Facial Plastic Surgeon
24 years of experience
Video profile
Accepting new patients
2400 Clay St
San Francisco, CA 94115
(415) 567-7000
Locations and availability (1)

Education ?

Medical School Score Rankings
University of Florida (1986)
Plastic Surgery
  • Currently 4 of 4 apples
Top 25%

Awards & Distinctions ?

Awards  
SIR HAROLD DUFF GILLES AWARD, TRIOLOGIC SOCIETY
AMERICAN ACADEMY FACIAL PLASTIC SURGERY COMMUNITY AWARD
Castle Connolly's Top Doctors™ (2012 - 2013)
Patients' Choice Award (2011 - 2012)
Compassionate Doctor Recognition (2011 - 2012)
Appointments
University Of Calif, California College
ASSOCIATE PROFESSOR & CHIEF, DIV OF FACIAL PLASTIC SURGERY
University of California, San Francisco School of Medicine
Associate Clinical Professor
California Pacific Medical Center
Associations
American Academy of Cosmetic Surgery
Member

Affiliations ?

Dr. Maas is affiliated with 10 hospitals.

Hospital Affilations

Score

Rankings

  • California Pacific Medical Center - Davies Campus
    Otolaryngology
    2333 Buchanan St, San Francisco, CA 94115
    • Currently 4 of 4 crosses
    Top 25%
  • Tahoe Forest Hospital District
    10121 Pine Ave, Truckee, CA 96161
    • Currently 3 of 4 crosses
    Top 50%
  • St. Luke's Hospital
    Otolaryngology
    3555 Cesar Chavez, San Francisco, CA 94110
    • Currently 3 of 4 crosses
    Top 50%
  • California Pacific Medical Center- Davies Campus
    Otolaryngology
    45 Castro St, San Francisco, CA 94114
    • Currently 1 of 4 crosses
  • UCSF Medical Center / Moffitt-Long Hospitals *
    Otolaryngology
    521 Parnassus Ave, San Francisco, CA 94143
    • Currently 1 of 4 crosses
  • Incline Village Community Hospital
    880 Alder Ave, Incline Village, NV 89451
  • California Pacific Medical Center Opens in new window
  • Ft Miles Va Hospital, San Francisco, Ca
  • Stanford Medical Center, San Francisco, Ca
  • Otolaryngology - HNS
  • * This information was reported to Vitals by the doctor or doctor's office.

    Publications & Research

    Dr. Maas has contributed to 43 publications.
    Title Twelve-month Persistency of a Novel Ribose-cross-linked Collagen Dermal Filler.
    Date August 2008
    Journal Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [et Al.]
    Excerpt

    BACKGROUND: The porcine collagen-derived dermal filler Dermicol-P35 (Evolence, Colbar LifeScience Ltd, Herzliya, Israel) has low immunogenicity and the potential to provide a long-lasting corrective response for soft-tissue contour deficiencies and deformities. OBJECTIVE The objective was to assess the persistence of the corrective response with Dermicol-P35 up to 12 months after obtaining an optimal cosmetic result (OCR) in a randomized, multicenter study comparing the efficacy and safety of Dermicol-P35 with the hyaluronic acid (HA) filler Restylane (Medicis Pharmaceutical Co.). METHODS & MATERIALS: Subjects with moderate to deep nasolabial wrinkles (n=149) were randomized to injections of either Dermicol-P35 or HA on one side of the face and the alternative preparation on the contralateral side. If necessary, one touch-up injection could be given after 2 weeks to obtain an OCR. RESULTS: Although the mean Modified Fitzpatrick Wrinkle Scale score increased gradually after achieving the OCR with Dermicol-P35, 95.3 and 76.5% of subjects, respectively, met the criteria for persistence of the corrective response after 9 and 12 months. Persistency rates were similar regardless of the requirement for a touch-up injection at Week 2. No unexpected, severe, or serious injection-related adverse events were experienced. CONCLUSION: The effectiveness of Dermicol-P35 appears to be maintained for up to 1 year after achieving an OCR, both for touch-up and for non-touch-up subjects.

    Title Perioral Rejuvenation and Lip Augmentation.
    Date February 2008
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    In general, the aging process of the face is a process of atrophy, most noticeable in the perioral region. This article discusses rejuvenation of the perioral region, including fillers, surgery, and facial resurfacing, as correction for this process. Detailed techniques for each of the approaches are outlined. Composition of the various fillers is discussed in conjunction with their respective outcomes and duration of effect. Clinical preoperative, intraoperative, and postoperative photographs are presented.

