A technique created by E. Gaylon McCollough, M.D., F.A.C.S., the transcutaneous approach, is designed to prevent scleral show and ectropion.

"If the incision is made in the first wrinkle line, then quite a bit of orbicularis muscle on the lid margin is left behind, providing support to the (lower) lid," says Dr. McCollough, founder of the McCollough Plastic Surgery Clinic, Gulf Shores, Ala. "The incision also coincides, ironically, with the lower border of the tarsal cartilage."

Dr. McCollough's transcutaneous approach, a technique he developed 15 years ago, is gaining acceptance by colleagues who now realize its effectiveness in preventing scleral show and ectropion.

In the middle-aged and older patient who has loose skin and a large amount of fat under the eye, the transcutaneous approach is best when completing a lower lid blepharoplasty, yet the traditional incision placed immediately below the eyelashes often results in scleral show. Many surgeons try to correct the complication with suturing techniques used deep in the lower lid, suspended up to the bone of the orbit creating a hammock effect, but this approach often leads to inflammation and infection.

"It occurred to me that one of the problems when we made an incision immediately below the lashes (was that) we were destroying part of the support mechanism of the eyelid due to the destruction of the tarsus cartilage — a major support to the lower eyelid that, when incised, is destroyed immediately, making it necessary to do something to correct it," Dr. McCollough says. "However, if the incision is made in the first wrinkle line, quite a bit of the orbicularis muscle on the lid margin is left behind."

One reason for acceptance of the lower incision is its ability to prevail aesthetically. An important contributor to the end result is how the incision is closed.

Dr. McCollough

Temporary temptation While the avoidance of scleral show and potential complications from additional procedures is key to Dr. McCollough's approach, he is reserved in his application of adjuvant therapies.

"If the patient has wrinkles, caused by loose, sagging skin, Botox is not going to correct the problem. Restylane and other fillers will provide some temporary improvement, but the only way to correct the problem is with surgery. If the patient's condition is bulging fat, then certainly Botox or Restylane is not going to benefit them," Dr. McCollough says. "I personally do not use Botox on my patients."

His stance places him in the minority among cosmetic surgeons, but Dr. McCollough bases his belief on theoretical concerns that point to the possibility of future problems from the overuse of botulinum toxin. He points to other models in medicine that prove that paralyzing muscles can cause loss of strength and ultimately atrophy.

New York— It isn't difficult to understand what a patient likely wants from his or her facelift surgery. The patient wants to look great, without looking like they had surgery, and they want the results to last. But a patient also wants to return to normal life as soon as possible. At the crux of plastic surgery is the expectation of improved recovery time. David Rosenberg, M.D., P.L.L.C., has not only improved recovery time, but has done it without compromising the facelift's outcome.

He has assembled a protocol that effectively reduces the amount of swelling, bruising and discomfort from the surgery. He hopes this will encourage people whose career, familial or social obligations might otherwise keep them from considering facelift surgery.

The preoperative period, he says, is a rigorous preparation in relaxation and education for the patient. He took his cue from more than 200 articles in anesthesia and dental journals that make a direct correlation between a patient's pre-surgical anxiety level and the degree of pain and ability to recover afterward. "If you can minimize anxiety before surgery, then I know the patients are going to require less pain medication and have less discomfort afterwards," he says.

"Patients, I have found, find drains coming out of their skin to be extremely anxiety-producing," Dr. Rosenberg says. "By reassuring them that it's nothing like that, their blood pressure drops."

He sets up a supplement regimen for the two weeks preceding surgery that aims to keep the bruising and swelling to a minimum. He has the patient stop taking any supplements that thin the blood — such as aspirin, Vitamin E, green tea and St. John's Wort, as well as omega-3 fatty acids and fish oils. He replaces these supplements with those that aid in healing for a five-day regimen prior to surgery. It includes bromelain (500 mg, three times a day) and Arnica montana, as well as a prescription for vitamin K (Mephyton, 5 mg). He also issues a prescription for Valium (Roche Pharmaceuticals, Nutley, N.J.) to further minimize anxiety.

