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PubMed2006

Rejuvenation of the aging eyelid.

Rejuvenation of the aging eyelid subunit provides a youthful appearance to one of the focal points of the face. As the age of our population increases, these procedures are likely to become increasingly more common. Accurate preoperative examination, assessment, and counseling are imperative to achieve an excellent result. As well, careful selection from the spectrum of available techniques, combined with meticulous surgical precision, will assist the surgeon in rejuvenating the individual patient. Although no one ideal surgical procedure exists, many safe and effective strategies have been developed as we have learned more about the effects of aging. This article aims to provide a history of techniques used in eyelid rejuvenation, as well as an overview of the evaluation process.

Adipose Tissue↗
PubMed2004

A policy analysis of funding for ambitious interventional gerontology: the possibility of rejuvenation research at the National Institute on Aging.

Issues related to the development of ambitious interventional gerontology-rejuvenation research-at the National Institute on Aging (NIA) within the National Institutes of Health (NIH) are discussed. Creating a separate branch for rejuvenation research within the NIA is probably neither feasible nor desirable at this time. However, it may be both feasible and desirable to begin rejuvenation research by establishing a bioengineering laboratory offering technologies that complement the disease-orientated focus of other NIA intramural laboratories. Such a bioengineering lab could use modern engineering tools for cell and gene therapies to uncover mechanisms of aging and to attempt to repair age-associated pathogenic damage. It is argued that, even in the absence of a full understanding of the complex causes and manifestations of human aging, interventional bioengineering could create methods for reversing aging processes. Exploring technical interventions may both reverse aging processes and significantly advance current disease-specific research.

Aged↗
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↗
PubMedDate not supplied

Rejuvenation in the early 20th century.

The first theoretical reflections concerning the relation of hormone production with the ageing process stemmed from Charles Edouard Brown-Séquard (1817 1894). At the age of 72 years he experimented on himself with an injection of animal testicular extract. The Viennese physiologist Eugen Steinach (1861 1944) gained world-wide acknowledgement for his theory of 'autoplastic' treatment of ageing. He deduced that after vasoligation, an increased incretory hormonal production would ensue following the cessation of the secretory output of the gonads. The first operation was performed in 1918 and resulted in a vasectomy boom over the next two decades. The Russian Serge Voronoff (1866 1951), working in Paris, was one of the first to transplant testicular tissue from a monkey into a human reproductive gland in 1920. Five years later he had already performed this procedure on 300 patients and attracted patients from all over the world. In America early efforts of human testicular transplantation were performed by Frank Lydston and V.D. Lespinasse. Steinach's vasoligation was taken over by many American doctors, e.g., Harry Benjamin and Charles H. Chetwood. Among the patients who underwent a rejuvenation operation according to Steinach's method were Sigmund Freud (1856 1939) and the Irish poet and Nobel Prize winner William Butler Yeats (1865-1939). Two caricatures from the German magazine Simplicissimus published in 1927, confirm that the rejuvenation operations were constantly in the limelight of the printed media. From 1935 onwards rejuvenation operations gradually lost their appeal due to the introduction of artificial androgens.

Europe↗
PubMed2004

Clinical evaluation of enhanced nonablative skin rejuvenation using a combination of a 532 and a 1,064 nm laser.

BACKGROUND AND OBJECTIVES: Improvements in the physical signs of photoaging can be achieved by non-invasive laser resurfacing procedures. To evaluate the effectiveness and safety of the Nd:YAG 1,064 nm and KTP 532 nm lasers for non-invasive skin rejuvenation. STUDY DESIGN/PATIENTS AND METHODS: Subjects requesting non-invasive skin rejuvenation underwent two treatments with the 532 nm laser to one side of the face and with both lasers to the other side, followed by three treatments with the 1,064 nm laser to both sides. Skin characteristics were evaluated before, during, and up to 4 months after treatment. RESULTS: A >25% improvement in overall skin condition was observed for >30% of subjects at the 1 month follow-up and >40% of subjects at the 4 month follow-up. The greatest improvements were observed for visual dryness, roughness, and uneven pigmentation. No adverse events were reported. There was a trend for greater improvement in patients who received more 1,064 nm treatments but this was not statistically significant. CONCLUSIONS: The 532 nm KTP and 1,064 nm Nd: YAG lasers can be effectively and safely used for non-invasive skin rejuvenation.

