The American Academy of Cosmetic Surgery (AACS) conducted its 23rd annual scientific meeting in January at the the Arizona Biltmore Resort and Spa in Phoenix. Its theme, “Renewal and Rejuvenation,” offered attendees a chance to network with one another, preview products in the industry, and listen to lectures led by experts who provided information on the latest aesthetic techniques. PSP reviews six of them.

Albert E. Carlotti III, MD, DDS, of Desert Palm Surgical Group, Scottsdale, Ariz, presented “The Aggressive Submentoplasty—Achieving Consistent Results at the Neck-Jaw Angle.”

Achieving the defined neck–jawline angle has often provided a challenge to the aesthetic surgeon. Various techniques exist, including isolated submental liposuction, thread lifts, platysmal imbrication, and platysmal plication. An analysis of skeletal morphology, pretreatment hyoid bone position with cephalometric radiographs, and submandibular gland position helps define the limitations of any result, regardless of the methods, according to Carlotti.

The submentoplasty technique is often a part of a face and neck lift—the modified four-dimensional facelift, in particular. The surgery involves a 2-cm submental incision, as well as preauricular and postauricular incisions.

According to Carlotti, a more defined neck–jaw angle is accomplished with the aggressive submentoplasty technique, compared to the plastysmal plication technique alone.

Ronald W. Strahan, MD, of Santa Monica, Calif, discussed a study conducted over 10 years that evaluated 451 facelift cases. The study examined the long-term results of three common types of facelifts: the skin–SMAS technique, the deeper-plane technique, and the subperiosteal technique.

“The greatest positive impact for long-term (10-year) satisfaction of the facelift patient is not the technique of the surgery, but whether or not the patient had concurrent cosmetic nose surgery and cosmetic eyelid surgery,” Strahan says. “Therefore, any treatment program of the aging face that does not offer nasal and eyelid surgery most likely will have mediocre results.”

For the study, written or telephone contacts with more than 1,000 patients who had facelifts before 1997 were established. Each participant was given a questionnaire, and 451 responded. The respondents’ charts were then reviewed for age, sex, type of facelift, and complications.

According to Strahan, 56% of the respondents were satisfied 10 years after the surgery, and 18% were satisfied with some parts of their facelifts, but dissatisfied with others. Most were younger than 50 years at the time of surgery. Satisfaction rates with procedures on specific parts of the face ranged from 59% to 94%.

Selecting the “correct” facelift technique for a patient is often a difficult decision for plastic surgeons, according to Darrick E. Antell, MD, of New York City. A technique that provides optimal results for one patient may not provide the same for another because the character and severity of facial aging may differ, says Antell, who discussed his study of aesthetic surgery on sets of identical twins.

“After checking photographs of hundreds of twins, what impressed us the most were the differences in some of the twins in how they had aged,” Antell says. “In looking at the questionnaires that the twins had completed, it became apparent that certain factors, most importantly smoking and sun exposure, seemed to be the largest contributors in causing a difference in how the twins aged.”

The study included 34 sets of identical twins, ranging in age from 45 to 75 years old. Comparisons of photographs of each twin set were made with respect to appearance and lifestyle. Histological skin differences were compared for seven sets of twins in the study group. A questionnaire was used to compare lifestyle and personal habits, including sun exposure, tobacco use, medications, health history, alcohol consumption, diet, exercise, and stress.

The study found that wrinkle patterns and hereditary blepharoptosis were identical. However, such factors as severity of wrinkles, amount of excess skin, and quality of skin texture differed in direct proportion to the lifestyle differences within a twin set.

According to Antell, the study shows that a patient’s environment and lifestyle can accelerate the aging process. He notes that the factors that exert the greatest influence are sun exposure, smoking, alcohol use, and emotional stress.

Orbital decompression is an important modality for orbital expansion in patients with non-Graves’ orbitopathy– related prominent eyes and in patients who do not need robust retrodisplacement of the globe, but require protection of the globe from exposure symptoms, according to Robert Goldberg, MD, of Jules Stein Eye Institute, Los Angeles. Goldberg’s presentation included an assessment of the surgical outcome of a series of patients who underwent orbital decompression.

In the study, a review of the electronic medical records of 21 patients who underwent the procedure between 1995 and 2006 was performed. Patients with euthyroid and Graves’ orbitopathy, and patients with intra-orbital tumors were excluded. Data collected included patient demographics, preoperative indications, decompression methods, postoperative outcomes, and complications.

The indications for surgery included facial palsy (three patients), exorbitism (two), prominent eye with lid retraction (one), fat fullness and exposure keratopathy (two), congenital proptosis (four), post-traumatic prominent eye (four), hypoplastic malar eminence (two), maxillary hypoplasia (two), and midface descent (two).

