Dr. Taylor

Fibrin glue is a fibrin sealant made up of an allograft of fibrinogen and thrombin. Traditionally, the glue has been employed as a tissue adhesive and has been useful in assisting intraoperative hemostasis, as the glue can help seal many of the very small traumatized blood vessels.

More than this, however, fibrin glue has a special utility in facelift surgery by helping the skin flap adhere to the underlying tissues, says Dr. Taylor, director of the Cosmetic Surgical Arts Centre in Missoula, Mont.

TECHNIQUE SPECIFICS Dr. Taylor says he prefers to aerosolize the fibrin glue with the help of compressed air. At the termination of the facelift case, he positions and holds the skin flap into its final position with suspension sutures and completes the final trimming.

Next, he raises the flap with retractors and, using a special syringe, he sprays the fibrin glue on the underside of the skin flap and into the base of the underlying tissue. He then places the subcuticular sutures while manual pressure is applied on the skin flap for approximately five minutes, allowing the fibrin glue to set.

"The assistant should continue to manually hold down the skin flap while the sutures are placed so that you do not inadvertently pull up any edges of the skin flap. This really helps to find a perfect juxtapositioning of the tissue edges and optimizes the result," Dr. Taylor says.

Using an appropriate amount of glue in the surgical site is instrumental in achieving a good surgical result, Dr. Taylor says. He typically sprays 1 cc of fibrin glue per side in facelift cases and 0.75 cc to 1 cc of fibrin glue in forehead lift cases.

Dr. Coleman

"People wonder why we're putting fat in the hand," Dr. Coleman says. Normally, after childhood, "There's little if any fat in the hand. But we're learning now that aging has a lot to do with atrophy," he says.

Dr. Coleman says that initially, "I approached the hands by restoring fullness to them, which undoubtedly is a component in reversing aging. However, hand rejuvenation isn't just filling, if it involves changing the quality of the skin."

More than a decade ago, researchers discovered that fat contains a high quantity of mesenchymal stem cells whose functions include repairing tissues, improving blood supply and preventing or even reversing scarring, Dr. Coleman says. "These are almost exactly the same stem cells found in bone marrow."

Subsequent investigators showed in an animal model that injecting fat under normal skin thickened the skin as much as 100 percent, due most likely to neocollagenesis at the recipient site (Mojallal A, Lequeux C, Shipkov C, et al. Plast Reconstr Surg. 2009;124(3):765-774). "That's probably the more important aspect in dorsal hand rejuvenation — not just filling, but thickening the skin and rejuvenating it," he says.

HOW IT'S DONE One patient Dr. Coleman treated in this fashion was a 52-year-old female with arthritis and wasting between the fingers that made her hands look much older than she was. "I injected 26 cc over the back of each hand, up to the middle joint of each finger. There are veins going up that far. And if you don't go that far out on the fingers, the rest of the hand suddenly looks better, but the fingers don't," he says.

A typical patient receives 25 cc to 35 cc per hand. "It sounds like a lot, and on the face, it would be," he adds. "But to the back of the hand, it's just a very thin layer." Dr. Coleman says he usually starts injecting at the fingers then works his way down the back of the hand past the wrist.

Typically, Dr. Coleman injects through seven or eight puncture-like incisions per hand. "I used to use a knife, but now I use a large needle to make the incision sites," he says. "And I place the fat entirely against the skin. I don't inject anything deep, so I'm staying between the skin, and the veins and tendons."

Additionally, he says that to prevent entering and injecting arteries, which could cause not only bleeding and bruising but also a pulmonary or arterial embolus, he uses only blunt cannulas — typically 17 or 18 gauge, and 19 gauge in the fingers.

Along with preserving veins and arteries, Dr. Coleman says, blunt cannulas provide more stable results. "Cutting a swath in the tissue with a sharp needle destabilizes the tissue, whereas if you're pushing a blunt cannula through, the cannula goes through the natural tissue planes." That way, he says that when the cannula is withdrawn, the tissues fall back into their natural plane.

