Biomedical subjects
Publications and source records attributed to R C Webster.
In this article, face lift, forehead lift, and blepharoplasty procedures are addressed. Special emphasis is made on anatomical and surgical guidelines. Some results and complications of the different procedures are presented.
A concern in the current trend toward more aggressive undermining in rhytidectomy and liposuction surgery has been the potential for damage to the marginal mandibular nerve. This study was undertaken in an attempt to clarify the exact peripheral pathway of the marginal mandibular nerve. A series of 22 fresh cadaver heads were studied bilaterally by gross dissection and histologic studies. It was found that dissection superficial to the platysma up to a point 2 cm lateral to the lower lip can be done safely. Medial to this point, dissection is hazardous and is not indicated because the marginal mandibular nerve becomes more superficial as it travels to innervate its effector muscles. Additionally, dissection in this area is technically difficult because of the tight adherence of the skin to the underlying muscles. This adherence generally permits only the formation of fine superficial rhytids that are best treated by chemical peel or dermabrasion.
Dermatologic surgeons' rights to perform surgery are being and will be challenged more and more. Some methods of peer review and credentialing are suggested and the specialty is urged to move ahead with formal planning for more training in the surgical aspects of dermatology.
Amputations of the nose and of the auricle present difficult management problems. Application of simple reattachment techniques, followed by aggressive medical therapy which consists of cooling, anticoagulation, antibiotic coverage, and multiple stab incisions in the amputated tissues, have resulted in the successful replantation of major portions of an amputated nose and an amputated auricle with satisfactory cosmetic results.
We report 20 years of experience with conservative and cautious injection of small amounts of medical-grade liquid silicone in 347 postrhinoplasty patients for a total of 1,937 treatments. Medical-grade silicone was found to be a safe, effective, and valuable adjunct to cosmetic rhinoplastic procedures. Microdroplet technique with very small doses is recommended for the correction of nasal defects that may not be amenable to revisional surgery. Controlled release of this material to the medical profession after appropriate evaluation is recommended, along with proper training prior to its use.
Medical-grade injectable silicone has been safely and efficiently used for facial soft-tissue augmentation in 235 patients. Our 20-year experience with the microdroplet technique included 2,811 treatments performed for camouflaging furrows and grooves, augmentation of facial eminences, and elevation of certain depressed scars. The indications and techniques of injection are discussed. The augmenting effect is greater than that produced by the small volumes of silicone injected. Our study supports other work indicating induction of collagen deposition in the patients around the microdroplets of silicone, thus providing augmentation from volumes of collagen and silicone as well.
The effects of cigarette smoking on the skin flaps of the face lift procedure are discussed. Reported elsewhere is a significant incidence of skin slough in smokers with use of wide undermining techniques. This complication is thought to be due to the vasoconstrictive effects of nicotine on the peripheral circulation. Our group has employed a conservative bilateral undermining technique in 407 face lifts. Of these, 32.4 percent were smokers and 67.6 percent were nonsmokers. No cases of skin slough were encountered. Our conservative undermining technique is briefly discussed. Among its advantages are shorter operative time, use of less local and/or general anesthesia, less intraoperative bleeding, adequate exposure for SMAS and platysmal surgery, and snugger skin closure without the risk of flap necrosis. As shown by our statistics, it is a safer procedure in smokers than the usually performed more radical procedure.
An analysis of patient response to less-than-ideal results in rhinoplasty reveals a marked discrepancy between the way patients react and the way in which surgeons think they would react. We feel that, by showing less-than-ideal results to prospective patients, we may be able to develop a method to predict the degree of dissatisfaction that a patient might show to a result that was less than ideal.