    Title A Randomized, Multicenter Study of the Safety and Efficacy of Dermicol-p35 and Non-animal-stabilized Hyaluronic Acid Gel for the Correction of Nasolabial Folds.
    Date January 2008
    Journal Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [et Al.]
    Excerpt

    BACKGROUND: Non-animal-stabilized hyaluronic acid (NASHA) offers longer-lasting cosmetic improvement and reduced risk of hypersensitivity and requires less injection volume than bovine collagen-derived dermal fillers. Porcine collagen-derived Dermicol-P35 has low immunogenicity and has the potential to provide durability at least equivalent to that of NASHA. OBJECTIVE: The objective was to evaluate the efficacy and safety of Dermicol-P35 and NASHA for correction of nasolabial folds (NLFs). METHODS AND MATERIALS: A total of 149 subjects with moderate NLFs were randomized to receive Dermicol-P35 and NASHA on contralateral sides of the face. If needed, subjects could receive a repeat injection 2 weeks later to obtain an optimal cosmetic result (OCR). RESULTS: Significant (p<.001) improvement in the Modified Fitzpatrick Wrinkle Scale scores relative to screening was observed after treatment with Dermicol-P35 and NASHA. Relative to the OCR visit, mean scores increased (p<.001) over time, but there were no significant differences between treatments (+0.39 and +0.37 at 6 months; p=.626). Greater proportions of subjects experienced swelling, bruising, and pain at the NASHA site. Several subjects had more induration at the Dermicol-P35 site. There was no evidence of any adverse immunologic effect. CONCLUSION: The effectiveness of Dermicol-P35 is maintained for at least 6 months and is equivalent to NASHA for the correction of NLFs.

    Title Botulinum Neurotoxins and Injectable Fillers: Minimally Invasive Management of the Aging Upper Face.
    Date June 2007
    Journal Otolaryngologic Clinics of North America
    Excerpt

    Attitudes on the use of injectable agents for rejuvenation of the face have changed dramatically over the last decade. This is particularly true for the upper third of the face, where the impact of the use of Botox had its first application. In the author's opinion, no technique, device, or pharmaceutical has had a greater impact on the aesthetic surgery than the now widely used botulinum toxin as an injectable agent.

    Title Anatomic Considerations for Treatment with Botulinum Toxin.
    Date May 2007
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    Botulinum toxin A treatment continues to increase in popularity and number. Many more patients are undergoing cosmetic Botox procedures and many, diverse practitioners are providing them. The best results are obtained from a careful history and physical examination of the patient combined with a detailed understanding of facial and neck anatomy. Understanding the dynamic anatomic relationships, such as agonist-antagonist muscles and contraction force vectors, is key to providing the patient with an excellent outcome.

    Title Botulinum Toxins for Facial Wrinkles: Beyond Glabellar Lines.
    Date May 2007
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    Botulinum toxin type A (BTX-A) has been used for years with excellent results for upper facial cosmetic applications. Because of this success, the use of BOX-A for facial aesthetics has expanded to the lower facial and neck regions. BTX-A, especially when used in combination with fillers, has generally proven to be safe and efficacious in these areas. For optimal results, however, several issues must be taken into considerations, including dosing differences versus upper facial applications, the specific type of botulinum toxin used and the importance of precise placement and injection technique. In this article, the authors present their experience with BTX-A in the lower face and neck, and compare and contrast their current practices with those reported by others.

    Title Botulinum Neurotoxins and Injectable Fillers: Minimally Invasive Management of the Aging Upper Face.
    Date October 2006
    Journal Facial Plastic Surgery Clinics of North America
    Title Effect of Homeopathic Arnica Montana on Bruising in Face-lifts: Results of a Randomized, Double-blind, Placebo-controlled Clinical Trial.
    Date April 2006
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVES: To design a model for performing reproducible, objective analyses of skin color changes and to apply this model to evaluate the efficacy of homeopathic Arnica montana as an antiecchymotic agent when taken perioperatively. METHODS: Twenty-nine patients undergoing rhytidectomy at a tertiary care center were treated perioperatively with either homeopathic A. montana or placebo in a double-blind fashion. Postoperative photographs were analyzed using a novel computer model for color changes, and subjective assessments of postoperative ecchymosis were obtained. RESULTS: No subjective differences were noted between the treatment group and the control group, either by the patients or by the professional staff. No objective difference in the degree of color change was found. Patients receiving homeopathic A. montana were found to have a smaller area of ecchymosis on postoperative days 1, 5, 7, and 10. These differences were statistically significant (P<.05) only on postoperative days 1 (P<.005) and 7 (P<.001). CONCLUSIONS: This computer model provides an efficient, objective, and reproducible means with which to assess perioperative color changes, both in terms of area and degree. Patients taking perioperative homeopathic A. montana exhibited less ecchymosis, and that difference was statistically significant (P<.05) on 2 of the 4 postoperative data points evaluated.