On the day of surgery, an anesthesiologist starts an intravenous combination of propofol and midazolam; Dr. Rosenberg follows that up by administering a long-lasting local anesthetic of lidocaine (1 percent) with epinephrine (1:100,000) equally with marcaine (0.25 percent) with epinephrine (1:200,000). The anesthesiologist administers Decadron (Merck, Rahway, N.J.) and Zofran (Glaxo-SmithKline, Research Triangle Park, N.C.), both to limit any lingering potential for nausea. The local anesthetic typically lasts through the night, barring the need for morphine or other narcotics in the recovery room, and in fact, Dr. Rosenberg finds that this combination prevents the need for anything stronger than a Tylenol (1,000 mg) later that evening.

"Hiding the scar is a must," Dr. Rosenberg explains. Thus, he says he uses post-tragal incision. "This is very meticulous and takes a few extra minutes," he says. "But when the stitches come out at seven days, you don't see a scar in front of the ear."

He then performs a deep plane facelift with minor modifications — a technique that he's found to leave less bruising and swelling than a subcutaneous or a submusclar aponeurotic system(SMAS) lift. In modifying the traditional deep plane lift, he says, "I leave the fascia and a small amount of fat on the zygomaticus major muscle. I find this approach reduces the swelling in the cheeks."

Vancouver, British Columbia — Houston plastic surgeon Thomas Biggs, M.D., says he not only has learned new approaches to commonly performed procedures, he also has learned that some newer procedures — such as the buttock lift — are safe and accepted among plastic surgeons from around the world.

Dr. Biggs, who is clinical professor of plastic surgery at Baylor College of Medicine, president of the International Society of Aesthetic Plastic Surgery and editor-in-chief of the journal Aesthetic Plastic Surgery, moderated a session at the recent meeting of the American Society for Aesthetic Plastic Surgery during which international researchers presented information on about 30 papers.

He offers these pearls:

• Surgeons are performing facelift surgery in younger patients with less need for extensive incisions by using a series of purse-string sutures, passed through the SMAS.

• Doctors can get increased efficiency with fat injection by using simple technical tips.

Torrance, Calif. — When June Wilbanks' fianc石uggested she meet with Dr. Christine Petti, M.D., F.A.C.S., to talk about getting an abdominoplasty, she hadn't, until that moment, considered having cosmetic surgery. She thought cosmetic surgery was "a vanity thing. It wasn't me." Furthermore, she says, the last time she had surgery was when she had her tonsils out as a child.

But even though she did aerobics three times a week, once she took a good look at her physique, she had to admit that since she entered her 50s, "things weren't in the same place they used to be."

Looking for answers

"She included him in the discussion and she put us both at ease."

Hot topic Doctor-patient interaction has become a hot topic since The Federation of State Medical Boards added a test on bedside manner to the 2004 physician exams. Good bedside manner, it's believed, means better communication, which hopefully means fewer doctor errors, and therefore, fewer malpractice suits.

But could there be more to the equation of ensuring good doctor-patient relations than training? Dr. Petti would agree that there is.

Simply put, she says, many women patients feel more at ease with a woman doctor. She credits this to a tradition perhaps as old as time itself — the art of "girl talk" — and she's not alone in this theory.

In a study conducted at the University of California, Davis Medical Center Primary Care Center, and published in the Journal of the American Medical Women's Association, female patients were found to be the most satisfied with their quality of care when treated by a female physician than those treated by male doctors, and more satisfied than men treated by male or female physicians. Similar studies have concluded the same, except for one study that found male patients treated by female physicians were the happiest group with their quality of care.

Operative factor And quality, not necessarily quantity, may be the operative factor.

The Davis Medical Center study revealed that both male and female physicians dedicated roughly equal amounts of time to their patients. However, the female physicians spent more time counseling the patient and covering preventive measures, while the male physicians spent more time on technical routine and practical discussions. Yet when the male doctors adjusted their rapport to a more nurturing approach, the female patients still preferred their female caregivers.

It may just be that some women are more comfortable talking with a woman doctor.

Dr. Petti has found that by encouraging an open dialogue, many women patients are more relaxed once they realize they can confide some of their deepest insecurities.