Because this approach creates minimal tissue disruption, it allows one to inject more fat, and it's less likely to move than it would if injected via sharp needle," Dr. Coleman says. It's also important, he says, to weave the fat into the subcutaneous layer with multiple passes, using the blunt cannula to place miniscule amounts of fatty tissue with each pass (Coleman SR. Plast Reconstr Surg. 2002;110(7):1731-1744; discussion 1745-1747).

Dr. Fagien

"Once collagen went away, we stopped injecting the skin because all of the products currently available are subcutaneous or deep dermal fillers at best, and we kind of left the skin because we did not have an adequate skin filler," he explains.

"If you really want to fortify and rejuvenate the skin, I do not believe that you can do it consistently with energy-based devices universally. I also believe that most of our currently available fillers are not as appropriate for applications to the skin (dermis). I think we have ignored the fact that there are ways that you can manipulate existing products, particularly Juvéderm (Allergan), and make them skin fillers," Dr. Fagien says.

According to Dr. Fagien, some of the main components of the aging face include volume loss of fat; soft tissue descent due to lack of integrity of the retaining ligaments and other structures that hold the soft tissue to the skeleton; and the thinning and loss of elasticity of skin with its ongoing depletion of native dermal components.

"For volume augmentation such as those performed in the jawline, chin and cheeks, the fillers that have the most capability of projection are going to be the preferred fillers, as one can achieve more result with less filler product," Dr. Fagien says.

Due to its greater viscosity, Juvéderm Voluma (Allergan) is one of the better fillers for voluminization, Dr. Fagien says. However, it is not available in the United States. Of the more robust fillers with a greater G prime that have Food and Drug Administration approval, Dr. Fagien says he often chooses Perlane (Medicis), Restylane (Medicis), and Radiesse (Merz) for volumizing purposes.

For softer results in areas where less projection and firmness is desired, such as in the lips or the nasolabial folds, Dr. Fagien says Juvéderm works very well.

According to Robert L. Simons, M.D., rhinoplasty remains the top facial plastic procedure for long-term enhancement of beauty. He is a Miami facial plastic and reconstructive surgeon and otolaryngologist. Based on more than 40 years' experience, he offers the following advice:
PEOPLE'S NOSES AREN'T NEARLY AS BAD AS THEY THINK. Dr. Simons says this quote comes from one of his instructors, Morey L. Parkes, M.D., of Beverly Hills, Calif. Dr. Simons says he embraces this statement because "rhinoplasty should be conservative in nature." When a patient says he or she doesn't like the hump or the thick tip of his/her nose, "It doesn't mean we must excavate the problem by removing the entire hump or getting rid of all the cartilage in the nasal tip," Dr. Simons says.

FACIAL PLASTIC SURGEONS DO A LITTLE TO ACHIEVE A LOT. Rhinoplasty is also a subtle procedure, Dr. Simons says. "It's an operation that often is not seen, or shouldn't necessarily be seen, in the nose itself, but it should be seen in the eyes of the individual." Rhinoplasty should make the patient's features more beautiful, "But in a way that draws attention to the beauty, not to the operation itself."

DON'T BE QUICK TO CRITICIZE — OR REVISE. "When you see a nose to be done or one that's been done, it's a mistake to quickly jump and get your hands on it or make a comment. What happens in rhinoplasty takes time for either the beauty of the refinement, or the stigmata of contractures or complications, to occur," Dr. Simons says. For example, he says four months postsurgery is too soon to tell a patient she needs hydroquinone, dermabrasion or laser treatment to address dark circles under her eyes. "Tincture of time often serves us well. This is something we must remember when we have a very anxious patient before us with perhaps less than her desired result."