The anatomy of the supraorbital and supratrochlear notches and foramina has been studied in 111 human skulls. Of 108 skulls, 49.07% had bilateral supraorbital notches, 25.93% had bilateral supraorbital foramina, and 25% had a notch on one side and a foramen on the other side. Of 101 skulls, 97.03% had bilateral supratrochlear notches, 0.99% had bilateral foramina, and 1.98% had a notch on one side and a foramen on the other side. The methods of study and clinical relevance are discussed, along with the varying nomenclature used in the literature for defining the supraorbital and supratrochlear structures. Knowledge of the anatomy of the region is important for those doing forehead and brow lift surgery in order to avoid injuring the neurovascular bundles passing through these notches and foramina.
The trapdoor effect is an elevated and bulging deformity of tissue within the semicircular confines of a U-, C-, or V-shaped scar. Various theories to explain this phenomenon are lymphatic and venous obstruction, hypertrophy of the scar, excessive fatty and redundant tissue, beveled wound edges, and contracture of the scar. Our data suggest that scar contracture is the predominant cause of the trapdoor effect in nasolabial flaps. For mild to moderately severe trapdoor deformities, multiple, small Z-plasties about the periphery of the nasolabial flap are indicated. Intralesional triamcinolone acetonide injections may produce a "pharmacologic Z-plasty" effect in some trapdoor deformities. For marked trapdoor deformities, the combination of multiple, small Z-plasties along the semicircular scar and peripheral undermining about the trapdoor defect is the corrective procedure. The trapdoor deformity may be prevented or lessened by peripheral undermining about the recipient site of the flap equal to or greater in area than the recipient site.
A new rapid strength loss catgut suture material can be used for skin closures in wounds of the face and body. Seventy-six comparisons were made under controlled conditions between the new material and one formerly recommended. The new material was used in 588 other wounds as well. It is concluded that the new material is superior to the other in several important ways.
The nose relates intimately to the upper lip. As in all facial cosmetic surgery, anatomic and aesthetic diagnosis of the deformity is essential to providing the best treatment possible in a particular patient. Within a reasonable range, changes may be made easily in the columella-labial area. Often these changes enhance the results of typical rhinoplastic maneuvers and make safer and more predictable the results of the rest of the rhinoplastic surgery. Techniques for altering the columella-labial region are presented. Examples are shown demonstrating diagnostic, aesthetic, and therapeutic aspects.
Lateral canthopexy using permanent suspending sutures to shorten the lateral canthal tendon helps prevent scleral show, increased sloping of the upper lid, and inferomedial displacement of the lateral canthus following lower lid blepharoplasty. While these complications usually are prevented by flap suspension techniques, in which more skin is excised above and lateral to the commissure than below it, sutures running from the inferomedial part of the lateral canthal tendon to its superolateral aspect and to periosteum just inside the orbit still further reduce the tendency toward the complications mentioned. We report technical aspects and results. After several years of clinical experience, we have the impression that the technique is a useful adjunct, even though it may produce more swelling and inflammation and a longer recuperative period.
Otolaryngology shares responsibility for provision of plastic surgical services involving facial and cervical structures, but many training programs have been weak in this part of the specialty. Some still are. Beginning in 1963 when a national organization was formed, leading facial plastic surgeons and the senior author analyzed the weaknesses and embarked on a program to correct these educational deficits. There was widespread lack of surgical background, woefully inadequate knowledge of soft tissue techniques, and poor understanding of dynamics involved in cosmetic procedures. Annual meetings, international symposia, numerous courses, and extensive videotape and microfiche production, as well as political and academic recognition, have all helped plastic surgical teaching endeavors at both residency and postgraduate levels. However, much remains to be done. Program directors are the "key" people here. Suggestions for future action are presented.
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Some patients coming for esthetic blepharoplasty should have one of three supplemental procedures performed to elevate or change the position of the eyebrows. The most precise eyebrow alterations are effected with brow lifting procedures, but these may produce adverse scarring. The temple lift may be employed to draw the lateral part of the eyebrow upward and laterally. Drooping of the central part of the eyebrow requires a frontal or coronal lift or an eyebrow lift. Additional guides to the selection and combination of the procedures are provided.