Combined Modality Therapy↗
PubMedDate not supplied

Minimally invasive facial rejuvenation endolaser mid-face lift.

Endolaser mid-face lift was performed on patients in a multi-center study over a 36-month period (Feb. 1998 to Feb. 2001). It permits significant facial rejuvenation through small incisions. This technique achieves aesthetic results and wider rejuvenation while being less traumatic and creating minimal morbidity. Combined with other procedures, it rejuvenates the face by three strategic methods: soft tissue suspension, reversal of photo aging, and correction of the depletion of volume. To achieve this triple result, the mid-face lift is performed by endoscopic approach, and in every case is combined with the endoscopic lift of the frontal area. Laser resurfacing was used to reverse skin photo damage. The Ultrapulse CO2 laser and/or the Ultrafine Erbium YAG(Coherent, Inc, Palo Alto, CA) were used. The third combined procedure was the introduction of fat graft to compensate the atrophy/ptosis of fat and the depletion of bone mass (other filling materials besides fat may be used, depending on the preference of the surgeon). Our method of fixation using the Casagrande Needle (an evolution of Reverdin Needle) makes the mechanical purchase on the tissues to be suspended much easier, permitting the intra-oral and/or infra-orbital incisions to be eliminated. The present study of the technical evolution of the endolaser mid-face lift method allows us to conclude that a very satisfactory outcome has been reached, offering patients a minimally invasive procedure, which can be performed under local anesthesia, with low morbidity, imperceptible incisions, and an excellent long-term result.

Adult↗
PubMedDate not supplied

Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation.

Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.

Adipose Tissue↗
PubMedDate not supplied

Standardizing the evaluation of treatment outcomes after skin rejuvenation: the qualitative scoring system.

Current treatments to correct and reverse diseased or aged skin yield widely divergent results. Judging the outcome of such treatments is done in an arbitrary and subjective fashion that is often limited to a patient's feedback or the physician's opinion. This makes it difficult for inter-physician or physician-patient agreement as to the degree of improvement achieved. In an age where skin rejuvenation is being widely practiced, a tremendous void needs to be filled by a system that appropriately evaluates and scores treatment outcomes. Such a system will help physicians communicate better in lectures, help them to better assess the results of various treatment modalities, and facilitate patient-doctor communication. The objective of this paper is to present a standardized scoring system against which skin rejuvenation results can be judged. This system is based on a model of healthy skin that can be defined by practical criteria against which patients can be judged pre- and post-skin rejuvenation procedures. A gold standard for healthy skin (baby skin) is established from a clinical, functional, and histologic perspective. Each patient's skin is compared with the healthy skin model and graded before and after treatment by implementing our scoring system which encompasses objective and subjective criteria. Objective criteria include the following skin characteristics: smoothness, firmness, even coloration, normal texture, and absence of any clinically evident disease. Subjective criteria include proper hydration and normal tolerance, and are not considered in the final scoring. Grading of each element in the scoring system [minimal (1), average (2), maximal (3)], and subsequently the final score [excellent (12 to 15), average (7 to 11), poor (<7)] are done with reference to the healthy skin model defined. The scoring system is novel and easy to use, and can be implemented to help improve communication between physicians and patients as well as during the dissemination of knowledge during medical conferences. In conclusion, treatment end-results can be consistently and more accurately assessed when the scoring system (based on objective criteria and a model of healthy skin) is used. Adopting this protocol will also help in directing our treatment to achieve the best possible results.

Dermatologic Surgical Procedures↗
PubMed2006

Periorbital and midfacial rejuvenation via blepharoplasty and sub-periosteal midface rhytidectomy.