A TWISTED NOSE DEFIES PERFECTION. Attempting to straighten a twisted nose perfectly is "one of the hardest problems we're faced with," especially for the long term, Dr. Simons says. In one case, he says a 69-year-old woman he treated for a crooked nose and inability to breathe still had satisfactory results 12 years later. In this case, he made septal incisions to straighten out the septum and extended these incisions to the top of the curvature at the dorsum. Along with external rhinoplasty, Dr. Simons says he used a strut and plumping grafts while removing a conservative amount from the dorsum. He used the patient's upper-level cartilage for support (he did this procedure before the advent of spread grafts). Ultimately, he says, her postoperative photos showed a bit of saddling in the supratip area, but the patient liked her results.

Conversely, a 17-year-old boy he treated for a badly twisted nose with a markedly deviated septum and inability to breathe returned two years later for routine follow-up. "Though he was markedly improved cosmetically and functionally, he still had a slight curvature of the nose," Dr. Simons says. "This underscores how difficult it is to obtain a perfectly straight nose postoperatively" when trying to fix a twisted one. In fact, Dr. Simons estimates that in such cases, "Revision rates double, from about 5 percent normally into double figures."

In nasal reconstruction, the most complex procedure or diagnostic test isn't necessarily the best, according to one surgeon.

Dr. Lesavoy

Conversely, Dr. Lesavoy says that a procedure he calls the "reverse nutcracker" is "an extremely simple way of fixing the airway. It has nothing to do with aesthetics at all. It's all about maintaining and improving the airway."

SIMILAR EFFORTS According to Ronald P. Gruber, M.D., "Many years ago, Dr. Lesavoy and I realized we were both doing the same thing — he was using a Pean, and I was using a large nasal speculum. When you spread with a nasal speculum, you fracture perpendicular plating and outfracture the turbinates. I'm happy it works in most all cases." In a few cases, "I have to go back and do some bony work on the perpendicular plate if the patient has an unusual piece of bone sticking up that is separate from the cartilaginous septum." Dr. Gruber is an Oakland, Calif., plastic surgeon and an adjunct clinical faculty member of Stanford University School of Medicine.

Dr. Gruber says he performs this maneuver routinely on every nasal reconstruction patient. "Often, we are doing lateral osteotomies, which compromise the airway," he says. "So we should do a prophylactic septoturbinotomy to compensate for what is going to be some partial airway obstruction from the lateral osteotomy."

Surgeons can perform the reverse nutcracker procedure in conjunction with other nasal reconstructive procedures, Dr. Lesavoy says. "If I'm doing it in conjunction with a rhinoplasty, for example, I don't even charge for it. There is essentially no dissection and very little bleeding." In his hands, the procedure works for any patient who complains of inability to breathe through the nose, he says.

The extended superficial musculoaponeurotic system (SMAS) lift avoids high levels of tension and creates results superior to those of conventional SMAS lifts in properly selected patients, says the extended SMAS lift's co-developer.

James Stuzin, M.D., a Coconut Grove, Fla., surgeon in private practice, says he began devising the procedure in 1989 with a colleague, Miami plastic surgeon Thomas Baker, M.D.

"We believed that the standard lateral SMAS procedure wasn't doing what we wanted to do — we wanted to get away from more skin-tension facelifts. By extending the SMAS more anteriorly, we believed we could get better postoperative contour correction. And that's been true in our experience (Stuzin JM, Baker TJ, Gordon HL, Baker TM. Clin Plast Surg. 1995;22(2):295-311)," Dr. Stuzin says.

However, he says that as he continued to research the procedure through cadaver work, "I realized that this incision design, from an anatomic viewpoint, was very useful because it allows you to free the superficial fascia from the restraint of the retaining ligaments," namely the carotid, zygomatic and masseteric ligaments. "Once you got into the mobile area of the SMAS, it moved more freely," with virtually no increase in tension.

Similarly, Dr. Stuzin says facial aging studies showed that the extended SMAS lift's incision design is also very useful aesthetically. It allows repositioning of descending anteriorly based facial fat back up into the lateral midface, where it resides during youth, he explains.

