SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison

Although there are a multitude of techniques currently used for performing face lifts, there is no general agreement as to which, if any, of these techniques is most effective. There may never be a definitive answer to this issue because of the highly subjective nature of aesthetics, variability among surgeons, differences in patient anatomy, and specific patient desires. In an attempt to evaluate face lift techniques objectively, this study compares the rate of patients undergoing a tuck procedure after traditional SMAS (superficial musculoaponeurotic system) rhytidectomy to that of patients after deep plane rhytidectomy. A retrospective chart review was performed on all patients who underwent a tuck procedure following a face lift by the senior author (Kamer) between July of 1990 and January of 1997. There were 634 patients who electively underwent either a SMAS or deep plane type of rhytidectomy during the 6.5-year period; 48 patients subsequently underwent tuck operations, and adequate information was available on 44 patients. Of these, 43 were women and the average age was 57 years. The overall tuck rate from July of 1990 to January of 1997 was 7.5 percent. The tuck rate following SMAS rhytidectomy was 11.4 percent, and that following deep plane rhytidectomy was 3.3 percent. Therefore, a tuck was required 71 percent less frequently after a deep plane lift than after a SMAS lift. This was found to be a statistically significant difference with a p value of .0001 (Fisher's exact test, 2-tail). If the assumption is made that the need for a tuck procedure implies a less than optimal face lift, then the data of this study suggest that the deep plane technique is more effective than the SMAS technique.     

Computerized morphometric quantitation of elastin and collagen in SMAS and facial skin and the possible role of fat cells in SMAS viscoelastic properties

Recently, the superficial musculoaponeurotic system (SMAS) was found to be a composite tissue comprising collagen, elastic fibers, and fat cells in an extracellular viscous matrix. Both SMAS and facial skin tissues exhibit viscoelastic properties, but SMAS tissue has delayed stress relaxation. As a consequence, SMAS is viewed as a firmer elastic foundation for the more viscous facial skin. In some patients, a slackening effect of SMAS tissue takes place over a period ranging from weeks to months after tightening. To determine the relative quantity of viscoelastic components and better understand their biomechanical behavior, a quantitative morphometric study of the elastic and collagen fibers in the SMAS and facial skin was conducted. Thirty-four SMAS preparations were taken from 17 patients during either primary face lift operations (12 women) or reoperative face lift procedures (4 women, 1 man), which were performed 4 to 9 months after the original surgery, to examine the elastin and collagen content. For comparison, preauricular skin was also gathered from these patients. The specimens were stained with Weigert's staining to identify elastin and collagen fibers. Using a computerized morphometric analysis, 100 fields of each SMAS and skin specimen were examined. According to our findings, the average percentage of elastin and collagen fibers in SMAS and facial skin was as follows: (1) the percentage of elastin fibers in the SMAS was 4.71 +/- 1.2 (standard error of mean +/- 0.0291); (2) the percentage of elastin fibers in the skin was 6.1 +/- 1.8 (standard error of mean +/- 0.0436); (3) The percentage of collagen fibers in the SMAS was 38.7 +/- 5.9 (standard error of mean +/- 0.1430); and (4) the percentage of collagen fibers in the skin was 48.47 +/- 6.96 (standard error of mean +/- 0.1688). A statistical significance of p < 0.0001 was demonstrated between the collagen and elastin groups. A different percentage of elastin and collagen fibers was found among the 17 patients and within each of them separately. Neither gender nor age differences were found regarding elastin and collagen fiber content. No statistical differences were demonstrated between specimen sources, i.e., whether the operations were primary or reoperative face lift procedures. Findings from previous studies indicate that the cheek has two viscoelastic layers, the skin and the SMAS. The proportional similarity in average percentages of elastin and collagen in SMAS and facial skin cannot explain the relatively delayed stress relaxation effect of the SMAS. Therefore, the fat cells that are found exclusively in the SMAS probably lend a certain degree of firmness to this layer and play a significant role in the long-term efficacy of SMAS surgery.     

Anterior cruciate ligament-plasty and high valgus tibial osteotomy as a combined procedure in anterior instability and varus deviation

Besides patients having an acute rupture of the ACL with a clear therapeutical strategy there are increasingly young patients with chronical anterior instability and degenerative arthritis of the medial compartment and varus malalignment. This constellation is taxing severely the operative procedure considering that there is not only the instability which has to be treated but that also an improvement of the arthritis symptomatology has to be achieved. In this paper we present a therapeutical concept of high tibial osteotomy combined with an arthroscopic assisted reconstruction of the ACL which is performed as a single procedure since the early 80-ies. The goal is to remove two severe arthrogenic factors correcting the instability and the pathological anatomical axis, to reduce the medial knee pain and to improve the use of the knee in life activities.     