The stigmata of midfacial ageing are the malar descent, lateral orbital festoon formation, tear-through deformity, deep melojugal sulcus, buccal fat pad and sub-orbicularis oculi fat (SOOF) prolapse, deep nasolabial folds and cutaneous and muscular descent. The signs of periorbital ageing include dermatochalasis, skin hooding of the upper eyelids, lacrimal gland prolapse, adipose prolapse, and lateral canthal descent and orbital septum diastasis. All of these deformities can be addressed through upper and lower blepharoplasties with arcus marginalis release, lateral canthopexy, sub-periosteal midface rhytidectomy with temporal suspension of the malar mound and SOOF repositioning. The same technique can be utilized for the restoration of facial symmetry after Bell's palsy. In the following report the technique and the authors' experience in the rejuvenation of the periorbital and midface region are presented. There were a total of 20 patients in this series. Sixteen were female and 4 were male. All the patients were followed-up on a monthly basis after surgery for the first 6 months. They were then seen at 1 year post-surgery. All of the patients were evaluated by the senior author. In the beginning of the study there was 1 Asian female patient with mild postoperative ectropion, which resolved and did not require operative intervention. The patients experienced prolonged postoperative oedema. The patients were satisfied with their postoperative outcomes. In all patients, the goals of periorbital and midfacial rejuvenation were achieved with the above technique. Simultaneous periorbital and midfacial rejuvenation can be achieved via upper and lower blepharoplasties, lateral canthopexies and sub-periosteal midface rhytidectomy.

Adult↗
PubMed1999

Periorbital rejuvenation: a review of dermatologic treatments.

BACKGROUND: The periorbital region serves as a barometer of chronologic and environmental age and, as such, patients often seek its cosmetic rejuvenation. OBJECTIVE: The purpose of this article was to review the dermatologic treatments available for periorbital skin rejuvenation. METHODS: Topical retinoic and glycolic acid preparations, chemical peels, botulinum and collagen injections, dermabrasion, and laser resurfacing procedures for periorbital skin rejuvenation were reviewed. The relative benefits and risks of each treatment were detailed. RESULTS: Minimal photodamage with mild rhytides should be responsible to topical acid therapy and superficial peels, whereas moderate wrinkling and photodamage generally require medium-depth peels, collagen injections, or erbium:YAG laser resurfacing. Deeper rhytides and more extensive cutaneous photo-damage usually necessitate CO2 laser resurfacing and botulinum injections. CONCLUSIONS: Proper patient selection and assessment of aging severity are critical to determine the best therapeutic option.

Botulinum Toxins, Type A↗
PubMed1998

A quantitative method for the assessment of facial rejuvenation: a prospective study investigating the carbon dioxide laser.

Laser resurfacing has been reported to have a useful role in the treatment of facial rhytides, however the results of published series have relied on subjective methods of assessment. The aim of this investigation was to develop an accurate method of measuring wrinkle depth and secondly to use this to assess the efficacy of laser rejuvenation. Wrinkle depth was measured in 30 patients with perioral rhytides using a silicone mask to provide a negative replica. Depth was measured using simple light microscopy and the accuracy of this was confirmed with the electron microscope. A highly significant correlation was found between these two methods of measurement (R2 = 0.97, P < 0.0001) with an accuracy of 0.03 mm. Using this method laser rejuvenation was evaluated in a prospective series of 30 patients with perioral rhytides (median follow-up 11.5 months, range 5-20 months). Resurfacing was found to achieve a significant reduction in mean wrinkle depth of 91% (paired t-test, P < 0.00001). The only complication reported was erythema which was always transient. The use of light microscopy on silicone moulds therefore provides a simple and accurate method for assessing the outcome of facial rejuvenation. Using this technique, the carbon dioxide laser was objectively found to provide a safe and effective treatment for facial rhytides.

Aged↗
PubMed2000

The central oval of the face: tridimensional endoscopic rejuvenation.

