures for platysma cording.

We describe the technical details used in applying nonabsorbable sutures running from the anterior platysma muscles and/or adjacent fascia back to the fascia just in front of or covering the sternocleidomastoid muscles. These sutures usually pass 1.5-2 cm below the angle of the mandible. Anteriorly, they cover or are attached to the platysma muscles at the level of the cervical concavity or angle. The sutures suspend or draw back the superficial musculoaponeurotic system (SMAS) at this level, preventing some of the anterior displacement of the platysma when it is contracted in normal use. We believe that the sutures have relatively long-lasting effects and that they delay the early return of "platysma cording" after cheek-neck lifting. Their application using Reverdin and Keith needles is demonstrated. Differences in technique when submental lipectomy is and is not performed with the lift are shown.

Face↗

PubMedDate not supplied

Coupled-spin fast spin-echo MR imaging.

Distinguishing between lipid and water-containing tissues is clinically important. Current techniques rely on the chemical shift difference between fat and water resonances or differences in relaxation times of the tissues, or a combination of both. A method is presented for separating the signals of lipid protons from those of water protons by using fast spin-echo magnetic resonance imaging based on the principle that lipid protons behave differently from water protons in multi-echo sequences. Two images are acquired with different echo train lengths and echo spacing but with identical TEs, and then subtracted to exploit differences in the behavior of lipid and water protons in multi-echo sequences. The method is insensitive to B0 inhomogeneities or susceptibility effects and provides separate lipid and water images with a high signal-to-noise ratio. The advantages of the method are demonstrated with phantom studies and clinical examples.

Female↗

PubMedDate not supplied

Motion artifact in T2-weighted fast spin-echo images of the liver: effect on image contrast and reduction of artifact using respiratory triggering in normal volunteers.

The purpose of our study was to evaluate the effect of respiratory motion on the image contrast of T2-weighted fast spin-echo (FSE) images of the liver as well as the reduction of motion artifact using respiratory triggering of the data acquisition. We imaged the livers of 10 healthy volunteers using a fast spin-echo T2-weighted sequence. Images were obtained both without and with patient triggering. Triggered images were acquired in a segmented fashion during multiple sequential breath-holds using an echo train of 8 or 16, both with and without flow compensation (gradient moment nulling). Ratios of signal difference to noise (SD/N) of the liver and gallbladder as well as the liver and spleen were compared for all sequences. All of the triggered images showed statistically significant improvement of SD/N for the liver and gallbladder as well as for the liver and spleen when compared with the nontriggered images. Triggered images obtained with an echo train length of 8 and, with flow compensation, showed the highest SD/N ratios. In one volunteer whose liver contained multiple small cysts, the triggered images showed improved visualization of individual cysts and identified a larger number of cysts. Respiratory motion causes a significant loss of contrast on T2-weighted fast spin-echo images of the liver. This can be reduced by using a segmented data acquisition triggered by the respiratory cycle obtained during sequential breath-holds.

Adult↗

PubMedDate not supplied

Percutaneous control of a portacaval H-graft: description of a new device and its initial clinical application.

A percutaneously-controlled inflatable cuff which can change the diameter of a portacaval H-graft has been developed and used in 10 patients. When inflated, the cuff narrows the H-graft to increase portal pressure and reduce shunting. Use of the cuff has been of clinical significance in 3 of 7 long-term surviving patients. Narrowing the shunt improved the clinical state in 2 patients with encephalopathy, and reopening a closed shunt improved ascites in the third patient. Duplex ultrasound and deep Doppler have demonstrated an alteration of hepatic portal blood flow following inflation of the cuff after 6 months. It is concluded that further development of this controlled portacaval H-graft is warranted.

Adult↗