The SMAS (subcutaneous musculo-aponeurosis system) flap: a possibility for filling out soft tissue defects after parotidectomy

BACKGROUND: Parotidectomies sometimes leave a conspicuous soft-tissue defect in the dorsal part of the cheek. METHODS: The authors present a modification of the standard technique of parotidectomy which is reserved for the surgical management of benign parotid tumors. The incision of the skin follows the guidelines for standard subcutaneous rhytidectomy with a modification according to the Redon incision. They use flaps of the subcutaneous musculoaponeurotic system (SMAS), which they fold or rotate in order to fill the soft-tissue defect following parotidectomy. The preparation of the skin and the SMAS in layers from the lateral to the medial aspect of the cheek does not affect the blood supply which comes from medially running vessels. RESULTS: Forty patients have been operated on using these modifications of the standard technique. A postoperative follow-up of more than one year could be controlled in 31 cases. Thirty patients showed an inconspicuous dorsal region of the cheek without a soft-tissue defect compared to the other side. They did not wish a secondary operation for an aesthetic improvement except two scar revisions. CONCLUSION: To date this surgical concept has proved its worth.     

Laparoscopic management of superior mesenteric artery syndrome

Superior mesenteric artery syndrome (SMAS) is a rare clinical condition that should be considered in patients with long-standing abdominal complaints where endoscopic and conventional roentgenographical findings are often negative. It has been claimed that SMAS is caused by intermittent obstruction of the horizontal portion of the duodenum between the superior mesenteric artery and the spine and the aorta. The main target of this presentation is to present our experience in the laparoscopic management of 4 cases of documented SMAS after failure of medical treatment. The laparoscopic severing of the ligament of Treitz is a feasible and safe technique. It could bring about total relief of symptoms in three out of the four patients. The operative time rapidly decreased with the acquaintance of the field. The visualization (exposure) is quite satisfactory. the technique offers added precision and accuracy to the dissection manoeuvres. Recovery was uneventful and rapid with minimal needs for postoperative analgesia. We recommend the use of mini-endoshear (pediatric). Phases of dissection from the mesocolon and retro-pancreatically are presented. We stress the finding of the drainage of the inferior mesenteric vein into the superior mesenteric vein instead of the splenic vein. This could put the inferior mesenteric vein (looking as a fibrous band) in jeopardy. Also it reduces the area of access to the retropancreatic dissection. We raise the possibility of an etiological role of this anatomical variation to the duodenal compression and call upon the study of such a possibility. The importance to attain the proper retropancreatic space has been shown by the possibility of dissecting between the uncinate process and the rest of the pancreas. The psychological impact of a minimal invasive approach together with symptoms relief was quite rewarding.     

Polyadenylic acid size and position found in Sindbis virus genome and mRNA species

We have investigated the superficial musculo-aponeurotic system (SMAS) in the parotid and cheek areas by anatomical dissections, by radiographs, and by histological sections. The SMAS may be helpful in corrective surgery for facial palsy and during face lifting operations if a retrofascial approach is used. This procedure, safe in the parotid area, can become dangerous in the area anterior to the parotid gland.     

The zygorbicular dissection in composite rhytidectomy: an ideal midface plane

Traditional face lift and blepharoplasty techniques are based on two consistent principles. Conventional face lift techniques have always incorporated unopposed lateral vector tissue advancement, which is typical of subcutaneous lifts or rhytidectomies that include the platysma muscle (SMAS) or cheek fat (malar fat). When they are not adequately repositioned, the tissues of the lower eyelid and upper cheek continue to age, which may create a "lateral sweep" of the lower face as those malar soft tissues descend at a more rapid rate than the repositioned SMAS. Removal of the lower eyelid fat in conventional blepharoplasties may also lead to a more hollow-appearing lower eyelid. Hollow eyes and the lateral sweep could be prevented with a rhytidectomy technique that includes orbicularis repositioning and preservation of the lower eyelid fat with an arcus marginalis release. All patients who have been operated on who exhibit these unfavorable signs can have an impressive correction by utilizing the principles of superomedial vector orbicularis repositioning to counter the "lateral sweep" and arcus marginalis release to recreate a youthful shallow and narrow lower eyelid contour. This technique is invaluable to patients seeking secondary surgery to regain harmony of the rejuvenated face.     

