Shout Outs

Updated 3/2017 -- photos/videos and all links removed (except to my own posts) as many no longer active.

Afternoon Nap Society is the host for this week’s Grand Rounds. You can read this week’s edition here.

………….This week, Grand Rounds is mine, and in selecting blog posts, I evaluated submissions based on their topicality, writing style, and personal appeal. What I look for in a blog as an ePatient may differ from what a physician or even another ePatient looks for; however, the goal of Grand Rounds is to foster dialogue, and more and more we are learning that in order for a healthcare dialogue to be truly effective, it must include the patient perspective. As a result, Sean Ahrens, an ePatient and software designer who is building Chronology, an online network on which patients with Crohn's and Colitis may connect and learn from one another, opens this week's session….….

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In the current JAMA, a thoughtful commentary article by Traber Davis Giardina, MA, MSW and Hardeep Singh, MD, MPH:  Patient's direct access to test results - pros and cons. (subscription necessary for full access)

In the outpatient setting, between 8% and 26% of abnormal test results, including those suspicious for malignancy, are not followed up in a timely manner. Despite the use of electronic health records (EHRs) to facilitate communication of test results, follow-up remains a significant safety challenge. In an effort to mitigate delays, some systems have adopted a time-delayed direct notification of test results to patients (ie, releasing them after 3 to 7 days to allow physicians to review them).

On September 14, 2011, the Department of Health and Human Services jointly with the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and the Office for Civil Rights proposed a rule allowing patients to access test results directly from the laboratory by request (paper or electronic).  .……….

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For those of you like me trying to follow the face transplant recipients and procedures progress, CBC News recently had an update on one of them:  Conn. woman mauled by chimp praised for new face

…….."I've had people tell me I'm beautiful," Nash said in the interview that aired Monday. "And they were not telling me I was beautiful before."
Nash said she was cheered by a simple "hello" from a child while she was shopping recently.
"That didn't happen before," she said. "It was nice. The little girl was saying 'hi' to me. ... I'm not scaring anybody." ……

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This article from Science Daily caught my eye and I look forward to when it might be possible in humans:  Cleft Lip Corrected Genetically in Mouse Model

Scientists at Weill Cornell Medical College used genetic methods to successfully repair cleft lips in mice embryos specially engineered for the study of cleft lip and cleft palate. The research breakthrough may show the way to prevent or treat the conditions in humans. ...…….

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H/T to @medicallessons for this tweet “Is a Ban on Drinking Water Hours Before Surgery Necessary? (maybe not) -- ttp://nyti.ms/uTAQgl”  The link is to a New York Times Q & A article by C. Claiborne Ray:  Cool, Clear Water

Q. Is it really necessary to prevent patients from drinking water for many hours before surgery?

A. The well-known rule that a preoperative patient should have “nothing by mouth after midnight” was not based on scientific evidence, and many medical organizations now have more flexible guidelines. For example, American Society of Anesthesiologists guidelines generally permit clear liquids until two hours before surgery. .…….

Be sure you ask your surgeon and anesthesiologist what the rule is for you as the above is for healthy individuals.  It may vary depending on your set of health problems and the surgery you are scheduled to have.

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I love watching my dog shake water off. 

H/T to @DrVes for the link to this NPR story by Robert Krulwich:  Shake It! How Dogs, Cats, Even Hummingbirds Keep Dry (photos, including the one below, and video)

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The Alliance for American Quilts received 119 quilts for it’s 2011 "Alliances: People, Patterns, Passion" contest.   You can see all the quilts here. My entry was “Redwork Quilt” and is included in this week’s (Week Two --Mon, Nov. 21- Mon, Nov. 28) quilts being auctioned off on eBay.

All contest quilts will be auctioned via eBay starting on Monday, November 14, 2011 and ending December 12, 2011. All proceeds will support the AAQ and its projects. ….

Week THREE auction guide: Monday, November 28 - Monday, December 5  ……

New this year: "Alliances" contest artist's were offered the chance to record their artist's statements thanks to the generous services of AAQ Business member, VoiceQuilt, visit them at www.voicequilt.com.

New Composite Material

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Yesterday, I came across this press release from John Hopkins regarding a new composite material which may someday be used to restore damaged soft tissue.  (photo credit)

The liquid material is a composite of biological and synthetic molecules which is injected under the skin.  Transdermal light is then used to "set" the material into a more solid structure.

The results of the early experiments in rats and humans has been reported in the July 27 issue of Science Translational Medicine (full reference below).

It is hoped that the new liquid material is a biosynthetic soft tissue replacement composed of poly(ethylene glycol) (PEG) and hyaluronic acid (HA).

From the press release

"Implanted biological materials can mimic the texture of soft tissue, but are usually broken down by the body too fast, while synthetic materials tend to be more permanent but can be rejected by the immune system and typically don't meld well with surrounding natural tissue," says Jennifer Elisseeff, Ph.D., Jules Stein Professor of Ophthalmology and director of the Translational Tissue Engineering Center at the Johns Hopkins University School of Medicine. "Our composite material has the best of both worlds, with the biological component enhancing compatibility with the body and the synthetic component contributing to durability."

The researchers created their composite material from hyaluronic acid (HA), a natural component in skin of young people that confers elasticity, and polyethylene glycol (PEG), a synthetic molecule used successfully as surgical glue in operations and known not to cause severe immune reactions. The PEG can be "cross-linked"—or made to form sturdy chemical bonds between many individual molecules—using energy from light, which traps the HA molecules with it. Such cross-linking makes the implant hold its shape and not ooze away from the injection site, Elisseeff says.

To develop the best PEG-HA composite with the highest long-term stability, the researchers injected different concentrations of PEG and HA under the skin and into the back muscle of rats, shone a green LED light on them to "gel" the material, and used magnetic resonance imaging (MRI) to monitor the persistence of the implant over time. The implants were examined at 47 and 110 days with MRIs and removed. Direct measurements and MRIs of the implants showed that the ones created from HA and the highest tested concentration of PEG with HA stayed put and were the same size over time compared to injections of only HA, which shrank over time.

The researchers evaluated the safety and persistence of the PEG-HA implants with a 12-week experiment in three volunteers already undergoing abdominoplasty, or "tummy tucks." Technicians injected about five drops of PEG-HA or HA alone under the belly skin. None of the participants experienced hospitalization, disability or death directly related to the implant, which was about 8 mm long—or about as wide as a pinky fingernail. However, the participants said they sensed heat and pain during the gel setting process. Twelve-weeks after implantation, MRI revealed no loss of implant size in patients. Removal of the implants and inspection of the surrounding tissue revealed mild to moderate inflammation due to the presence of certain types of white blood cells. The researchers said the same inflammatory response was seen in rats, although the types of white blood cells responding to implant differed between the rodents and humans, a difference the researchers attribute to the back muscles— the target tissue in the rats—being different than human belly fat.

It will be interesting to watch how this develops.