    Title Use of Bioglue Surgical Adhesive for Brow Fixation in Endoscopic Browplasty.
    Date February 2006
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVE: To determine the efficacy, longevity, and safety of BioGlue Surgical Adhesive for periosteal fixation in endoscopic browlifts. METHODS: Retrospective review of 80 patients who underwent endoscopic browlift using BioGlue as the primary means of periosteal fixation. Visits were categorized as preoperative, 1 to 2 months, 3 to 6 months, and 7 to 12 months, and photographs of the first 15 patients were evaluated for change in brow position at each of these visits. Brow position was measured at the lowest brow hairs at the midpupillary and lateral canthus positions. Follow-up was 3 months to 3 years. RESULTS: All of the first 15 patients were included in the 1- to 2-month postoperative grouping, 13 in the 3- to 6-month grouping, and 10 in the 7- to 12-month grouping. At all postoperative visits, brow elevation was significantly maintained during 12-month follow-up. Revision has been required in only 1 of 80 patients to date. CONCLUSIONS: BioGlue is an effective and safe method of maintaining brow position in endoscopic browplasty. Brow elevation achieved using BioGlue was significantly maintained during the 7- to 12-month postoperative period. Tissue adhesives such as BioGlue have the potential to become significant adjuncts in facial plastic surgery and warrant more critical evaluation.

    Title A Validated Rating Scale for Hyperkinetic Facial Lines.
    Date October 2004
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVE: To test the reliability of a simple rating system to describe hyperkinetic facial lines. METHODS: A rated numeric kinetic line scale was developed and presented to 11 postresidency physicians specializing in aesthetic facial care. These physicians independently reviewed photographs of 20 patients, first at rest, then with activation of the frontalis, corrugator, and orbicularis oculi muscles. Kappa statistics for multiple raters were used to assess interobserver reliability. RESULTS: The nonweighted kappa values were between 0.4 and 0.8 for the frontalis, corrugator, and orbicularis muscle groups. This represents moderate to substantial observer agreement and is highly significant for each muscle group. CONCLUSIONS: A new rating scale for hyperkinetic facial lines accounts for facial appearance at rest and with expression. It is easily used and has interobserver reliability. As the only objective and validated scale for hyperkinetic facial lines, this rated numeric kinetic line scale is recommended for the evaluation of pretreatment and posttreatment results in patients undergoing therapy for this problem. Moreover, an alternative scale rating resting and kinetic lines as independent variables is also being developed. Both must be considered to evaluate treatment outcomes when using neurotoxins.

    Title Relevant Anatomy for Botulinum Toxin Facial Rejuvenation.
    Date July 2004
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    Over the last several years, Botox has become an integral treatment modality in the management of facial aging. Through selective chemical denervation, rhytids that are associated with hyperfunctioning muscles can be considerably softened or eliminated. Most practitioners rely on surface anatomy and landmarks to guide accurate needle insertion and Botox therapy. Therefore, a detailed appreciation of the underlying muscular anatomy is paramount in improving the practitioner's cosmetic results and the patients' overall satisfaction.

    Title New Procedures in Facial Plastic Surgery Using Botulinum Toxin A.
    Date July 2004
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    New indications for botulinum toxin A injection in facial plastic surgery have begun to emerge beyond the management of facial rhytids. This paper described a role for botulinum toxin in the rehabilitation from facial nerve paralysis, in the pharmacologic browlift, and in the nonsurgical management of platysmal bands. These procedures are not meant as a replacement for surgery, but rather as a less invasive alternative, or as an adjunctive modality. They are most useful in cases of functional or dynamic disorders, as opposed to problems of excessive or lax tissues. This article presented several clinical studies that give supportive evidence for the efficacy of the procedures. Further, larger studies with more objective measurements are necessary before these procedures become widely accepted.