Quantitative motivational differences between volunteers and nonvolunteers for a psychological experiment.

How do volunteers compare with paid Ss in research? What part does anxiety play in volunteering? "Two classes each of 89 students were given the short form of the Taylor MAS (the SMAS), the Christie and Budnitzky Short Forced-Choice Anxiety Scale (the SFCAS), and a 20-item scale purporting to assess Murray's n Harmavoidance." 2 weeks later the Ss were invited to participate as paid Ss in an "experiment." Need for cash and fear of the electric shock were assessed. Volunteers needed cash more, feared the shock and harm less. "As in other reported studies of this kind, the SMAS did not at all discriminate volunteer from other Ss; nor in fact did the SFCAS." (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Medial thigh lift and DE.C.LI.VE

Vertical dermocrurolipectomy is a technique that in Italy has been named "DECLIVE," (which in Latin means something that moves downward). The first medial thigh lift with the DECLIVE technique was done in 1993. Since then, based on its excellent results 50 patients have been operated on, following DECLIVE. Therefore, DECLIVE should be considered just a variant in the medial thigh lift, because resecting a triangular portion from the perivulvar skin, it stops the displacement of the scar downward. Special acknowledgment goes to Ted Lockwood's studies for his role in the development of this technique.     

Thoracoscopic anterior spinal procedures in children

METHODS: From February 1996 through July 1997, 20 patients were determined to be appropriate for a thoracoscopic approach for the anterior portion of their spinal surgery. Ages ranged from 8 to 17 years of age and weight from 20 to 70 kg. The diagnosis included severe idiopathic and neurogenic scoliosis or kyphosis (n = 20) and congenital hemivertebra (n = 4). The procedures performed included diskectomy and anterior release from two to nine vertebral levels, hemivertebrectomy, and epiphysiodesis. Four patients also had an open lumbar exposure and all had a posterior fusion. RESULTS: All procedures were completed successfully endoscopically. Surgical times for the thoracoscopic portion of the procedure averaged 106 minutes and total procedure times were comparable with the standard open technique. Three patients were extubated at the end of the procedure with the majority extubated on postoperative day 1. Average intensive care unit stay was 1.8 days, and chest tubes were removed between postoperative day 1 and 5 (average, 2.2 days). In follow-up, surgical correction was deemed to be acceptable and equivalent to open techniques in all cases. CONCLUSION: This technique has proven to be safe and effective in children and appears to be associated with less pain and morbidity as evidenced by earlier extubation and chest tube removal and shorter ICU stay.     

Reconstruction of the scapholunate ligament in a cadaver model using a bone-ligament-bone autograft from the foot

This study is an investigation of a new procedure in which the scapholunate interosseous ligament (SLIL) is reconstructed using a bone-ligament-bone autograft from the foot. After investigation, the dorsal medial portion of the navicular-first cuneiform ligament (NFCL) was chosen for testing as a potential donor since it is similar in length and thickness to the SLIL and it is easily harvested with minimal potential donor site morbidity. Eight SLILs and NFCLs were harvested from fresh-frozen cadavers. Biomechanical extensometry testing was performed using an Instron 1000 machine. A 5-mm-wide central portion of the NFCL was tested since this width was compatible with the technical aspects of reconstructing the SLIL. Both ligaments were tested for elastic properties, including stiffness, load to failure, and deformation to failure. Mean length of the NFCL was 7.6 mm (range, 5.5-8.5 mm). Stiffness of the NFCL was 10.6 x 10(5) Nm (range, 8.0-13.0 Nm) compared with 14.4 x 10(5) Nm for the SLIL (range, 10.0-19.5 Nm). Peak load to failure for the NFCL was 1,980 N (range, 1,530-2,940 N) compared with 2,940 N for the SLIL (range, 1,780-4,050 N). Total elongation to failure for the NFCL was 2.50 mm (range, 1.7-3.2 mm) compared with 3.2 mm for the SLIL (range, 2.1-5.2 mm). Thus, the biomechanical characteristics of the NFCL were found to be very similar to those of the SLIL. Having established the biomechanical similarities of the 2 ligaments, we are currently using the NFCL to reconstruct the sectioned SLIL in a fresh-frozen cadaver model. Early results suggest that this procedure is feasible for restoration of normal kinematics of the wrist.     

