The American Journal of Cosmetic Surgery

Lipomas are among the most commonly presenting benign forehead masses. They commonly cause cosmetic concerns for patients. The purpose of this report is to introduce a novel endoscopic technique allowing for forehead soft tissue mass removal with superior cosmetic outcomes. We detail a case of a large 3.5-cm lateral forehead lipoma that was successfully removed endoscopically through a single incision via a subtemporoparietal approach. The lipoma presented is the largest documented case removed endoscopically using this approach. We introduce a novel technique using a single incision in the temporal area to remove a forehead mass via a dissection between the temporoparietal fascia and deep temporal fascia. Our broad literature search only found one other report of this approach used for forehead lipoma removal. Our report further validates this approach and highlights its efficacy in removing large masses. Patients with cosmetic concerns about having a facial scar, children, and those with predisposition for keloids or hyperpigmented/hypertrophic scars stand to benefit most from this procedure. When comparing the endoscopic approach with the commonplace open-incision approach, our approach shows superior cosmetic results, less risk of damage to important neurovascular structures, and, most importantly, higher patient satisfaction. Even when contrasting the technique outlined in this report versus other endoscopic approaches, our method produces enhanced results.

A 55-year-old man who previously underwent a successful hair transplantation for androgenetic alopecia now presents with rapid onset hair loss over the anterior to mid-scalp areas during a 2-month period. The alopecic area noticeably extended diffusely from anterior hairline to scalp vertex while rows of previously transplanted hair follicles appeared intact. Further dermoscopic features and a scalp biopsy were consistent with alopecia areata incognita. This patient was subsequently successfully treated with intralesional steroid injections. This case report is the first demonstrating the relative resistance of transplanted hair follicles to the process of alopecia areata when compared with local indigenous hairs. Prior to this, a few reports have demonstrated the use of hair transplantation to treat stable areas of alopecia areata resistant to medical treatment with mixed results but at least some initial success. This could be related to the local irritation and inflammatory response resultant from needling during hair transplantation that causes a degree of scarring and fibrosis around each transplanted graft, hence lending a protective barrier to an autoimmune-based T-lymphocyte attack on hair bulbs and subsequent increased survival of transplanted hair follicles. This unexpected observation provides new avenues for investigation into alopecia areata pathophysiology and further supports hair transplantation as a viable option for patients with stable, localized alopecia areata that is recalcitrant to other modalities.

Aesthetic surgery has become increasingly popular in the last several decades, with facial aesthetic surgery accounting for a large percentage of the procedures performed. With this surge in popularity and the increase in the number of cosmetic surgeries and procedures completed, comes an inevitable increase in the number of complications encountered. This review elucidates common complications and effective management of frequently performed cosmetic facial surgeries. This article represents a general overview of the topic. For a more exhaustive review, the reader is encouraged to turn their attention to the facial plastics and additional surgical subspecialty literature. Aesthetic procedures discussed in this article include rhinoplasty, rhytidectomy, facial augmentation, otoplasty, brow lift, blepharoplasty, skin resurfacing and chemical peels, and facial injections.

The aim was to examine the validity of a peri-orbital rejuvenation protocol with clinical surgical results evaluating patient satisfaction and complications. Retrospective patient data and chart review was performed on 367 patients who underwent a blepharoplasty procedure. Outcome measures were dependent upon direct patient responses on postoperative visits, photographic documentation, and physical examination findings. The other outcome measure was termed a successful surgical outcome. This definition included the procedure goal was met, no postoperative complication was observed, there was no need for a revision, and the patient was satisfied with the outcome. From a cosmetic result standpoint, 99.5% (365 of 367 patients) were satisfied with the outcome. There were a total of 456 blepharoplasty surgeries: 203 upper, 75 lower, and 89 quad blepharoplasties. The patients defined with a successful outcome totaled 94.0% (345 of 367 patients). There was a complication incidence of 2.5%. Revision surgery occurred in 3% of upper blepharoplasties and in 1.8% of lower blepharoplasties. Adjuvant procedures performed either at the same time or as a staged procedure to complete the peri-orbital rejuvenation protocol were as follows: browlift surgery 24, brow or hairline dermal filler placement 4, facial silastic implant surgery 9, mid-facelift 16, lateral canthopexy 7, facelift 41, laser skin resurfacing 53, trichloroacetic acid peels 19, radiofrequency skin treatments 19, lower eyelid fat transposition 10, and facial fat transfer 25. The peri-orbital rejuvenation surgical protocol, surgical blepharoplasty techniques, and adjuvant procedure techniques performed revealed a high benefit to risk profile and high patient satisfaction rate.