REFERENCE
New Composite Material May Restore Damaged Soft Tissue; John Hopkins Medicine, August 1, 2011

Photoactivated Composite Biomaterial for Soft Tissue Restoration in Rodents and in Humans; Hillel AT, Unterman S, Nahas Z, Reid B, Coburn JM,  Axelman J, Chae JJ, Guo Q, Trow R, Thomas A, Hou Z, Lichtsteiner S, Sutton D, Matheson C, Walker P, David N, Mori S, Taube JM, and Elisseeff JH; Sci Transl Med 27 July 2011: Vol. 3, Issue 93, p. 93ra67; DOI: 10.1126/scitranslmed.3002331

Modification of Square Face

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Recently an article in the Archives of Facial Plastic Surgery (full reference below) led to a Reuters news by Genevra Pittman:  Face too square? There's a surgery for that

The journal article is from China where the surgical procedure to modify a square face to a more oval face is done much more commonly than in the United States.  The Reuters article includes quotes from two U.S. surgeons:  Dr. Jeffrey Spiegel, chief of facial plastic and reconstructive surgery at the Boston University School of Medicine, and Dr. Ross Clevens, a cosmetic surgeon in Melbourne, Florida.

Spiegel states he does the procedure described in the Archives article two to four times each week.  Clevens states “he doesn't treat many male patients who want a more "feminine" face shape.”

Xiaoping Chen, MD, International Plastic and Cosmetic Center, China, and colleagues reviewed the procedure done for nineteen men with a square face (aged 22-30 years).  The time span of the cases was not given (ie 2001 to 2010) in the article.

The procedure involves an ostectomy with resection of the mandibular angle, splitting of the lateral cortex around the mandibular angle, and reduction of the width of the chin by an intraoral approach. (photo credit)

It sometimes was necessary to resect part of a hypertrophic masseter muscle. In addition, partial buccal fat pad removal was performed in patients with prominent cheeks. When the operation was completed, the wound was irrigated; a suction tube to allow drainage was then placed and maintained for 48 to 72 hours. The patient's lower face was lightly compressed with a dressing. Antibiotics were administered for 3 to 5 days, and the sutures were removed 7 days postoperatively.

In this series of 19 patients, there were no complications.  Complications that can occur include:  microgenia, facial asymmetry, hematoma, infection, or permanent mental nerve injury.

All patients developed edema in their lower face  (tx’d with corticosteroid therapy, 10 mg/d for 3 days) and varied amounts of difficulty in opening their mouth for 1 to 2 weeks.

Results can be as dramatic as the procedure needed to achieve them  (photo credit)


The Reuters news article states, “The procedure typically takes an hour or two, and costs up to $10,000, surgeons said.”



REFERENCE

Modification of Square Face in Men; Xiaoping Chen, Jinde Lin, Jie Lin, Jian Shen, Yudan Zhou, Xuan Wu, Yanwu Xu; Arch Facial Plast Surg. 2011;13(4):244-246.doi:10.1001/archfacial.2011.47

Recalling My Episode of Bell’s Palsy

Yesterday I received a call from one of my high school teachers who I remain in touch with.  She wanted to ask me about my Bell’s Palsy as she now has a friend who has been diagnosed with it. 

Nine years ago today I diagnosed my Bell’s Palsy.  I still recall that summer day well.  It was a Saturday.  A beautiful sunny summer day.

I was home alone with my dogs (Columbo, Girlfriend, and Ladybug) as my husband was working out of town.  I was on ER call.  I had had a horrible headache the past few days with severe pain in my right ear.

I can recall noticing my face in the bathroom mirror mid-morning and thinking my mouth didn’t look quite right.  I ignored it.  Later that day as the ascending paralysis of Bell’s Palsy progressed, I would not be able to ignore it.

As far as the world can see now, all my facial function returned.  There are some very minor things that still bug me – the teeth on the right side of my mouth are very sensitive (I use Senodyne toothpaste which helps but find I avoid professional cleaning on a regular basis).  Sometimes the right facial muscles feel tight so I will try to discretely massage them.  When I am really tired, my right eye gets an odd “itching” sensation.

One of these days I want to do a self-portrait quilt (ala Picasso) that reflects my face (or my perception of it) during the Bell’s Palsy episode.

I disliked speaking during the weeks when my mouth didn’t work.  I never drooled but  the poor control over the right side of my mouth made some words difficult to pronounce (plosive constant's need a good lip seal).  It seemed to me that people had more trouble understanding me over the phone than in person. 

My friend’s phone call brought it all back so very clearly.

Check out this essay:  HOW CRUEL TO CALL IT 'BELL'S PALSY!' By Graeme Garden

Dysport or Botox for Crow’s Feet?

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

A new study published online in Archives of Facial Plastic Surgery suggests Dysport (abobotulinumtoxinA) is better for treating Crow’s feet than Botox (onabotulinumtoxinA).

Let’s look at the study which only had 90 patients, all older than 18 years of age (mean age 54½, 77 women), were enrolled in a randomized, double-blind, split-face study.

The authors include this history of both products:

….in 2002, the FDA approved Botox Cosmetic (onabotulinumtoxinA) (Allergan Inc, Irvine, California) for the treatment of corrugator-mediated glabellar lines.

Concurrently, another botulinum toxin type A product manufactured by Medicis Aesthetics (Scottsdale, Arizona), Dysport (abobotulinumtoxinA), had been used in other countries since 1991. It was approved for cosmetic use in Europe in 2001, before being approved by the FDA in April 2009 for the treatment of moderate-to-severe glabellar lines.

Today, the cosmetic applications for onabotulinumtoxinA and abobotulinumtoxinA have expanded to the treatment of hyperfunctional lines related to the orbicularis oculi, frontalis, transverse nasalis, and depressor anguli oris, among other muscle groups.

The 90 patients were seen and treated between December 2009 to August 2010. To be included in the study, the men (n=13) and women (n=77) had to have moderate to severe lateral orbital rhytids at maximal contraction and NOT had botulinum neuromodulator treatment to the crow's feet within the prior 6 months.

Other exclusion criteria included: prior face-lift, brow-lift, or blepharoplasty; prior periocular laser or chemical resurfacing; prior adverse reaction associated with botulinum neuromodulator; or a history of degenerative neuromuscular diseases.

Each of the 90 participants were photographed prior to treatment and during each subsequent follow-up visit (posttreatment days 2, 4, 6, and 30).

A standard 5-view photographic series was taken for each patient at rest and at maximal contraction.

Patients and investigator separately assessed the crow’s feet at rest and at maximal contraction on each side, according to a validated 5-point photographic scale (0, no wrinkles; 1, very fine lines; 2, fine lines; 3, moderate wrinkles; and 4, severe wrinkles). This assessment was done prior to treatment and at each follow-up visit.

The treatment consisted of 10 U of Botox on one side of the face while the contralateral side received 30 U of Dysport with treatment sides of the face being randomized by computer-aided software. The recommended dosage ratio of Dysport to Botox varies from 5:1 to 3:1. The article sites the reason for this dosage “recent studies and the clinical experience of the senior investigator point to a 3:1 ratio as being optimal.”

Sixty-seven percent of patients preferred the side treated with Dysport, while 33% of patients chose the side treated with Botox. This difference was statistically significant (P = .002).

On post-treatment day 30, the investigator-assessed efficacy score at maximal contraction averaged 2.60 for the Dysport-treated side of the face and 2.33 for the Botox-treated side (P=0.01).

However, two other secondary end points, investigator and patient assessments of resting lateral orbital rhytids, did not achieve statistical significance (P = .42 and P = .28, respectively).

I would say this is a start in determining which might be better, but it needs to be remembered that this is a very small study and has not been duplicated.