The central oval of the face is a distinct anatomic and aesthetic unit. Early signs of aging and advanced features of aging are manifested primarily in this unit. Standard face lift techniques are ineffective in treating this area. Intermediate layer (sub-SMAS, [superior musculo-aponeurotic system], intermuscular, etc.) and deep layer (subperiosteal) techniques were developed to treat this rather difficult part of the face. All variations of the intermediate layer technique have negative features, primarily safety issues related to potential nerve-muscle injury and protracted facial edema. Early described subperiosteal techniques (open, first generation endoscopic) were also associated with these types of complications. The author has outlined 14 principles of the ideal technique for the rejuvenation of the central oval. The advances and modifications to the first and second generation endoscopic central oval rejuvenation method comply with these principles. There are several principles that distinctly separate it from all other techniques: (1) direct approach to the central oval; (2) interconnected subperiosteal plane of dissection to the upper and midface; (3) use of small hidden slit incisions; (4) absence of eyelid incisions; (5) use of endoscopic techniques; and (6) absence of traction on skin or SMAS from the peripheral hemicircle. Another important advance made in this approach is the manipulation of soft tissues in the brow, glabella, cheek, and chin to provide a tridimensional rejuvenation. This was lacking in all previously described procedures. This method has been used with several modifications in over 500 patients. Aesthetic results have been excellent, with minimal sequela and a low complication rate. The subset of patients in whom this third generation endoscopic subperiosteal approach has been used have also had a three-dimensional remodeling and enhancement. The aesthetic results and safety factors surpass all other previously described techniques done at the intermediate or deep layers of the face.

Adult↗
PubMed2000

Laser peel: facial rejuvenation with a superficial erbium:YAG laser treatment.

BACKGROUND: Facial rejuvenation is a popular procedure to temporarily mask the effects of aging. Most patients desiring this treatment are younger and want improvement without any down time. This study was conducted to evaluate the use of Er:YAG laser as a facial rejuvenation tool. METHODS: The full faces of 18 volunteers were treated with an Er:YAG laser using a fluence of either 5 or 10 J/cm2. All volunteers applied EMLA cream (lidocaine 2.5% and prilocaine 2.5%) two hours before the procedure and were treated with a single pass using a pulse duration of about 300 microseconds. Follow-up visits were made in order to evaluate the degree of discomfort, erythema, swelling and improvement in skin aging. Skin biopsy was performed in one volunteer before and two hours after EMLA application, although preceding laser treatment. RESULTS: Most volunteers experienced moderate discomfort during the treatment. There was mild to moderate erythema and mild swelling. The improvement in general skin appearance, actinic bronzing and photo-damage was mild to moderate. The microscopic evaluation of pre-laser treated skin two hours after EMLA application was suggestive of increased water content in the dermis. CONCLUSION: The Er:YAG laser is an effective and safe tool for facial rejuvenation. With a superficial treatment, resolution of intense erythema is fairly rapid, averaging two to three days. The improvement, however, is mild compared to full laser skin resurfacing (LSR).

Adult↗
PubMed2002

Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation.

Standard face-lift techniques are excellent for the treatment of the jawline and neck. Treatment of the area between the lower eyelid and the corner of the mouth required the development of techniques in the intermediate lamella of the face. Alternative techniques of subperiosteal dissection by means of lower eyelid incisions were described with good aesthetic results but at the expense of increased morbidity and complications. All these techniques were also two-dimensional manipulations of the soft tissues of the face. The author presents a different approach that he believes is close to the ideal in terms of safety, morbidity, and complications. Although midface rejuvenation may be performed alone, it is more commonly done as a component of total facial rejuvenation. The midface is approached by means of a combination of a temporal slit incision and an upper oral sulcus incision; no eyelid access is used. Fifty percent of the midface dissection is performed under direct visualization, and 50 percent is performed under endoscopic control. Dissection of the temporal area is done under the temporoparietal fascia down to the zygomatic arch. The anterior two-thirds of the zygomatic arch periosteum is elevated along with a few millimeters of the intermediate temporal fascia and the fascia of the masseter muscle. The subperiosteal dissection of the zygoma and maxilla is completed with the medial extension of the dissection just medial to the infraorbital nerve. The orbital fat pads are released by means of intraoral route, and the lateral and middle fat pads are advanced over the orbital rim and fixed to the masseter tendon and the periosteum of the maxillary shelf at the intraoral incision. Three suspension points are typically used on the midface, each one with a different action. All are anchored to the temporal fascia proper. The vascularized Bichat's fat pad is mobilized and fixed with 4-0 polydioxanone sutures. This provides a volumetric cheek augmentation and improvement of the jowl. The inferior malar periosteum and fascia is used for malar imbrication with 4-0 polydioxanone sutures. This provides an anterior projection of the cheek and elevates the corner of the mouth. The suborbicularis oculi fat is used for en bloc vertical suspension of the cheek. This also improves the infraorbital V deformity. This technique has been used in close to 200 patients over the last 5 years. The complications have been minimal: two cases of temporary paresis of the levator of the upper lip, one case of paresis of the orbicularis oris (unilateral), one case of buccinator muscle dysfunction, and two moderate infections that were treated with simple drainage. The degree of facial edema has been minimal compared with the open or the transblepharoplasty approach. Typically, patients can return to work 2 weeks after surgery.The three-dimensional endoscopic midface enhancement provides a technique of midface remodeling that provides the missing dimension (volume) to the rejuvenation of the midface. This can be done with a minimal rate of complications, and the aesthetic results surpass by far the results of other midface techniques previously described by the author.