"I think they're worried about conveying some of their deficiencies or some of the things that have perhaps made them feel they don't look their best —- maybe revealing their eating habits or how they feel sexually. I think they feel more comfortable speaking to a woman and less self-conscious than perhaps revealing those things to a man," she says.

Another source of comfort for women patients is that they're talking about issues with someone who shares their common life experiences — especially if the surgeon is raising children, has experienced post-childbirth changes in her body and opted for cosmetic surgery to improve those changes.

Defends colleagues Dr. Petti is quick to defend her male colleagues.

Las Vegas — Traditional lower lid blepharoplasty is based on an incomplete formula that initially derived its success from the removal of fat and skin. While this approach has been modified through attempts to restore the skin by reshaping deep tissue, doctors have become much more focused on the non-surgical approach aided by customized diagnosis, according to Robert A. Goldberg, M.D., who spoke here at the Facial Aesthetic Excellence meeting.

"Patients don't want lower lid blepharoplasty, even though they may at first request this procedure," says Dr. Goldberg, professor of ophthalmology and chief, orbital and ophthalmic plastic surgerydivision, at Jules Stein Eye Institute in Los Angeles.

"In my practice, I may see many patients who say they want lower lid blepharoplasty, yet what they want is to look less tired and have less sagging skin," he says.

"Understanding the anatomic basis helps to customize a treatment plan. Although it may include traditional blepharoplasty, more often there are going to be other treatments that are recommended," Dr. Goldberg says.

When looking at 114 consecutive patients who had lower eyelid concerns, Dr. Goldberg and his colleagues noted that some 10 different procedures were recommended in various combinations to customize an approach that best suited different anatomic features.

"When looking at the whole group of patients, only a small minority would benefit from lower lid blepharoplasty," Dr. Goldberg says. "Most often, patients would benefit from other procedures, such as skin resurfacing or radiofrequency eyelid sponge thermoplasty, where we use radiofrequency energy to dry up excess fluid — a procedure completed under topical anesthesia."

Foregoing the traditional Other examples of in-office procedures used as alternatives to lower lid blepharoplasty include Restylane used for three-dimensional filling of the various peri-orbital hollows, and Botox used to sculpt the obicularis.

"The obicularis is a very complex muscle that can change the dynamic aesthetic shape of the eyelid," Dr. Goldberg says. "When analyzed, we realize that this is often the most significant problem for the patient. Blepharoplasty, with or without fat repositioning, is offered among these other therapies, yet the minority of my patients end up having blepharoplasty after considering the other therapies that are offered. This is the biggest difference I've seen in the last five years. ...

"You will be increasingly successful the broader your palate of minimally invasive approaches ," Dr. Goldberg says.

This 61-year-old patient had an endoscopic browlift, upper eyelift and lower eye fat repositioning. The result is a "non-surgical," natural look

"It rejuvenates the lower eyelid complex wonderfully," says Paul S. Nassif, M.D., F.A.C.S., who, along with Guy G. Massry, M.D., has performed approximately 150 of these procedures in the past four years. Drs. Nassif and Massry are in private practice at Spalding Drive Cosmetic Surgery and Dermatology, Beverly Hills, Calif.

Dr. Nassif began performing the technique in response to patients who previously had transcutaneous and transconjunctival lower eyelid blepharoplasties, but became dissatisfied when the final results left them looking gaunt or hollow.

"The cheek descends inferiorly with age and produces a depression at the medial inferior orbital rim, resulting in a double convexity deformity. The first convexity around the lower eyelid fat is pseudo herniating or bulging, and the next convexity is the cheek or the mid face, and this is a sign of the tear trough deformity and the natural evolution of aging," Dr. Nassif says. Another contributor to the tear trough deformity, he points out, is a bony deficiency of the maxilla.

Dr. Nassif uses a transconjunctival approach to reposition the medial and the central lower lid herniated fat into the nasal- jugal fold to prevent hollowness and fill in the tear trough deformity.

"There are some disadvantages to this technique because there is a steep learning curve," he says. Potential complications include diplopia, fat granuloma, soft tissue irregularities and prolonged edema. "Fat granulomas are rare but can occur with even the best surgical technique possible," he adds.