REFERENCE

An Internally Controlled, Double-blind Comparison of the Efficacy of OnabotulinumtoxinA and AbobotulinumtoxinA; Kartik D. Nettar, Kenneth C. Y. Yu, Sumit Bapna, John Boscardin, Corey S. Maas; Arch Facial Plast Surg. 2011;Published online June 20, 2011. doi:10.1001/archfacial.2011.37

Advances in Surgical Treatment of Facial Nerve Paralysis in Children – an article review

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I read the second article below first.  I was struck by the opening paragraphs of Daniel Alam, MD’s commentary which note the importance of smiling in human communication and how it is often taken for granted EXCEPT by those who have lost the ability to smile.

This is far from the case for patients who have lost the ability to smile. Patients who have endured facial paralyses (even in the transient cases that occur in certain idiopathic facial nerve palsies, ie, Bell palsy) understand the true psychological effects of this disability. …...

I can attest to this on a personal level having had Bell’s palsy in 2002.  I have a quilt I’d like to make, a personal portrait ala Picasso, that would reflect the way it affected me.  I can’t seem to get it worked out yet, but will.

Back to these articles.  Alam commends Hadlock and colleagues (the first article below) for not just relying on emotional checks from the patients who often feel any improvement is a great result (bold emphasis is mine):

… Although this report is another well-designed clinical series of a well-established surgical technique, the true significance of this work extends far beyond the patients presented. ….This group, more than any other in facial plastic surgery, has made a concerted effort to quantify (to measure and validate) the outcomes they report. …

With that recommendation went looking for the Hadlock’s article.  

Hadlock and colleagues begin with background information which notes “free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation.”

While myriad muscles have been transferred into the face to restore the smile, most large series describe the use of the gracilis muscle, the latissimus dorsi muscle, or the pectorals minor.  Of these, the gracilis muscle is the most widely used, based on predictable pedicle anatomy, an acceptable donor deficit and scar, and favorable muscle microarchitectural features resulting in fast and robust excursion when activated.

Hadlock and colleagues used their SMILE program to objectively measure the functional outcome of 17 pediatric patients who had undergone 19 consecutive pediatric free gracilis transplantation operations.  The procedures were done over a 5-year period from October 2004 through September 2009.  The mean age of the patients was 11.5 years (range, 4-18 years).

All patients were prospectively administered the Facial Clinimetric Evaluation (FaCE) instrument which is a validated, standardized QOL instrument for patients with facial movement disorders.   Hadlock’s article referenced the Laryngoscope (3rd reference below) article for FaCE.

Hadlock and colleagues results

The mean commissure excursion improvement was 8.8 mm ± 5 mm (Figure 4), commensurate with the findings in other facial reanimation series.   When subdivided into those driven by a cross-face nerve graft vs those driven by the masseteric branch of the trigeminal nerve, the latter provided more excursion on average, as expected.

There was only one muscle failure in the series.  It resulted from an arterial thrombosis.
In conclusion:

In conclusion, free gracilis transfer for smile reanimation in children carries an acceptable failure rate, significantly improves smiling, and seems to improve QOL with respect to facial function. It should be a cornerstone intervention in the appropriately counseled patient and family. Because it carries a lower failure rate than a similar cohort of adult patients, there is no need to wait until patients reach adulthood to offer dynamic reanimation. Early facial reanimation provides the advantage of permitting children to express themselves nonverbally through smiling and may in fact lead to fewer negative social consequences as they interact with peers.

REFERENCES

1.  Free Gracilis Transfer for Smile in Children:  The Massachusetts Eye and Ear Infirmary Experience in Excursion and Quality-of-Life Changes; Hadlock TA, Malo JS, Cheney ML, Henstrom DK; Arch Facial Plast Surg. 2011;13(3):190–194; doi: 10.1001/archfacial.2011.29

2.  Advances in Surgical Treatment in Facial Nerve Paralysis in Children (commentary); Daniel Alam, MD; AMA. 2011;305(20):2106-2107;  doi: 10.1001/jama.2011.689

3.  Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale; Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ; Laryngoscope. 2001;111(3):387–398.

Recovery of Sensation Post-Facial Transplantation

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Have you ever lost your sense of smell or taste?  Recall how it feels when your face/mouth don’t work properly until the nerve blocks wear off after a dental procedure.

Those are all things (and more) a facial transplant patient has to deal with.  The article discussing recovery of sensation after facial transplantation in the May issue of Plastic and Reconstructive Surgery discusses this topic (first reference below).

In addition to reviewing their own face transplant patients (n=4), Dr. Maria Siemionow and colleagues did a literature review (English literature for peer-reviewed articles published between 1940 and 2010) of sensory recovery after various standard nerve repair techniques. 

These other nerve repair techniques included repair of the peripheral branches of the trigeminal nerve; sensory return after free tissue transfer (ie noninnervated flaps, including radial forearm, lateral thigh, anterolateral thigh, latissimus dorsi, trapezius, et al and innervated free flaps, including radial forearm, anterolateral thigh, and rectus abdominis musculocutaneous flaps); and sensory recovery following replantation of scalp and forehead.

Image: Pathways of sensory recovery in face transplantation are summarized.

(1) Direct sensory nerve growth through microsurgical nerve repair.

(2) Trigeminofacial communications.

(3) Nervi nervorum of the facial nerve.

(4) Somatic afferents of the facial nerve.

(5) Adrenergic plexus of the vascular pedicle.

Siemionow and colleagues report that only one of the four face transplant recipients underwent direct repair of the sensory nerves.  In the other three cases, it was impossible to reconnect the nerves because of technical difficulties or the severity of the patient's injuries.

Even so, all four patients began regaining sensation in the transplanted face as early as two weeks after surgery and had normal or near-normal sensory function by the end of the first year.

The extent of recovery was similar to that achieved with simple repair of injured sensory nerves in the face-and even better than that of grafting procedures where tissues are transferred to the face from different areas of the body without reconnecting the nerves.

Siemionow and colleagues note in their discussion:

Based on the results of our comparative analysis, we can conclude that, in the absence of extensive soft-tissue injury, simple repair of facial sensory nerves leads to restoration of nearly normal sensation. ….. Interestingly, face transplantation is the only clinical condition where, in the absence of sensory nerve repair, good functional outcome is achieved despite severe trauma causing soft-tissue and sensory nerve damage.

As they also note (bold emphasis is mine)

An important issue that emerged from the comprehensive review of the literature is an evident lack of universal methods of neurosensory assessment and an urgent need for establishment of guidelines that will help with comparative analysis of the sensory recovery data. This applies to the reported cases of face transplantation, where documentation of sensory recovery is either marginal or overlooked.

For the face transplants, as with head injury patients, the olfactory nerve function needs to be assessed as well and it wasn’t in this study.   If the person can’t smell smoke or gas leaks, then extra care or caution has to be taken at home.

REFERENCE

Pathways of Sensory Recovery after Face Transplantation; Siemionow, Maria; Gharb, Bahar Bassiri; Rampazzo, Antonio; Plastic & Reconstructive Surgery. 127(5):1875-1889, May 2011; doi: 10.1097/PRS.0b013e31820e90c3

Discussion: Pathways of Sensory Recovery after Face Transplantation; Chong, Tae; Plastic & Reconstr Surgery 127(5):1890-1891, May 2011; doi: 10.1097/PRS.0b013e31820e88c9

ASPR Press Release, May 9, 2011:  Sensation Recovers to 'Near-Normal' After Face Transplant, Study Finds

Setting Goals, Rehabilitating After Brain Injury; NPR, May 16, 2011

FDA Update: Restylane

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

The FDA General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee met on April 27, 2011 to review the request for expanding the use of Restylane for augmentation of the lips.  The panel voted 6 to 0 (1 abstaining) that Restylane for lip augmentation is generally safe and effective for this purpose and that the benefits outweigh the risks.