Corticothalamic connections of extrastriate visual areas in rhesus monkeys

Corticothalamic connections of extrastriate visual areas were studied by using the autoradiographic anterograde tracing technique. The results show that the medial extrastriate region above the calcarine sulcus projects mainly to the lateral pulvinar (PL), medial pulvinar (PM), and lateral posterior (LP) nuclei. In addition, the dorsal portion of the medial region has connections to the lateral dorsal (LD) as well as to intralaminar nuclei. The dorsolateral extrastriate region projects strongly to the PL and LP nuclei, to the PM and inferior pulvinar (PI) nuclei, and to the LD and intralaminar nuclei. The lateral extrastriate region above the inferior occipital sulcus (IOS) has strong connections to both the PL and PI nuclei and has minor projections to the PM and oral pulvinar nuclei. The ventrolateral extrastriate region below the IOS projects mainly to the PI nucleus and to the caudal portion of the PL nucleus and has some projections to the PM nucleus. The ventromedial extrastriate region medial to the occipitotemporal sulcus has strong connections with the ventral and medial sectors of the PI nucleus. This region also projects to the caudal portion of the PL nucleus and has minor connections to the LP nucleus. Finally, the annectant gyrus projects to the PL nucleus and to the rostral portion of the PI nucleus and has minor connections to the PM nucleus. Thus, the medial and dorsolateral extrastriate regions are related mainly to the PL and LP nuclei as well as to intralaminar nuclei. In contrast, the ventrolateral and ventromedial regions are connected strongly with the PI nucleus. This connectional organization appears to reflect functional differentiation at the cortical level.     

Methodology for Impact Modeling of Triaxial Braided Composites Using Shell Elements

In this paper, a two-dimensional triaxial braided composite model has been studied using the nonlinear explicit finite-element code LSDYNA. The unit cell consists of six subcells and material properties associated with shell element integration point simulate braiding architecture. The local material properties were selected by correlation of the global behavior of a coupon model with static specimen tests. By changing subcell size and orientation angle at integration points, different braids architectures were obtained. Panel ballistic models were performed with benefits of computation efficiency of shell elements. Mechanical properties, panel impact threshold velocities, and failure initiations for braids with bias angles of 75, 60, 45, and 30° were studied. Boundary effects were also investigated.     

The in vitro effect of fluconazole on the filamentous form of Pityrosporum ovale

A variation of the SMAS technique is introduced. During the operation, the SMAS was treated in two parts. The fixed part that is closely attached to the preparotid fascia is on the pre-auricle area. The movable part of the SMAS is from the lower part of the parotid gland to the platysma. The movable part of the SMAS was mobilized, elevated and fixed upwards to the fixed area. From January to November of 1995 at Chirurgie Esthetique Europeenne in Strasbourg, the authors did rhytidectomy on 31 cases using this technique with impressive results and minimal complications.     

Segmental liver resections, present and future-caudate lobe resection for liver tumors

BACKGROUND/AIMS: Resection of the caudate lobe of the liver is difficult to perform because of a deep location and an adjacency to the major vessels. METHODOLOGY: A total of 30 patients with hepatocellular carcinoma (HCC) originating in the caudate lobe underwent hepatic resection. The lobe was classified to Spiegel's portion, the process portion, and the caval portion. The operative procedure undertaken was chosen on the basis of tumor location as well as hepatic function of each patient. RESULTS: In 14 patients who had an HCC located at Spiegel's portion or the process portion, the tumor was removed by local resection of the caudate lobe (n = 10), or by resection combined with lobectomy (n = 2) or subsegmentectomy (n = 2). In 16 patients with an HCC at the caval portion, caudate lobe resections with preparatory lobectomy (n = 6), segmentectomy (n = 1), or subsegmentectomy (n = 4) were performed. In the other 5, isolated total or partial resection of the caudate lobe was carried out because of the presence of severe cirrhosis. All operations were defined as curative, but produced two operative deaths due to liver failure. The cumulative rate of overall survival was 41% at 5 years after surgery. CONCLUSIONS: Caudate lobe resection for HCC can be performed even in cirrhotic patients with a favorable surgical outcome.     