Another key to the procedure is Dr. Stuzin's commitment to two-layer SMAS facelifts including formal SMAS dissection. "We now have many alternatives to this procedure, such as plication techniques or SMAS-ectomies," he says. "But at least in my hands, when I mobilize the superficial fascia and get the SMAS free from the restraint of the retaining ligaments, I have greater aesthetic versatility and control. It seems intuitive to me that once you get this layer up, you can vector it anyway you want to," thereby achieving more patient-specific results. "I have more control in terms of keeping the fat where I want it postoperatively."

Over the years, Dr. Stuzin says he has made modifications to the procedure that have allowed him to further titrate it according to individual patients' needs and to achieve more consistent results. "I have a better feel for what this procedure does, as well as what it doesn't do," he says.

VALUE IN VARIABILITY Biomechanically, Dr. Stuzin says, the extended SMAS lift allows one to vary the SMAS' release, its vector and how one chooses to fix it (Mendelson BC. Plast Reconstr Surg. 2001;107(6):1545-1552; discussion 1553-1555, 1556-1557, 1558-1561). These variables will determine the resulting contour, he says.

"I still believe you must free the SMAS from the restraint of the retaining ligaments so that it moves freely, or you will lose contour. But when I first started doing the operation, because I was so focused on anatomy, I used to overdissect the SMAS, taking down basically all the retaining ligaments. And that isn't necessary," he says. Instead, surgeons need merely to access the mobile area of the SMAS, "So that when you pull on it, it gives you the traction effect you're looking for. Therefore, at this point, I tend to dissect the SMAS less than I used to."

Dr. Stuzin says he dissects through the fibrous and somewhat difficult area of the restraining ligaments. "Then suddenly, the SMAS will free up, and the dissection becomes easy," he says. "When this happens, I know I'm into the mobile area of the SMAS. I'll pull on it" to make sure before stopping the dissection.

Limiting the SMAS dissection reduces the procedure's morbidity and improves its precision, Dr. Stuzin says. Additionally, "Patients tend to look a little less 'surgical.' If you overdissect, there's a tendency toward more of a surgical stigma in the results."

Dr. Brown

"I believe that capsular contracture (formation), or hardening of scar tissue around the breast implant, in the absence of a clear reason why it occurred like a hematoma or trauma to the breast, is a result of subclinical infection or biofilm formation on the breast implant," said Dr. Brown at the 12th annual Toronto Breast Surgery Symposium.

Because of the concern about biofilm, it is important to remove the implant from the local environment where it is sitting, he says.

"Reusing the same implant may not be an effective treatment if in fact biofilm formation is the underlying problem," says Dr. Brown, noting that biofilm can't be seen but attaches itself to the implant. "Consideration should be made for taking the implant out of the local environment and replacing it with a new device."

QUANTIFYING COMPLICATIONS The rate of capsular contracture in implant surgeries has been placed at 10 to 15 percent, and the complication occurs with varying severity. It is the complication that most frequently results in the need for additional surgery (Kjøller K, Hölmich LR, Jacobsen PH, et al. Ann Plast Surg. 2002;48(3):229-237). Furthermore, Dr. Brown says, it's a challenge to predict which patients will develop capsular contracture.

Recently, there has been an effort to use artificial "dermis" to reduce the ability of the capsule to contract. In the end, however, the best way to manage contracture is to do everything possible to prevent it, he explains.

IMPLANT MALPOSITION Implant malposition is another significant cause for revision surgery, Dr. Brown says.

"The implant can be either superior, inferior, medial or lateral," he says. "You need to identify the direction of the malposition and develop a surgical plan to get it back to a normal position."

Malposition is not a problem of the implant, but of the implant pocket. To resolve the problem of malposition, the pocket can either be repaired or the implant should be removed from the pocket, and a new pocket should be surgically prepared to insert the new implant. "You either fix the pocket or change the pocket," Dr. Brown says.