Dr. Nassif described his technique at the annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

The vast majority of patients in Drs. Nassif and Massry's series had excellent outcomes.

"Four years after surgery, the majority of these patients have no hollowness and the area looks very smooth," Dr. Nassif says. Two patients had fat granulomas; one is ongoing and has become persistent, and the other was temporary and has been resolved, he says. A few patients had prolonged swelling in the lower eyelid area for two to three months, which also resolved.

Technique A critical part of Dr. Nassif's technique relies on identifying the inferior oblique muscle.

"Once that's accomplished, I then dissect the fat and the soft tissue from the fat that's attached to the muscle away from it so that the fat essentially has no attachment to the muscle," he explains.

Once a fat pad pedicle is created and all soft tissue attachments to the inferior oblique muscle are eliminated, he performs an arcus marginalis release and subperiosteal dissection nasal to the infraorbital nerve.

"Then we perform an out-to-in transcutaneous suture into the subperiosteal space, into the fat pedicle with a horizontal mattress suture and then into the subperiosteal space and out to the skin," Dr. Nassif explains.

"When I place the fat into the subperiosteal pocket, I spread it out and make sure it's not folded on itself and flat. Then I tie the stitch over a cotton bolster; perform force ductions to make sure there's no tethering of the inferior obliquemuscle, and after five days I remove the suture." Once the technique is perfected, according to Dr. Nassif, the outcomes far exceed just removing the fat.

Traditional blepharoplasty techniques, removing skin muscle and fat, can result in hollowness, an aged look, and scleral show with poor eyelid closure.

"There are many who are rethinking traditional blepharoplasty because of how they view their patients," says Dr. Goldberg, professor of ophthalmology and chief, Orbital and Ophthalmic Plastic Surgery Division at Jules Stein Eye Institute in Los Angeles. "The most important factor is the detail in pre-operative analysis," he says.

While the advances in upper eyelid blepharoplasty may be much more conceptual in nature, the discerned structural differences among patients is literally shaping today's approach — one that includes both non-incisional surgery and non-surgical options.

Eye-opening optionsBefore engaging in any type of upper eyelid procedure, the surgeon should survey the various physical attributes that can help determine the correct procedure.

An example is bony asymmetry that may be significant enough that the surgeon may have to change the position of the globe relative to the orbit before effectively and safely performing blepharoplasty, according to Dr. Goldberg.

"The eyebrow fat pads are also critically important. If you look at MR scans, the roof fat pads are a powerful participant in creating the eyelid contour," Dr. Goldberg says. "Learning how to recognize the contour of the eyebrow fat pads and to differentiate this from other contours is absolutely critical for surgery. If you mistake an eyebrow fat pad fullness or deflation for an orbital change, you may do the wrong procedure. Eyebrow fat pad surgery may involve reinflating it with Restylane or fat, three-dimensional reshaping, or it may involve an upper facelift."

While the surgical process of an upper eyelid blepharoplasty has only seen recent minor modifications, Dr. Goldberg has fine-tuned his approach. For example, he performs the lateral fixation of the arcus marginalis, or "eyebrow brassiere," to design and reshape the lateral eyebrow. His practice also offers non-incisional surgery options — including the closed crease-forming surgery, an approach used for many decades by aestheticians in Asia — that avoid the need to remove fat, skin and muscle.

Transitory transformationA paradigm shift occurring among plastic surgeons is contributing to the non-traditional approach to the eyelid, one where success is no longer measured by the length of time a procedure lasts, according to Dr. Goldberg.

"Something that is permanent might be right for now, but it could be different in 10 years. For example, the excision of fat may help the 40-year-old look 32, but when she's 60 and she's missing a lot of volume it's very hard to replace," Dr. Goldberg says. "Permanence is not really what we're looking for, and the patient is very receptive to the idea of maintenance."

"Nowadays, I do far fewer blepharoplasty surgeries; rather, I'm more inclined to offer non-incisional options such as Botox, Restylane and closed suturing techniques — using to my advantage the fact that they're not permanent," Dr. Goldberg says.