Healon GV versus Healon in demanding cataract surgery

Spontaneous nasal tumors are rare in mice, and only one adenocarcinoma and two more primary neoplasms of the nose have been observed in our files of long-term feeding studies, which are composed of 3,419 male and 3,521 female CD-1 (Crl:CD-1 (ICR)BR) mice. This adenocarcinoma was a 1-cm-diameter mass observed grossly in the right nasal cavity of a 454-day-old, male CD-1 mouse from a treated group in a bioassay study conducted with 340 males and 340 females. The neoplastic epithelial cells affected the normal nasal architecture on the right side of the nose. Roughly, tumor neoplastic cells of the outer, lateral portion occurred as cuboidal to low columnar cells with basilarily located nuclei and eosinophilic cytoplasm. These cells were arranged in cylindrical profiles and frequently entrapped acini of the glands of the maxillary sinus. Neoplastic epithelial cells of the inner, medial portion appeared as serous acinar or ductular structures circumscribed by multiple lagers of myoepithelial-like cells. Staining failed to demonstrate mucous secretion. The site of origin of this neoplasm appeared to be the serous glands of the maxillary sinus. The adenocarcinoma was believed to be spontaneous.     

The counting method for ameliorating traumatic memories

The three-dimensional (3-D) architecture of myosalpinx in the rat has been investigated by means of scanning electron microscopy after microdissection and removing interstitial connective tissue with 6N NaOH digestion. In the extramural portion of tube-uterine junction the myosalpinx shows circularly arranged fibers originating from the uterus, together with oblique fibers typical for the salpinx, which occur more frequently in the deeper layers. As fibers approach the mucous folds they assume a plexiform arrangement, which is maintained through all tubal segments. In the isthmus surface fibers form wide muscle rings around the elbow of loops, peculiar to the rat tubal morphology. Surface fibers in the ampulla and pre-ampulla have an even circular course. Our 3-D results reveal that the muscular architecture of rat tube is mainly organized in concentric, monolayered shells with a plexiform arrangement tightly fastened together. Functionally, this muscular arrangement seems to be capable of stirring rather than pushing the embryo and gametes. Finally, such a plexiform network might work as a mechanism of "tube locking" in proximity of isthmic loops as well as at the level of the ampullary-isthmic junction.     

Endoscopic malar/midface suspension procedure

Aging in the midface area is seen with ptosis of the malar tissues, hollowing of the infraorbital area, deepening of the nasolabial and mandibular labial folds, and increased jowling. Some of these aging changes are usually not corrected by a standard SMAS face lift. An endoscope-dependent technique was created specifically to address the midface area. The midface tissues are elevated and released in a subperiosteal manner and then suspended to a higher position after endoscopic dissection of the temporal area. The tissues are repositioned to a higher position on the malar area with softening of the nasolabial fold, decreased jowls, and recreation of the desired youthful fullness in the malar and infraorbital area. This procedure can be combined easily with other facial procedures such as rhytidectomy, neck lift, temple lift, and laser resurfacing when indicated. More than 200 procedures have been completed in the last 22 months. This report presents the surgical technique with early follow-up results.     

Pulmonary atresia with intact ventricular septum: long-term results of "one and a half ventricular repair"

BACKGROUND: Between 1982 and 1984, we successfully performed "one and a half ventricular repair" using a Glenn shunt for 3 patients with pulmonary atresia with intact ventricular septum. Here we review the 10-year follow-up results. METHODS: In these patients, the preoperative Z scores of the tricuspid valve diameters ranged from -5.2 to -6.5. Right ventricular outflow tract reconstruction combined with a Glenn shunt were performed in all patients. Cardiac catheterization was done at least 10 years post-operatively. RESULTS: All 3 patients have maintained New York Heart Association functional class I status for more than 10 years. Angiography in 2 patients confirms sufficient left pulmonary artery pressure with pulsatile blood flow and good right ventricular contraction. A pulmonary arteriovenous fistula has developed in 1 patient. CONCLUSIONS: Although the lower limits of the tricuspid valve diameter for "one and a half ventricular repair" using a cavopulmonary shunt have not yet been determined, we successfully performed this procedure in 3 patients with severely hypoplastic right ventricles and tricuspid valve diameter Z scores of less than -5.0. The results up to 10 years postoperatively are acceptable.     

A controlled, powerful multiple-comparison strategy for several situations.

The multiple-comparison procedure originally proposed by R. A. Fisher (1935) for the 1-way ANOVA context has several desirable properties when K (the number of groups) is equal to 3. In this article, the logic of the procedure is described in conjunction with those properties. A discussion follows of how the Fisher procedure can be similarly applied in a number of other K?=?3 (and, more generally, 2-degree-of-freedom) hypothesis-testing situations. Finally, the Fisher logic is combined with recent sequential applications of the Bonferroni inequality to illustrate the utility and versatility of that combination for the applied researcher. (PsycINFO Database Record (c) 2010 APA, all rights reserved)