Adult↗
PubMed2005

Eyelid rejuvenation: a marriage of old and new.

PURPOSE OF REVIEW: Lower lid anatomy and the subtleties of this region have been studied extensively in the past. The variations that are found in the lower eyelid can lead to complications if the surgeon does not have a complete understanding. Lower lid blepharoplasty techniques have progressed over the past from simple skin excisions to midface and lower eyelid repositioning. With these modifications, our understanding of the anatomy and the function of the lower eyelid improve. This review highlights the findings of lower eyelid anatomy and rejuvenating techniques reported over the past year. RECENT FINDINGS: Over this past year anatomic studies have been performed focusing on the aging eye and midface in both Asians and non-Asians. Controversial work has been presented using an injectable (phosphatidylcholine) to ablate fat in the lower eyelids. A myriad of articles have discussed various options for combined midface and lower eyelid rejuvenation. The age-old argument of transconjunctival vs skin muscle techniques has been presented. More recent debates over fat volumetric preservation continue. Finally, a highlight of this year was a retrospective study looking at a conservative approach to blepharoplasty. SUMMARY: This has been a year of confirmation of old techniques and anatomic findings and a year of increasing complexity in midface lower eyelid rejuvenation. What is clear is that no one technique is ideal for every patient. A basic understanding of lower eyelid anatomy, preoperative evaluation, and a grasp of the multiple techniques will allow us to formulate a treatment algorithm that can be safe and effective for our patients.

Adipose Tissue↗
PubMed2002

Rejuvenation of the midface by elevating the malar fat pad: review of technique, cases, and complications.

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.

Adipose Tissue↗
PubMed2004

Surgical anatomy of the midface as applied to facial rejuvenation.

Distinct anatomic structures provide attachments and support for the soft tissues of the central third of the face. Over time, laxity of these structures and descent of the malar fat pad contribute to the characteristic changes seen in the aging face. Mobilization of the midface soft tissues to allow reelevation of the malar fat pad is an effective method of rejuvenating the midface. A focused anatomic dissection of 8 fresh cadaver heads was performed to evaluate 4 soft-tissue structures that control mobilization of the malar fat pad. Specifically, the orbicularis retaining ligaments, the lateral orbital thickening, prezygomatic space, and zygomatic cutaneous ligaments were evaluated. The anatomic relationship of these structures explains the visible effect of aging in the central third of the face. In addition, it correlates with the outcomes of surgical rejuvenation as demonstrated in clinical cases. Effective repositioning of the malar fat pad was found to be reliably obtained by release of the lateral orbital thickening and the orbital retaining ligaments. Suspension of the malar soft tissue is in a cephalad direction after release of these structures recreates a youthful facial architecture. Motor nerve injury is less likely to occur with this technique than with traditional lateral facelift approaches. The conclusion reached is that ptosis of the malar fat pad can be corrected safely and effectively utilizing either the lower lid blepharoplasty approach or temporal prehairline incision. These findings were consistent with clinical data from facial rejuvenation procedures.

Adipose Tissue↗