New York — Jean Carruthers, M.D., thinks it might be appropriate for her and her dermatologist husband, Alastair, to change their middle names to "determination."

Dr. J. Carruthers

And the Carruthers now have a 15-year retrospective study to prove the drug's safety — an aspect often cited as a patient concern. The study coincides with Botox's 15^th anniversary. The Carruthers couldn't be happier that a drug they have believed in for many years and that has been in existence as a compound since 1979 now has the safety data to back its cosmetic use.

Dr. A. Carruthers

The study The study, Long-Term Safety Review of Subjects Treated with Botulinum Toxin Type A for Cosmetic Use, was presented at the recently concluded American Academy of Dermatology Academy '04 meeting in New York.

The study shows Botox is safe and well-tolerated for facial cosmetic procedures when used in multiple treatment sessions over an extended period of time, and when administered by a qualified and trained healthcare professional.

According to Alastair, looking back, the current study's positive results have been long-awaited.

"Getting accepted has been frustrating for so long," he tells Cosmetic Surgery Times. "We could see the potential, we knew it was a winner, but no one was listening to us."

"They were frightened," Jean continues. "There was an article published in 1969 that called botulinum type A 'the most poisonous poison.' That stuck in the consciousness of a lot of people. It had to overcome that reputation.

"Even though its use started in ophthalmology, it was dermatologists who had the open minds to accept it as a really interesting new treatment," Jean says. "It is a privilege to be able to present our retrospective study here (at Academy '04)."

Legacy The Carruthers describe the success of Botox as "absolutely amazing." A belief in themselves, the product and a healthy dose of tenacity fueled them.

"It was such a fringe idea in 1987; we never would've believed it would enjoy the success it's having today," Jean says. "It was quite difficult to get 30 participants to put our first study together. People would say, 'You want to inject what in my face?' We got used to disbelief. We got used to people saying, 'no thanks,' yet when you injected them and saw the results, it was so rewarding. We knew it was just a matter of keeping at it."

Still overcoming obstacles Even though Botox has overcome many of the obstacles that it first confronted, the education battle is still not over.

Atlanta— In vitro assessment of the efficacy of silver dressings may not adequately reflect their performance in a clinical setting, according to Stephen C. Davis, research associate professor, department of dermatology and cutaneous surgery, University of Miami School of Medicine. Carlos Ricotti, M.D., a wound healing fellow with Prof. Davis, discussed their work on the antimicrobial efficacy of silver dressings at the 14th annual meeting of the Wound Healing Society.

Silver has long been known to have antimicrobial activity. In recent years, silver-containing dressings have replaced topical silver sulfadiazine as the preferred silver treatment for chronic wounds or burn wounds.

"The problem with topical silver is that the silver is too readily released and may be rapidly inactivated due to proteins found within the wound exudates," Prof. Davis says.

Silver dressings have been shown to be effective in preventing pathogenic infection in chronic wounds or burn wounds, but their efficacy in combating pathogenic colonization and infection has not been adequately studied in vivo, according to Prof. Davis. All published reports evaluating the antimicrobial activity of silver dressings have been performed in vitro on the planktonic bacterial sub-population, not against biofilm bacteria.

In vitro assays not all-encompassing

"Results obtained using in vitro assays should be carefully interpreted," Prof. Davis says. "In vitro assays are good for determining initial efficacy of the silver dressing against specific pathogens, but fail to take into account other factors that may influence treatment efficacy, such as wound fluid, growth factors and proteinases."

In an unsponsored study, Prof. Davis and co-workers at the University of Miami compared the antimicrobial activities of a hydrocolloid dressing and a silver-containing dressing in an animal model. Each of three young, female pigs was given a second-degree burn wound on half of the back. The wounds were inoculated with a clinical isolate of P. aeruginosa from a burn wound. To encourage biofilm formation, the wounds were covered with polyurethane dressing for 72 hours.

After 72 hours, burn wounds were also created on the uninjured half of each animal's back, and the wounds were inoculated with P. aeruginosa. The bacteria in the older wounds had formed biofilms by this time, whereas the bacteria in the freshly inoculated wounds were planktonic. Before silver dressings were applied, cultures were taken from the older wounds to determine baseline biofilm bacterial counts.