The FDA still has to make a final decision on Restylane injectable gel for lip augmentation, but the agency usually follows the advice of its advisory panels, which consist of outside experts.

Restylane was approved by the FDA in 2003. It is a non-animal stabilized hyaluronic acid gel. Restylane is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Allergy pretesting is not necessary.

Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. Restylane is indicated for the correction of moderate to severe facial wrinkles and folds.

The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.  Both are available with lidocaine (Restylane-L, Perlane-L).  Patients should be limited to 6.0 mL per treatment.

According to Medicis, Restylane is the most-studied aesthetic dermal filler in the world, and has been used in over 10 million treatments worldwide.

From Medscape news article:

During the public comment portion of the meeting, Gloria Duda, MD, board-certified plastic surgeon from McLean, Virginia, who was representing the American Society for Aesthetic Plastic Surgery, noted that Restylane is commonly used off-label to augment and contour the lips, and she encouraged the panel to support its use for this indication.

Lip augmentation is a "very frequently" requested procedure, Dr. Duda said, and, in her experience, the results are "immediate and reproducible and the risks with hyaluronic acid are minimal."

"I perform over 120 lip augmentations per year with no complications and 95% retention with return visits at 8 to 12 months for repeat procedures," Dr. Duda said.

General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee. Meeting held April 27, 2011, in Gaithersburg, Maryland.

Related posts:
Dermal Fillers (August 30, 2007)
Lip Augmentation (January 25, 2008)
Guest Post by Dr Val--Lip Plumping With Restylane: What Your Doctor Might Not Tell You (September 25, 2008)
Injectables Roundup (November 11, 2010)


REFERENCES
Medicis Press Release, April 27, 2011
FDA:
Restylane™ Injectable Gel  (approval date December 2003)
April 27, 2011: General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee Meeting Announcement
2011 Meeting Materials of the General and Plastic Surgery Advisory Panel (April 27, 2011)

Rare Facial Replantation Performed at UAMS

UAMS mails out a publication called UAMS Consult a few times each year. I found a pdf file of their March 2007 issue online (no longer active, 2013) but couldn’t find the current one with this case report. So I’m taking the liberty (they may ask me to take it down) to publish it here.

The 20-year-old patient presented to the UAMS Emergency Department via ambulance from Malvern, about 50 miles away. The patient’s nose, upper lip and most of his right cheek were amputated by the edge of a hollow metal pole that came through the patient’s windshield during the single-vehicle rollover accident. He also had multiple facial fractures with extensive damage to the palate and teeth.

At the accident site, the property owner directed emergency responders to the severed portion of the patient’s face some distance from the vehicle. The avulsed tissue was properly stored and brought to the ED along with the patient.

Only One Choice

Mauricio Moreno, MD, director of the UAMS Head and Neck Cancer Division and a fellowship-trained microvacsular surgeon, saw the patient in the ED and determined that the only choice was to attempt one of the largest known composite facial replantation surgeries in medical literature.

The ischemia time was critical to the outcome since most successful replantations of facial tissues are performed in less than 8 hours. Due to inclement weather, an effort to fly the patient to UAMS had been aborted, and nearly six hours had passed when the patient was taken to surgery.

Without a successful replantation, the patient’s prognosis was poor for both function and appearance. No amount of plastic and reconstructive surgery would provide a cosmetically satisfactory result, and the patient’s ability to eat, drink, or speak would be severely affected.

Prior to surgery, Moreno consulted with UAMS’ Marcus Moody, MD, a facial plastic and reconstructive surgery specialist, who agreed that the facial bone fractures could be repaired at a later date.

The Challenge

Success depended on reintroducing blood supply via a microvascular anastomosis of the facial artery to the angular artery and microvascular anastomosis of the retromandibular vein to the facial vein. Given the nature of the injury, the vessels were severely damaged at the point where they were transected. In order to overcome this problem the vessels were dissected from the transection site until they appeared less damaged, and the anastomosis was made at that point. This was one of the most technically challenging aspects of the case. Very short vessels forced the release of some tissues in the face and neck in order to achieve a tension-free anastomosis.

Moreno worked as quickly as possible, completing the replantation in about two hours, maintaining the total ischemia time just under eight hours.

Six days after surgery, while the patient remained sedated in the ICU, the retromandibular vein thrombosed and the patient was taken back into surgery to repair the clotted vessel. Two days later the same vessel thrombosed again requiring a third – and final – microsurgical procedure.

The episodes of thrombosis likely were related to the vessel trauma that resulted from the accident.

Leeches Help

Because the tissue was unable to accommodate the increased blood flow, medical leeches were flown to UAMS and applied to the replanted tissue for 72 hours. The leeches corrected the venous insufficiency, which can have the same deleterious effect as when replanted tissue gets too little blood supply.

The replantation was a success. It appears to be the largest composite nasal replantation in the medical literature of about 15 cases described worldwide.

Ninety percent of the tissue survived; only a small portion of the patient’s nose and right cheek did not survive, but that tissue can be replaced.

The patient lost vision in his right eye, and the right side of his face is paralyzed as a result of the trauma. Multiple procedures will be needed to repair the numerous facial fractures, restore facial symmetry and achieve the best possible cosmetic and functional outcome.

………..

Kudos to UAMS.

First Full Face Transplant in US

 Updated 3/2017-- photos/videos and all links (except those to my own posts) removed as many are no longer active and it was easier than checking each one.

It continues to amaze me that colleagues are able to do such marvelous work to improve the lives of some.  For Dallas Wiens, 25, the benefits and hope of an improved life outweigh the risks of surgery and rejection (transplant).

He is a construction worker from Ft. Worth, TX who suffered severe burns to his head two and a half years ago when the boom lift he was operating drifted into a nearby power line. The nearly fatal accident left him in a coma for three months.

Related posts
Face Transplantation – First in the US Done (December 18, 2008)
Appearance Is A Function of the Face (December 30, 2009)
More on Facial Transplantation (March 1, 2010)
First Full Face Transplant Done!  (July 12, 2010)
Facial Prosthetics Restores Face (August 5, 2010)
First Full Face Transplant Done! (July 12, 2010)
Facing Monday  (January 24, 2011)

CO2 Laser Use

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Over the past couple of months there have been a few good commentary articles on the use of CO2 laser us. 

The first one referenced below is a commentary by Dr. Scott J. Trimas on the treatment of facial acne scarring using CO2 laser abrasion.  He references his article from 10 years ago (2nd reference).  Full references are given to both articles below.

Over a 10 year period, Dr. Trimas, did 54 additional patients not included in his first article (the 2nd reference below) using full-face CO2 laser treatment for facial acne scarring. Their ages ranged from 16 to 74 years. Of those patients reviewed, 8 were male and 46 were female. He notes this population was similar to that of the original study. Most patients were followed for up to 2 years.