Knowing the specific characteristics of a filler and the potential complications that can arise and how to deal with those complications is crucial in performing effective and safe filler procedures, says Joseph E. Hkeik, M.B.B.S., F.R.A.C.G.P., F.F.M.A.C.C.S., D.P.D.

"Filler treatments have become one of the most popular noninvasive cosmetic procedures performed in the aesthetic practice, and with appropriate training, the results achieved can be remarkable. However, many beginner cosmetic physicians who do not have appropriate training regarding the filler products and injection techniques they use may quickly get in over their heads, which can result in treatment complications," says Dr. Hkeik, a cosmetic physician and director and founder of All Saints Cosmedical Clinic, Sydney.

Though many fillers are effective in the treatment of lines and wrinkles of varying depths and useful in volume replacement, reversible fillers such as hyaluronic acid (HA) products are the most frequently used fillers used today. According to Dr. Hkeik, the HAs are popular not only because they can achieve excellent cosmetic outcomes, but also because they are resorbable and the physician can reverse an over-correction soon after injection.

WARNING SIGNS The typical side effects associated with filler treatments can include local erythema, edema, bruising and some tenderness following injection. These are all typically very minor, but other more serious complications can occur, many of which are usually associated with the use of improper injection techniques, Dr. Hkeik says.

Local skin necrosis is one complication that can be related to improper injection technique and can occur when injecting the glabellar region or the nasolabial folds, he explains. When injecting any filler product, Dr. Hkeik says he will always aspirate right before injection in order to help avoid injecting the filler material into a vessel. Failure to aspirate may result in vessel occlusion and subsequent skin necrosis at the target area.

Local blanching occurring after the injection of HA filler could also be due to a vascular occlusion. In a scenario where vascular occlusion is suspected, Dr. Hkeik says it's best to reverse it by applying nitrate paste and hot packs to the area. These will increase the local circulation and hopefully remove the concentration of local filler product. If these attempts fail, hyaluronidase injection may reverse the occlusion, he adds.

"As the face loses volume in layers, we should replace that lost volume in layers and slowly inject the filler across the whole target area. One should always try to keep the needle moving through the tissue and use a threading and fanning technique, depositing minutes amount of the filler along the way as needed. These will help you get a good spread of the filler throughout the target area," he says.

Hyaluronic acid fillers are also particularly hydrophilic, Dr. Hkeik says, meaning that they will absorb water after injection. Although this effect can result in a greater voluminization of the targeted area, the swelling of the target area could also increase the risk of extraluminal vessel impingement and possible occlusion.

"Similar to other filler products, the HAs have a range of moieties across the different products available, allowing the physician to aesthetically treat a range of lines, folds and wrinkles of all depths. Knowing the characteristics and individual properties of the filler you are using is extremely important in helping to avoid potential complications," he says.

Physicians who are just starting out with filler treatments should always undertreat the target area, he says. Though currently available fillers are all effective, he advises beginners to use the HAs.

"One needs to have an intimate knowledge of the anatomy where one injects and be aware of the complications that can occur, which are often related to the product one uses as well as injection technique. Do not try to be overly zealous in your aesthetic treatments because it can come back to haunt you and your patients," Dr. Hkeik says.

Disclosures:
Dr. Hkeik reports no relevant financial interests.

As the popularity of botulinum toxins for both cosmetic and therapeutic applications continues to grow, so too does development of new techniques and formulations. IncobotulinumtoxinA (Xeomin, Merz), the newest of the toxin formulations, is a promising product that according to clinical studies exhibits similar efficacy to onabotulinumtoxinA (Botox, Allergan), despite having a distinctly different biological makeup.

Timothy C. Flynn, M.D., of Cary Skin Center, Cary, N.C., participated in clinical studies of Xeomin as well as first-generation botulinum toxin products. He says Xeomin is unique biologically because it is free of complexing proteins. "Xeomin is 100 percent active toxin, so we were curious to see how it related to first-generation botulinum toxins," Dr. Flynn says.

