The American Journal of Cosmetic Surgery

Autologous fat transfer is an increasingly popular treatment for the aging face. Recently, studies have suggested increased duration of effect with the injection of fat into or adjacent to muscles. Subcutaneous depths of facial muscles have been demonstrated using cadaver dissections, but to our knowledge this is the first study to use radiologic measurements in living subjects in order to quantify muscle depths in the face.

Forty computed tomography (CT) scans were reviewed retrospectively using digital radio imaging software with a calibrated digital measurement tool that was used to measure the depths of the muscles of facial expression corresponding to fat-grafting sites. Correlation was made to formalin-preserved cadaver dissections.

Subcutaneous depths of facial muscles are listed as measured radio graphically and on cadaver sections.

The depths of the muscles of facial expression are more accurately measured using digital radiographs; these depths are important landmarks for facial cosmetic surgeons performing an autologous fat transfer. To our knowledge, this is the first study to characterize the anatomic depth of the facial muscles in the living human.

Laser treatment of congenital nevi, especially large nevi, is controversial. Currently, the standard of care is treatment by surgical excision, which can lead to scarring and permanent hypopigmentation. Furthermore, excision of giant congenital nevi might involve a substantial body surface area and could require multiple excisions, resulting in multiple scars. Additionally, some nevi are in cosmetically sensitive anatomic locations where surgical excision could compromise function or leave cosmetically unacceptable scars.

Seventeen patients with small to giant nevi of different sizes were treated with ruby and/or alexandrite lasers either in the same or different treatment sessions at 3–8-week intervals. Baseline biopsies of giant and some medium congenital nevi were obtained. All the nevi treated were histologically benign. In treating the two giant congenital nevi, the maximum effective fluences were determined through histological examination of treated anatomic locations after treatment at different energy levels.

Two small nevi (12%) completely cleared and 12 small and medium nevi (71%) showed partial or cosmetically acceptable response. The two giant congenital nevi achieved 50–75% lightening after 6 or 7 treatment sessions. Side effects were minimal in most patients and included crusting and purpura immediately postoperatively. More severe hemorrhagic reaction and superficial thermal necrosis resulting in several patches of scar tissue 1–2 cm in width was seen in one of the two patients with giant congenital nevi. The hypertrophic scarring was effectively treated with pulse dye laser and intralesional Kenalog and 5-FU. Histological examination of the treated giant congenital nevi showed elimination of nevus cells in the upper dermis without appreciable fibrosis.

The ruby and alexandrite lasers are effective in partial or complete elimination of small nevi and lightening of medium to giant congenital nevi. Treatment of the giant congenital nevi requires dedicated patients, as well as persistence and diligence on the part of the treating physician. The risks and benefits should always be weighed before starting a course of treatment.

Breast-reduction surgery utilizing the inferior pedicle technique is popular among breast surgeons because of its reliable areolar neurovascular preservation qualities. Although smaller, more elevated breast mounds are achieved, one shortcoming is persistent or recurrent glandular ptosis with loss of superior pole fullness (bottoming-out). A modification of the inferior pedicle technique is presented, which enhances and maintains the aesthetically desired bulk in the superior pole of the breast.

After creating an inferior pedicle with a generous base width, a superior portion of the pedicle is incompletely bifurcated. The superior section of bifurcated inferior pedicle is secured superiorly high on the pectoralis fascia after passing it through a bipedicle (bucket-handle) flap of pectoralis major muscle.

The support afforded by the pectoralis flap to the superior section of this bifurcated inferior pedicle helps maintain the position of the superiorly placed breast parenchyma. This provides long-term superior pole fullness.

The modification is safe, and surgeons who are comfortable with the inferior pedicle technique should master it easily. The technique and surgical results are presented.