Dr. Trimas writes “notable improvement can be achieved with the use of the carbon dioxide laser, especially in the areas of the forehead, medial cheeks, and perioral region. Lesser improvement is noted in the areas of the lateral cheeks and temples. Nevertheless, substantial improvement is achieved in all areas.”

He also adds that one of the most substantial changes he has made is the addition of surgical excision of ice-pick scars prior to the laser resurfacing procedure. He performs the excision of the ice-pick scars at least 6 weeks prior to carbon dioxide laser abrasion.

The rationale for this excision technique was that some of the areas of the face did not seem to improve enough with just resurfacing, and I felt that ice-pick scars may have been the contributing factor. In fact, most ice-pick scars that were punch excised were in the lateral cheek regions.

That makes sense to me, as ice-picks scars are often too deep to be adequately treated by resurfacing procedures (laser or chemical peel) alone.

…..

The other recent article (third reference below) covers the use of CO2 laser for more than simply acne scarring.  It was published in the February 2011 issue of the Plastic Surgery Practice.  In the article, Dr. Joseph Niamtu III, discusses his use of the CO2 laser, giving practical tips – both the traditional ablative and the newer fractional lasers.

Take for example his notes on “Postlaser Wound Care—Past and Present”

If there is one drawback in employing traditional CO₂ ablative laser resurfacing, it is the area of postlaser wound care. It adds extra layers of work (and sometimes frustration) for the patient, surgeon, and staff. If the process and experience of postlaser wound care could be ultimately simplified, the promoting of traditional CO₂ treatments would be much easier.

I know several experienced laser surgeons who have abandoned the procedure because of the intensity of the wound care and the hand-holding required to get the patient through it successfully.

Inducing an intentional and controlled second-degree facial burn removes the entire epithelium and part of the dermis. This is obviously a giant insult to the normally intact integument. Patients who undergo fully ablative, high-fluence, high-density, multipass CO₂ laser resurfacing have to understand in the preop period that this treatment will be their hobby for 4 to 6 weeks. I am very blunt with my patients who are considering this type of laser treatment, and I do not sugarcoat the recovery.

Incidentally, for new practitioners, understating a recovery from laser treatment—or any procedure, for that matter—can really come back and bite you in the foot. In an era of new "miracle" treatments and surgeries emerging daily, some surgeons feel compelled to downplay the patient-recovery phase of treatment in hopes of "selling" a procedure. There is no better way to infuriate a patient then to tell them that a 2-week recovery is 1 week, etc. Not only does it upset them, it can cost them in other ways, such as missed work and other scheduled events, and disrupt family life in general.

I tell my patients that they won't like me for a week, that they will need about 2 weeks before they can get back in makeup, and that they will be pink for several more weeks. If I tell them the recovery is 14 days and it takes only 10 days, I am a hero. If I tell the inverse, I am a zero.

Understating a recovery is unethical and promotes negative marketing. I have seen too many instances in which a physician says 1 week for a 2-week recovery, then tries to squirm out of it by blaming the patient for "not healing well."

I really appreciate how he is blunt with his patients regarding the recovery.  Patients need to hear this along with the expected results and risks.

REFERENCES 

1.  Facial Acne Scarring:  Ten Years of Treatment With the Carbon Dioxide Laser (Commentary); Trimas SJ; Arch Facial Plast Surg Jan/Feb 2011 2011;13(1):62-64.

2.  Carbon Dioxide Laser Abrasion: Is It Appropriate for All Regions of the Face?; Trimas SJ, Boudreaux CE, Metz RD;  Arch Facial Plast Surg. 2000;2(2):137–140, pmid:10925440

3.  Confessions of a Master Blaster:  How to use CO2 laster in a cosmetic facial surgery practice; Niamtu III, Joseph; Plastic Surgery Practice, February 2011

Rebuilding the Face Injured by War

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Monday I happened to catch the NPR segment by Terry Gildea:  Rebuilding The Faces Of War 

And now, a story about the effects of war and violence in a different part of the world and how specialists are learning from it. The wars in Iraq and Afghanistan have created a need for innovative treatments for severe battle wounds. Service members often suffer injuries that disfigure and even eliminate parts of their face. At a Defense Department clinic in Texas, surgeons are restoring missing facial features and in a way they're restoring the identities of the wounded.

Texas Public Radio's Terry Gildea takes us to the clinic at Lackland Air Force Base in San Antonio. …

He's now working with doctors at the Maxillofacial Prosthetic Clinic at Wilford Hall Medical Center. Today his anaplastologist, Nancy Hanson, is fitting him with a new set of ears. …………..

……

The story notes that the Department of Defense has two such clinics.  It mentions  Lackland Air Force Base in San Antonio, TX but didn’t specify the other.  It took some “googling” but I finally found an article that mentioned the other one:

The maxillofacial prosthetics program is only one of two such programs in the Defense Department, said Col. (Dr.) Alan Sutton, the program’s director. The other program is at the National Naval Medical Center in Bethesda, Md., he said.

While looking for the second clinic, I found this 2008 article on Air Force Senior Airman Justin Jones who at the time was a maxillofacial prosthetic technician with 59th Dental Squadron here.  His job was to help service members who have suffered disfiguring facial injuries.  [Face of Defense: Airman Helps Injured Warriors 'Face' World]

and this article from August 3, 2010:  Air Force dental team helps patients ‘face’ the world, also featuring the MacKown Dental Clinic, which explains the process:

………Often most important to the patient is the restoration of function – speech, chewing and swallowing — in cases where injury or cancer to the mouth or jaws has occurred.

The team’s first step frequently starts in the stereolithography lab, located at MacKown Dental Clinic, which is one of only two located in the DoD.

Stereolithography is a rapid prototyping method, which allows the fabrication of anatomically accurate, three-dimensional epoxy and acrylic resin models from various types of medical data. There are myriads of data formats that can be assimilated, some of which include those from computed tomography, magnetic resonance imaging, and optical scanners.

“I can take a CT scan of a burn patient’s head and create an exact replica so our anaplastologist can build replacement ears and noses that will fit perfectly,” said Mr. Dave Carballerya, stereolithography lab supervisor. “This technology is also used to incorporate dental and craniofacial implants to enhance the doctors’ diagnosis and treatment planning.”

The team’s anaplastologist then works to create facial prosthetics for the patient.

Anaplastology is the art and science of restoring a malformed or absent part of the human body through artificial means. Again, Lackland is unique in that MacKown Dental Clinic employs the only certified clinical anaplastologist in the DoD, Ms. Nancy Hansen.

“Our patients are going through the traumatic experience of missing anatomical features,” said Ms. Hansen. “We get to see them blossom because they are given hope.”

Ms. Hansen begins by making an impression of the area of the missing anatomy. Prosthetic noses, ears, jaws, even eyes can be made with silicone or hard resin. Many steps are taken to give the prosthesis a realistic look.   …………

How to Block and Tackle the Face

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

For medical students, residents, or anyone wanting a review, the March 1998 article by Dr. Barry Zide (first full reference below) is a great place to begin.  The article reviews the anatomy of each nerve, the areas of anesthesia obtained by each block, and gives instructions and tips for each of eight facial nerve blocks.   The article, also, has some nice photos.