The surgical techniques included intraconal fat debulking without orbital bone removal (five), bone removal without fat debulking (one), and combined bone and intraconal fat removal (15). The average amount of fat removed was 2.5 mL.

According to Goldberg, 15 patients underwent additional surgical procedures, such as myocutaneous flap to support the lids (three), fornix reconstruction (three), volume fillers with restylane (three), upper-eyelid retraction correction (two), temporary tarsorraphy (two), blepharoplasty (two), canthoplasty (two), lower-lid ectropion repair (one), and ptosis repair (one).

Postoperative complications were mild and temporary, and included conjunctival chemosis and hematoma formation. The results indicated that 15 patients were satisfied with the overall aesthetic and functional result, five patients were somewhat pleased, and one patient was not satisfied because of decreased visual acuity with worsening of pre-existent diplopia.

Facelift surgery is an elective procedure, and patients do not expect or accept complications, says Steven B. Hopping, MD, FACS, of the Center for Cosmetic Surgery, in Washington, DC, and the Washington DC Hair Institute, who presented a lecture on the safety of facelifts, emphasizing Richard Webster, MD’s concepts. Webster was a founder and the first president of the AACS, and he believed that cosmetic surgery should be its own specialty and that multidiscipline fellowship would optimally promote the field.

Hopping says that Webster’s concept of limiting flap dissection and plicating SMAS safely over the protective parotid gland was a precursor of the short-scar facelifts, including the S lift, MACS lift, Lifestyle lift, and Quick lift. Other Webster contributions to safe aesthetic surgery include the horizontal tightening suture, which prevents rounding and ectropion; conservation rhinoplasty techniques; and the non–cartilage-splitting otoplasty procedure.

Hair deformities have many origins, including natural male- and female-pattern baldness, trauma, cancer, and iatrogenic causes, according to E. Antonio Mangubat, MD, of Washington, DC. The various deformities and their degrees determine the treatment choice. Using a combination of hair-restoration surgery and aesthetic and reconstructive techniques can treat most deformities.

To read reports on previous technical meetings on PSP’s website, see our other InReview articles.

Mangubat reported specifically on one method that holds great promise for hair restoration. Tissue expansion, which was first described 50 years ago, takes advantage of “biological creep” of the skin. In this procedure, an expander is inserted under a portion of the scalp where hair already exists. The expander is injected with fluid to volumes as large as 1.4 liters. As the scalp skin itself expands, it grows additional hair.

After a few months, the expander is removed, the scalp skin that is devoid of hair is excised, and the newly grown skin and hair are placed over the excised area and attached with a no-tension closure. The tissue-expansion procedure has proven successful in studies to date and may well eliminate the need for skin grafts for patients who have lost scalp hair because of burns, disease, or other causes.

Assessing Skin Type

You may well have read or heard about the 16 Myers–Briggs personality types that psychologists and other mental health professionals use to understand patients’ feelings and behavioral preferences. Now, Leslie Baumann, MD, a University of Miami dermatologist, has developed a skin-type classification system that can help practitioners understand and treat their patients’ skin.

In a presentation at the 23rd annual scientific meeting of the American Academy of Cosmetic Surgery (AACS) in Phoenix in January, Baumann discussed the following four ways to classify skin:

  • oily versus dry;
  • sensitive versus resistant;
  • pigmented versus nonpigmented; and
  • wrinkled versus tight.

Baumann pointed out that in this context, “dry” means scaly skin; “sensitive” indicates that the skin is prone to acne and other blemishes; and “pigmented” does not refer to the Fitzpatrick skin-type classification, but rather means that the skin contains unwanted dark spots. She also said that wrinkled skin is primarily the result of environmental or behavioral factors such as sun exposure or smoking, rather than a congenital condition.

As with Myers–Briggs, combinations of the four main classifications lead to 16 different skin types. A patient can determine his or her skin type by taking the 45-question questionnaire that is contained in Baumann’s book The Skin Type Solution (New York: Bantam Dell Publishing Group; 2006). Based on the classification, the patient can then take advantage of Baumann’s advice for proper skin care.

Baumann and fellow presenter Suzan Obagi, MD, a Pittsburgh dermatologist, spent considerable time discussing the possible FDA ban on hydroquinone, a popular and effective lightening ingredient for dark spots in the skin. Their position is that the impetus for this action has come from a few cases of misuse of hydroquinone, and that it should remain on the market because it is by far the best product for this use. A recent blog by Baumann ( provides more information on this topic.