Approximately 20 minutes after the fresh wounds were inoculated, the wounds on both sides of the animal were treated with a non-crystalline silver dressing (Acticoat, Smith & Nephew), a hydrocolloid silver dressing (Contreet, Coloplast Corp.) or no dressing. A modified scrub technique was used to obtain cultures from the wounds in all groups at 24, 48 and 72 hours. Serial dilutions of the cultures were plated and counted using standard microbiological techniques.

Planktonic bacterial counts were significantly reduced at 24, 48 and 72 hours in wounds treated with the hydrocolloid dressing, compared to wounds treated with the nanocrystalline silver dressing or the untreated controls. However, neither dressing differed significantly from the untreated control in biofilm bacterial counts at any point.

"It is important to consider both in vitro and in vivo studies when developing antimicrobial dressings or agents," says Prof. Davis.

Disclosure: Prof. Davis reports no conflicts of interest.

Patient before and after an algorithmic procedure to correct bulging lower eyelids. Dr. Ramirez believes an individualized approach produces more successful results, and he bases his treatment algorithm on several variables.

"Given the complexity of the lower eyelid, lower lid blepharoplasty should not be approached in a simple or cookbook fashion," he says. "Successful results are best achieved using an individualized approach that is based on the unique characteristics of each case and appreciation for the features that define a beautiful lid. Those include absence of scleral show, a lateral canthus that is higher than the medial canthus, absence of ciliary tilt, tarsal fullness and a slight infratarsal depression to afford a nice blending between the lower lid and cheek."

Dr. Ramirez is clinical assistant professor of plastic surgery, Johns Hopkins University, Baltimore, and a private practitioner at Esthetique Internationale in Timonium, Md.

Tarsal laxity is assessed using three tests — the snap test, the distraction test and vertical canthal displacement. A total score 10 is considered normal, and in that situation, no additional intervention or only a preventive orbicular suspension is indicated for suspending the lower lid. A score of 11 to 20 represents moderate laxity, which is addressed with plication canthopexy and orbicularis suspension. Patients whose score is Ž21 are considered to have severe laxity that requires canthoplasty with shortening plus orbicularis suspension. Dr. Ramirez says the orbicular suspension (plication) is done without cutting the orbicularis oculi muscle.

For addressing wrinkles, a trichloroacetic acid peel is the preferred treatment if the wrinkles are min-imal. Moderate wrinkling is addressed with laser resurfacing as the first choice, although skin excision can also be performed. Skin excision is the treatment of choice, followed by laser resurfacing to improve the appearance of severe wrinkling.

Vector concerns Dr. Ramirez notes that the portion of the algorithm that determines treatment based on the vector is more complex, as it takes into account the absence or presence of a tear trough deformity and size of the eye. If the vector is positive and there is no tear trough deformity, the treatment is determined according to eye size. For individuals with small eyes, the fat pads are repositioned inside the orbit. However, if the eyes are normal or large, the fat can be safely removed, and Dr. Ramirez's preferred approach for achieving that is through a transconjunctival incision.

If the patient has a positive vector but a tear trough deformity is present, the fat is maintained within the orbit in patients with small eyes, and the tear trough deformity is treated with fat grafting or a vertical suborbicularis oculi fat (SOOF) lift. When there is a positive vector, tear trough deformity and the eyes are normal or large, the fat pad is slid to improve the tear trough, and then the patient may or may not need a SOOF lift.

Patients with a negative vector — i.e., location of the orbital rim >3 mm behind the corneal plane — are offered an orbital rim implant to convert the vector to positive. If the patient declines the implantation procedure, then canthoplasty is performed. In either case, additional treatment is determined, as described above, according to the absence or presence of a tear trough deformity and size of the eyes.

Orbicularis oculi intact Dr. Ramirez points out that, in contrast to a traditional blepharoplasty technique, his treatment approach avoids cutting the orbicularis oculi muscle in order to avoid denervation of the lower eyelid and associated complications.