1.  Infraorbital Nerve
Zide’s preferred technique is the transcutaneous nasolabial approach.

This approach has a point of injection medial to the upper nasolabial groove a few millimeters lateral to the alar groove. The injection point for the infraorbital nerve is in the center of the small triangle lateral to the alar rim and medial to the nasolabial fold. With your left index finger on the infraorbital rim, ask the patient to look straight ahead. Holding the syringe like a pen, you advance the needle to bone toward the designated point about 4 to 7 mm down from the rim. Often, the needle tip goes directly into the foramen itself. If you wish to inject the foramen, you may have to poke around for a couple of millimeters, but you will always be able to enter into the foramen this way. Then, inject 1 to 2 cc. There is a 100-percent success rate using this external block approach, and the senior author has never seen a neuritis from this or any of the three methods.

2.  Mental and Mental Plus

The mental nerve can be blocked at the mental foramen or a few centimeters after it leaves the foramen submucosally.

To block it at the foramen, locate the second lower bicuspid. Place the needle tip in the buccal sulcus near the base of the tooth and inject. The nerve itself is not covered by muscle after it leaves the foramen, just a thin layer of mucosa and perineural sheath. Often, the nerve can be palpated at the foramen or in the first few centimeters of its course. If the surgeon desires, he can inject away from the foramen by finding the upper fascicles visually or tactilely. Use the thumb of one hand to pull out the lower lip, lateral to the lower canine tooth. By squeezing the lip and sliding the thumb outward, the nerve is visible submucosally about 85 percent of the time.

Mental Plus block will also anesthetize the chin by blocking  an end branch of the mental nerve and the terminal branches of the mylohyoid.

These can be done immediately after the mental block by an anterior premandibular injection anterior to the vestibule in front of the anterior teeth.  You must change your position to behind the patient, turn the syringe more vertically, and inject in the supraperiosteal plane with at least a 1.5-inch needle. You must inject anterior to and beyond the lower border of the mandible (actually out on the lip) but not quite out of the skin. Only the mental plus block obviates the need for the inferior alveolar block (i.e., regardless of whether the mental nerve or mylohyoid nerve supplies the chin).

3.  Supraorbital/Supratrochlear/Infratrochlear
4.  Dorsal Nasal Nerve
5.  Zygomaticotemporal
6.  Zygomaticofacial
7.  Great Auricular

Have the patient flex the sternocleidomastoid muscle by pushing the head against a hand placed on the ipsilateral forehead. This maneuver will outline the sternocleidomastoid muscle against the neck skin. Mark the skin of the upper anterior and posterior sternocleidomastoid borders with two parallel lines. Then draw a third line between the first two parallel lines directly in midmuscle. Measure down 6.5 cm from the lower border of external acoustic meatus to the mid-sternocleidomastoid. A useful template is a measurement from your own hand. For example, 6.5 cm is the measurement of my baby finger tip to the webspace or my thumb metacarpophalangeal to tip. Inject a nickel to quarter sized circle of anesthetic onto the muscle fascia at this intersection

8.  V3 Block

I have included several other good references for you below.


REFERENCE

How to Block and Tackle the Face; Zide, Barry M.; Swift, Richard; Plastic & Reconstructive Surgery. 101(3):840-851, March 1998

Addendum To "How To Block and Tackle the Face"; Zide, Barry M.; Swift, Richard; Plastic & Reconstructive Surgery. 101(7):2018, June 1998.

Regional Anesthesia on the Lacrimal Nerve; Ross, Gary; Taams, Karl; Plastic & Reconstructive Surgery. 104(3):876-878, September 1999.

Nerve Block, Infraorbital; eMedicine Article, Updated: May 19, 2010;  Karen M Byrne, MD 

Regional Anesthesia for Office Procedures: Part I. Head and Neck Surgeries; Gohar Salam, MD, DO;Am Fam Physician 2004 Feb 1;69(3):585-590

Local Anesthesia Techniques in Oral and Maxillofacial Surgery; Sean M. Healy, D.D.S., Francis B. Quinn, M.D.; University of Texas Medical Branch Grand Rounds, October 2004  (pdf)

Closure of Facial Mohs’ Defects

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.I

t is very likely there will never be a complete consensus on the best or correct way to close defects left by Mohs’ surgical excision of skin cancers on the face. 

Which is best?  Direct linear closure.  Local flap. Skin graft.

In my opinion, it comes down to multiple factors but perhaps the most important are:   Where on the face is the defect?  How lax is the surrounding skin? 

The authors of the recent Plastic & Reconstructive Surgery Journal article on the topic (full reference below) write in their introduction in favor of direct closure (the first step in the reconstructive ladder):

This first step on the reconstructive ladder is often overlooked in favor of more intricate local flap options. If performed properly, direct linear closure results in superior aesthetic results that are more predictable and involve less tissue dissection than local flap options. 

The article is a retrospective review of 1354 reconstructions performed post-Mohs’ facial defects by the senior author (JFT)between 2001 and 2008.  

Forehead (96/125 closed directly in this study) –-their maximum size for direct closure was 3.6 cm.  A nice tip from JFT to determine orientation of the final closure:

The senior author's (J.F.T.) preferred technique for forehead repairs is to place a single silk stitch in both directions, tailor-tack the wound closed, and orient the resultant closure based on which direction yields the least tension, with dog-ear excision following the closure. Dog-ears are meticulously excised on the forehead.

Nose (46/707 closured directly in this study) –- maximum defect size 1.2 cm on nasal dorsum, < 1 cm on tip.

The indications for direct linear closure on the nose are more limited than other anatomical areas on the face because of the relative paucity of skin laxity and the risk of alar distortion.

Lip (37/138 closed directly in this study) – maximum defect 3 cm.

Numerous textbooks have described linear closure of the lip as the preferred technique for defects of 25 percent of the upper lip and up to 30 percent of the lower lip. Our experience has shown that superior aesthetic results can be achieved with defects approaching 40 percent on the upper lip and exceeding 50 percent on the lower lip. This is particularly true in the elderly patient.

Cheek (117/186 closed directly in this study) – maximum defect 4 cm. 

The cheek, particularly in the elderly population, is an ideal area for direct linear closure of very large lateral defects. …..

The inherent laxity in the aging cheek and the ability to generously undermine this well-perfused region contribute to this result.

Chin (4/6 closed directly in this study) – maximum defect 2.2 cm.

Care must be taken with direct closure on the chin, as there is little skin laxity. Direct closure must be avoided in a horizontal plane, to prevent the inadvertent development of extrinsic lip ectropion.

Related posts:
Bilobed Flap for Repair of Nose (March 26, 2008)
Skin Grafting in Lower Third Nasal Reconstruction (April 1, 2010)
Reconstruction of the Lip -- Part I (January 29, 2008)


REFERENCE

The Rationale for Direct Linear Closure of Facial Mohs' Defects; Soliman, Sameer; Hatef, Daniel A.; Hollier, Larry H. Jr.; Thornton, James F.; Plastic & Reconstructive Surgery. 127(1):142-149, January 2011; doi: 10.1097/PRS.0b013e3181f95978

Facing Monday

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Last Monday was reported to be the saddest day of this year.   So to help you and I face Monday and the beginning of a new week, in case you missed these stories…..

Roger Ebert has written in his Chicago Sun Times blog of how he will once again be “Leading with my chin.” 

………..That was the beginning of a two-year process that has now resulted with my coming into possession of a silicone prosthesis. Dr. Reisberg brought in David Rotter, also from the University of Illinois, and he involved Julie Jordan Brown, a Milwaukee artist and anaplastologist. Working from molds, they created a prototype prosthesis and sculpted it carefully to more closely resemble what had been there before. This device would fit over my lower face and neck and, colored to match my skin, would pass muster at a certain distance……….