A multitude of operative techniques to correct prominent ears are performed routinely. The propagated techniques have one common beginning: the injection of diluted adrenaline mixed with local anesthetics. The suggested benefits of this injection are vasoconstriction, anesthesia, and hydrostatic dissection of the surgical plane. Despite its routine use and the proposed surgical effects, the concrete anatomo-histological layer, in which the diluted adrenaline and local anesthetics are injected, has never been investigated. The aim of this study is to evaluate the concrete anatomo-morphological layer of injection and assess for possible hydrostatic dissection, which may have a clinical benefit in otoplasty. Retroauricular injection with the drawing ink was performed in 26 Thiel-conserved concha followed by a histological analysis. A juxta-perichondral (n = 11) or partially intraperichondral (n = 10) injection was observed in most cases. In 3 specimens, we observed ink deposition above the perichondrium and in 2 cases a subperichondral deposition. In 3 cases, ink was observed intravascularly. The mean distance of the dissected plane to the cartilage was 349 µm. The mean thickness of the perichondrium was assessed to be 444 µm. This experimental anatomical study reliably determines the level of injection in otoplasty as juxta-perichondral or partially intraperichondral. Optimal surgical dissection, resection as well as suture placement can be considerably facilitated by a juxta-perichondral deposition of vasoactive substances and the associated volume expansion. The results of our study provide empirical rationale toward a more evidence-based action for an important step in most of the propagated techniques in otoplastic surgery.

Breast augmentation mammoplasty is one of the most commonly performed cosmetic procedures in the United States. Currently, the common access incisions employed to perform the procedure are periareolar, inframammary, transaxillary, (TUBA) transumbilical, and (TABA) transabdominal (a technique that places breast prosthesis through existing abdominal scars or during the performance of an abdominoplasty). Asymmetries of the breast and chest wall are a common occurrence that is faced by aesthetic surgeons who perform breast augmentations. We aim to describe how our experience with using the supra-areola incision, for a primary breast augmentation procedure, has the added advantage of allowing us to address this problem. This article is a retrospective review of primary breast augmentation cases that were performed in our General Cosmetic Surgical Group and Fellowship Training Program from January 1, 2007, to June 30, 2015. The review addresses the incidence of nipple asymmetry in our primary breast augmentation patients and how we are able to address this problem by performing a crescent nipple-areola complex (NAC) lift via a supra-areola incision. From January 1, 2007, to June 30, 2015, 281 primary breast augmentations were performed, of which 184 (65.8%) had an NAC lift to address subjective and objective mild nipple asymmetry (~1 cm). There were no intraoperative complications. At follow-up, more than 92% of patients report satisfaction with their aesthetic outcome, 98% admitted to resolution or improvement of nipple asymmetry, 99% admitted to adequate postoperative nipple sensation, while 8% had secondary/revision breast surgery in the form of capsulectomies, scar revisions, and implant change revisions. Supra-areola incision approach should be strongly considered as a first-line approach in patients undergoing a primary breast augmentation procedure with adequately sized NAC and have evidence of mild (maximum study average = 0.95 cm) nipple asymmetry.

As under-eye filler injection has become widespread, it is important to understand possible differences and outcome of lower blepharoplasty in these patients. Herein, we describe our experience to address under-eye fat prolapse (via lower blepharoplasty) in patients with “residual fullness” after previous eyelid hyaluronic acid gel injections. Retrospective analysis of patients undergoing (transconjunctival) lower blepharoplasty (with fat repositioning) by one surgeon in eyelids previously injected with hyaluronic acid gel (+/− hyaluronidase), with “residual fullness.” Minimum follow-up time was 6 months. Preoperative and postoperative photographs at longest follow-up visit were evaluated by blind observers. Patient satisfaction was recorded using questionnaire. Surgical anatomy was observed. Total of 15 patients (28 eyelids; 13 females, 2 males) underwent lower blepharoplasty in eyelids previously injected with hyaluronic acid gel (latter to treat under-eye hollowness [tear trough deformity] and/or to camouflage under-eye fat prolapse [“bags”]). All patients had at least one prior hyaluronic acid gel injection with “residual fullness.” Ten patients had also received at least 1 previous hyaluronidase injection. Mean age was 47 years (range, 28-68 years). The surgical anatomy was slightly to moderately distorted with soft tissues (orbital fat, sub-orbicularis oculi fat, orbicularis oculi muscle) being more “spongy” with less clear delineation of surgical landmarks, septa, and fat pads. All patients reported satisfaction with surgical outcome, with no complications or reoperations. Three patients received “touch-up” filler injections. “Revision” lower blepharoplasty can be done safely and effectively to address “residual fullness” in eyelid previously injected with hyaluronic acid gel (+/− hyaluronidase).