XEOMIN BACKGROUND The Food and Drug Administration approved Xeomin for the temporary improvement in the appearance of moderate-to -severe glabellar lines in July 2011. Approval was based on results of two U.S. clinical trials involving 16 investigational sites and 547 patients. In both studies, Xeomin significantly improved the appearance of glabellar lines 30 days following the first injection, when compared to placebo.

Clinical trials have shown that when administered at the same dose, incobotulinumtoxinA is non-inferior to onabotulinumtoxinA for the treatment for blepharospasm,⁴ glabellar frown lines⁵ and cervical dystonia,⁶ and that both preparations display comparable treatment duration and waning of effect,⁷ according to Dr. Flynn.

"We participated in some of the dose-finding trials and the repeat dosing trials, and then we also had the opportunity to participate in a direct head-to-head trial that compared the use of 24 units of Botox to 24 units of Xeomin in the glabella," he says. "We found a non-inferiority of the Xeomin when compared to Botox, and there was no increase in adverse effects, either."

Because Xeomin doesn't include complexing, accessory proteins, all it comprises is the active toxin itself. "There are, of course, stabilizing proteins that keep the product from sticking to the side of the glass vile and some sucrose, but in terms of the toxin itself, all that's in there is 100 units of type A toxin," Dr. Flynn says.

"In essence, our injection techniques and everything else are completely the same as with onabotulinumtoxinA," he says. "While these formulations are not biologically similar, they are used clinically in much the same way. If you would inject 20 units of Botox in the glabella, we believe you could put 20 units of Xeomin and get the same result."

Dysport has been shown in several studies to require more for the same effect as Botox or Xeomin, Dr. Flynn says. "The generally accepted ratio is about 2.5 units of Dysport for every one unit of Botox or Xeomin. There are also a number of studies showing that when you dose at a 2.5-to-1 ratio you get a little bit of increased diffusion with Dysport in the area in which you inject."

Group consultations, coupled with the use of three-dimensional imaging, lead to greater patient satisfaction in breast augmentation patients, according to the chief of plastic surgery at Pennsylvania Hospital, Philadelphia.

"Group consultations are very patient-centred," says Louis Bucky, M.D., F.A.C.S., clinical professor of surgery, division of plastic surgery, University of Pennsylvania School of Medicine, Philadelphia. "Patients will ask questions that other patients have not thought of. I think that's very important."

Speaking at the 12th annual Toronto Breast Surgery Symposium, Dr. Bucky explained that he holds group consultations about twice per month and has about six to eight patients who take part in the consultation. He presents a slide show and discusses topics such as the surgery itself, preoperative planning, implant selection, and the complications that can arise. He also depicts preoperative and postoperative images of prior patients.

CONSULT DETAILS Consultations can be held up to three times a month at some points in the year, he says, noting the office must have sufficient space to hold a group consultation.

Dr. Bucky says his staff performs screening of women to determine which patients are appropriate to participate in a group consultation, since not all patients are suitable candidates for such.

"My staff gets to know who is a good candidate for a group consultation," Dr. Bucky says. "They like the process and like having an increased role in education. Individuals won't be selected for a consultation if they are expressing a lot of concerns over the phone or sound like they would not be comfortable in a group consultation. I would see a patient like that privately."

Patients who take part in a consultation rarely ask impertinent questions or are negative in regards to the process, he says. The screening by the office staff minimizes that occurrence.

Immediately following the group consultation, Dr. Bucky selects three or four patients for a private consultation if they are motivated and express great interest in pursuing breast augmentation surgery. These individuals are measured and imaged and meet privately with Dr. Bucky for about 15 minutes. He purposely selects a maximum of four patients, so that they don't experience long waits while in his office. While one person is being measured, for example, another patient is being imaged, he explains.

"The longest an individual waits is 45 minutes," Dr. Bucky says.