He will wear the facial prosthetic on his new show set to debuted Friday January 21, 2011:   Ebert Presents at the Movies.  He speaks using his voice through his laptop.

…….

Last week, we heard the voice of a woman who is only the second person to receive a larynx transplant.   The 52 yo California woman’s surgery was done by a team of surgeons at UC Davis Medical Center.

From this article by Aaron Saenz: Woman Speaks With Her Own Voice After Larynx Transplant (video) comes the reminder that just last year a 10 year old boy had a new trachea made from his own stem cells.

So is this surgery simply a fluke? …... According to Paolo Macchiarini, one of the surgeons involved, “Not only is it highly relevant for future transplants, it offers us insights that may one day lead to using stem cells to repair the voicebox and surrounding areas in the throat.”

When it comes to stem cells and the throat, Macchiarini knows what he’s talking about. Last year he was the leader of a team that grew a new trachea in a 10 year old boy using the child’s own stem cells. As he stated in regards to the Jensen case, “Being able to restore nerves and reconnect blood vessels in and around the larynx and trachea, and have it all work, was a real test.” Perhaps this most recent operation will lead to further remarkable work from Macchiarini in the near future.

 

Related posts

First Full Face Transplant Done! (July 12, 2010)

Facial Prosthetics Restores Face (August 5, 2010)

Double Hand Transplant on Twitter (August 26, 2010)

 

 

REFERENCE

Laryngeal Transplantation and 40-Month Follow-up; Marshall Strome, M.D., Jeannine Stein, M.D., Ramon Esclamado, M.D., Douglas Hicks, Ph.D., Robert R. Lorenz, M.D., William Braun, M.D., Randall Yetman, M.D., Isaac Eliachar, M.D., and James Mayes, M.D.; N Engl J Med 2001; 344:1676-1679

Injectables Roundup

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I have come across some interesting articles recently regarding injectables.  Let’s begin the non-controversial one: Behind the Lines by Linda W. Lewis, Nov/Dec 2010 MedEsthetics (pp 32-.  This one notes several filler discontinuations:

Johnson & Johnson (jnj.com) withdrew porcine collagen-based Evolence in November 2009; Allergan (allergan.com) discontinued its human and bovine collagen fillers, CosmoDerm, CosmoPlast, Zyderm and Zyplast, late last year and will stop distribution by the end of 2010.

The article mentions the latest filler introductions:

Juvederm XC from Allergan and Restylane-L and Perlane-L from Medicis (medicis.com).  These products differ from their predecessors only in the addition of lidocaine to the formulations.

Much greater changes are on the horizon, however, as manufacturers seek approval for exciting new products like Novabel (Merz Aesthetic, merzaesthetics.com) and Aquamid (Contura, aquamid.com).

The article also mentions that some physicians are using Restylane SubQ in buttock and breast enlargements.  This leads me to the next article (full reference below):   Macrolane(TM) for breast enhancement: 12-month follow-up.  The Swedish study used a new formulation of a stabilized hyaluronic acid-based gel of non-animal origin (NASHA(TM)-based gel) called Macrolane(TM) VRF30) in their open-label, multicentre, non-comparative study.

The aim of this study was to develop a reproducible technique for injecting NASHA-based gel posterior to the mammary gland (subglandular injection), and to assess treatment safety and efficacy. The feasibility of dual-plane submuscular injection was also explored.

Twenty-four non-pregnant, non-breastfeeding women (mean age 37 years) with small breasts were recruited, 20 of whom underwent subglandular injection.   Patients were treated in groups of four to enable step-wise revision of the injection technique. Safety and efficacy assessments (12-month follow-up) included adverse event (AE) reporting and the Global Esthetic Improvement Scale, respectively.

It’s a small study with the authors reporting 83% satisfaction in the post-procedure breast appearance at 6 months, 69% at 12 months.  I find it interesting that the most commonly reported adverse event was capsular contracture.   Obviously,  larger studies are needed before this can be routinely recommended to patients.

……………………….

Dentist are “pushing” their scope of practice beyond the teeth/dentition to include Botox and fillers.   While dentists may know how to do injections well and should know facial nerve/muscle anatomy well, I personally feel this is beyond the definition of dental practice.  I suppose it will be up to state dental and medical boards to work this out.

 The Evolving Role of Dentist in the Injectables Business by Jeff Frentzen, PSP Blog  leads you to the full article: The next revolution in dentistry: facial injectables by Bruce G. Freund, DDS, Oct 25, 2010.

REFERENCE

Macrolane(TM) for breast enhancement: 12-month follow-up; Per Hedén; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 14 October 2010; doi: 10.1097/PRS.0b013e318200ae57; Original Article: PDF Only

Longevity of SMAS Face Lift

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I think it is safe to say that all plastic surgeons have been asked, “How long will my face lift last?”  As pointed out, by Dr. Sundine and colleagues (first reference article) this question is difficult to answer using our current literature.  They tried to answer the question focusing specifically on the two-layer superficial musculoaponeurotic system (SMAS) face lift.

To do this, Sundine and colleagues conducted a retrospective chart review of 42 patients who underwent secondary face lifts performed by the senior author from January of 2001 to December of 2008. Patients who had their primary face lift performed by another surgeon were excluded.  The charts were reviewed for the dates of the initial surgery and subsequent operations, patient data, procedures performed, and complications. The patient photographs were also reviewed.

The average age at the time of the primary face lift was 50.7 years (range, 34.9 to 69.9 years), and the average age at the time of the secondary face lift was 61.9 years (range, 43.6 to 77.2 years).

The average length of time from the primary to secondary face lift was 11.9 years (range, 1.0 to 34.5 years). ….

One glaring shortcoming of the study is the failure of the authors to contact every patient the senior author performed a primary face lift (there were 299 during the time frame) to determine whether any patients received a secondary face lift with another surgeon.

So while the over-simplified answer may be “approximately 10 years,” there really is no simple answer.  Patients give many reasons for desiring a second facelift.  (second reference)

Readers of this article will already know that people have a universe of reasons for having a face lift. In practice, one commonly notes not only unhappiness with the mirror but also the loss of a spouse or the anticipation of finding one: the patient's social milieu and group dynamics (face lifts as a rite of passage). Some people perceive an advantage in finding or maintaining employment, all reasons that may have little to do with the face itself but with life conditions of the person requesting the procedure. In other words, subjectivity and life forces are major factors, and the decision to have such a procedure may have little relationship to how the patient actually appears.

Biological factors such as skin quality, facial weight, and the age at which the initial procedure is performed significantly affect both the quality of the initial result and its duration, and the same cultural and personal forces remain. There is no distinct tissue endpoint for undergoing a secondary lift, just as there is no distinct biological point at which a primary lift becomes “necessary.” With so many factors to be considered, the longevity of any type of face lift remains a difficult question to answer with any certainty.

In addition, to the above there are the constraints of life that may prevent a patient from returning for a desired facelift – poor health, financial concerns, family reasons, and perhaps even a poor experience the first time.

REFERENCE

Longevity of SMAS Facial Rejuvenation and Support; Sundine, Michael J.; Kretsis, Vasileios; Connell, Bruce F.; Plastic & Reconstructive Surgery. 126(1):229-237, July 2010.; doi: 10.1097/PRS.0b013e3181ce1806

Discussion: Longevity of SMAS Facial Rejuvenation and Support; Lambros, V.; Stuzin, J. M.; Plastic & Reconstructive Surgery. 126(1):238-239, July 2010; doi: 10.1097/PRS.0b013e3181dab6f3

The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Friel, M.T.; Shaw, R. E.; Trovato, M. J.; Owsley, J. Q.; Plastic & Reconstructive Surgery. 126(1):245-257, July 2010; doi: 10.1097/PRS.0b013e3181dbc2f0

Discussion: The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Pusic, A.L.; Klassen, A. F.; Scott, A. M.; Cano, Stefan J.; Plastic & Reconstructive Surgery. 126(1):258-260, July 2010; doi: 10.1097/PRS.0b013e3181dbba19

Stem Cell Face-Lifts?

Updated 3/2017--  all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

It’s been almost a month since the LA Times ran the article by Chris Woolston:  The Healthy Skeptic: Stem cell face-lifts on unproven ground.  It’s well written and presents a fairly balanced view.  While I am a fan of stem cell research, I think the “claims” are often put ahead of the science.  This is one of those times.  I can’t find any decent articles to support the claims of the plastic surgeons doing “stem cell face-lifts.”

My view is echoed in the article (bold emphasis is mine):

Rubin says he's excited about the potential of stem cells in the cosmetic field and beyond. Still, he adds, there are many unanswered questions about the cosmetic use of stem cells, and anyone who claims to have already mastered the technique is jumping the gun. As Rubin puts it, "Claims are being made that are not supported by the evidence."

While researchers in Asia, Italy, Israel and elsewhere are reporting decent cosmetic results with injections of stem cell-enriched fat, Rubin says that nobody really knows how the stem cells themselves are behaving. He points out that fat injections alone can improve a person's appearance, no stem cells needed.

Rubin believes it's possible that injected stem cells could create new collagen and blood vessels — as they have been shown to do in animals studies — but such results have never been proved in humans. And, he adds, the long-term effects of the procedures are an open question.

Stem cell face-lifts could someday offer real advances, says Dr. Michael McGuire, president of the American Society of Plastic Surgeons and a clinical associate professor of surgery at UCLA. But he believes that scientists are still at least 10 years away from reliably harnessing stem cells to create new collagen and younger-looking skin. Until then, promises of a quick stem cell face-lift are a "scam," he says.

The American Society for Aesthetic Plastic Surgery (ASAPS) issued a statement two weeks after the article first appeared --Stem cell therapy 'could offer women natural breast enhancement from stomach fat'

“Procedures with no solid science behind them, stem cells included, give unproven hope to patients and the marketing of them brings dishonor to our entire specialty,” said Felmont Eaves, III, MD of Charlotte, NC, President of ASAPS.  The Aesthetic Society is working together with the other core societies to address this through an evidence based medicine program that will rate any procedure or device on the legitimacy of the scientific evidence behind it.  This program is in its development stage and will be available to the public within the next 12 months”.

“The use of ‘stem cells’ in advertising for cosmetic surgical applications is a global problem," says Doug Sipp, Head of the Science Policy and Ethics Study Unit at the Center for Developmental Biology of RIKEN in Kobe, Japan, who monitors supposed stem cell treatment claims worldwide in all different specialties.  "There have been many cosmetics, nutraceuticals, and device makers who claim either to use stem cells in their products, or to use ingredients that activate the customer’s own stem cells. To the best of my knowledge, none of these has a basis in scientific evidence."

Marketing.  That seems to be the issue here.  And there is much money to be made in promises that may or may not be kept with the use of stem cells.  From the LA Times article:

Stem cell face-lifts: A Sept. 13 Health section story assessing stem cell face-lifts offered by two Beverly Hills doctors said that Dr. Nathan Newman charges between $5,500 and $9,500 for the procedure and Dr. Richard Ellenbogen charges $15,000 to $25,000. The story should have noted that Ellenbogen often performs a surgical face-lift along with his injection of stem cells. —

Facial Prosthetics Restores Face

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

This is an amazing story of restoring a face using surgery and prosthetics. I learned of it through the AMA News article by Carolyne Krupa: Medical team gives Oregon woman a new face.

A surgeon and two maxillofacial experts in prosthetics help a 27-year-old mother, disfigured by a shotgun blast, appear more normal to her young son.

Krupa tells the story and then links to this one:
REBUILDING CHRISSY STELTZ'S FACE: A Special Report by The Oregonian – chronicles the story from the beginning with a list of articles written through the years and a nice timeline slideshow which includes this one.

Other recent news stories regarding facial prosthetics
Military's Facial Prosthetic Program Transforms Injured Troops
Miracle Army Lab Gives Soldiers Their Faces Back
If you are interested in learning how to make such prosthetics, check out these sources
The Facial Prosthetics Training Program (John Hopkins)
International Anaplastology Association
University of Illinois Biomedical Visualization

Vampire Facelift?!

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. 

I first saw mention of the “vampire facelift” almost two weeks ago as a news article listed in the July 9th issue of the Plastic Surgery SmartBrief:  "Vampire face-lift" uses patient's platelets and fibrin in dermal filler.

The article begins:

Instead of a traditional facelift, patients are being offered another option to get rid of wrinkles. It's called Selphyl or the "vampire face-lift," and it uses a person's own blood to sculpt the face.

Selphyl according to the companies website

The patented SELPHYL® System enables the safe and rapid preparation of an activated Platelet-rich Fibrin Matrix (PRFM).  A small volume of the patient’s blood is collected and the platelets and fibrin are concentrated during a simple centrifuge process.  The resulting product (liquid, gel or membrane) can be applied to a treatment area of the face or body to stimulate natural, new tissue growth.  SELPHYL® prepared PRFM has been shown to increase skin volume and rejuvenation.

SELPHYL® ensures a preparation of fibrin and platelets, with virtually no red or white blood cells. Studies have shown these platelets to be viable and intact.  Platelets will release proteins, which have been reported to trigger cell migration, proliferation and differentiation over time.

With over 45,000 procedures performed world-wide, this technology has been extensively used for soft tissue regeneration in plastic surgery, orthopedics and maxillofacial surgery.

So how does Sephyl create any face-lifting effect?  Back to the news article, as explained by a non-physician owner of a medical day spa, Kathleen Stegman of Midwest Medical Aesthetics:

The Selphyl process is done in the office. A tube, filled with the patient's blood, is put in a centrifuge machine, where platelets and fibrin are separated and the blood is prepared for application as a dermal filler.

Oh, it is used as a dermal filler, but that’s not a face lift!   What nonsense!

It is my opinion that this news article and day spa are simply “cashing” in on the current vampire craze with increase vampire novels and movies.

I searched the Journal of Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, and PubMed for articles on Selphyl.  Here are the ones I found:

Platelet-rich fibrin matrix for improvement of deep nasolabial folds.; Sclafani AP; J Cosmet Dermatol. 2010 Mar;9(1):66-71.PMID: 20367676 [PubMed - in process]Related citations

Applications of platelet-rich fibrin matrix in facial plastic surgery., Sclafani AP., Facial Plast Surg. 2009 Nov;25(4):270-6. Epub 2009 Nov 18.PMID: 19924600 [PubMed - indexed for MEDLINE]Related citations