    Title The Role of Botulinum Toxin Type B (myobloc) in the Treatment of Hyperkinetic Facial Lines.
    Date November 2003
    Journal Plastic and Reconstructive Surgery
    Excerpt

    Botulinum toxin type B was studied for the management of hyperkinetic facial lines. It showed clinical longevity of up to 12 weeks on subjective rating scales and 8 weeks on objective rating scales. Botulinum toxin type B has shown relative safety but can have autonomic side effects at higher total doses, which limits the possibility of continued dose escalation. Although these findings may preclude its use as a primary modality for the use in hyperkinetic facial lines, botulinum toxin type B still has a role in the treatment of the aesthetic patient and is yet another tool in the armamentarium of aesthetic practitioners.

    Title Temporal Brow Lift Using Botulinum Toxin A: an Update.
    Date November 2003
    Journal Plastic and Reconstructive Surgery
    Title Dorsal Onlay Cartilage Autografts: Comparing Resorption in a Rabbit Model.
    Date August 2003
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVE: To compare the resorption characteristics of dorsal onlay cartilage autografts from the septum, auricle, and rib. METHODS: Fourteen New Zealand white rabbits underwent harvesting of equal-sized septal, auricular, and costal cartilage grafts free of perichondrium. All autografts were implanted subcutaneously on the nasal dorsum and then removed after 3 months. Graft mass, chondrocyte density, and histologic features from hematoxylin-eosin-stained sections were compared before and 3 months after implantation. RESULTS: At 3 months after implantation, septal cartilage grafts averaged 30.8% resorption by weight, followed by auricular (23.1%) and costal (7.6%) cartilage. All 3 groups demonstrated similar changes in chondrocyte density and minor calcification at 3 months. There was no evidence of necrosis or inflammatory changes in any of the specimens. CONCLUSIONS: Although the septum is often the preferred source of autogenous cartilage for nasal reconstruction, short-term resorption of septal cartilage appears to be higher for dorsal onlay grafts. The low resorption of costal cartilage may be due in part to its compact shape compared with septal and auricular cartilage. It remains to be seen whether these differences in resorption persist in the long term.

    Title Scarless Lip Rehabilitation for the Adynamic Lip.
    Date June 2003
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVE: Paralysis of the marginal mandibular branch of the facial nerve can be a debilitating condition resulting in compromised speech and oral incompetence. We describe a static procedure performed to address the functional and cosmetic deficits seen with an adynamic lip. METHODS: Three patients with complete facial nerve paralysis were evaluated after the scarless lip rehabilitation, a modification of the traditional wedge resection of the lower lip. The procedure is novel in that the removal of lip laxity and advancement of the contralateral innervated lip is achieved without an external facial skin incision. RESULTS: All 3 patients in the study reported improvement in oral competence and lip symmetry; however, articulation was less consistently affected. All 3 patients were able to drink from a glass without leaking from their oral commissure. No complications were seen in this series of patients. CONCLUSION: Oral incompetence and asymmetry are often the overlooked sequelae from complete facial nerve paralysis. Scarless lip rehabilitation of the adynamic lip is a novel, safe, and effective means to improve these functional and aesthetic deficits.

    Title A Novel, Conformable, Rapidly Setting Nasal Splint Material: Results of a Prospective Study.
    Date June 2003
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVE: To determine if a fiberglass splint material (3M Scotchcast, St Paul, Minn; Smith & Nephew, Inc, Charlotte, NC) serves as a better nasal cast than Aquaplast (Smith & Nephew, Inc) based on the criteria of total preparation time, ease of use, conformability, adhesion, and patient acceptability. DESIGN: Prospective randomized comparison study with statistical analysis. SETTING: University-based division of a facial plastic surgery private clinic. PATIENTS: Sixteen consecutive patients desiring a functional and aesthetic improvement underwent open structure rhinoplasty with lateral osteotomies. No patients withdrew because of adverse effects. INTERVENTION: Half of the patients were randomized to the study group (fiberglass splint material) and half to the control group (Aquaplast). Each patient was fitted with the appropriate casting material at the conclusion of the rhinoplasty procedure. Data were collected with respect to total preparation time, ease of use, conformability, and adhesion. Each patient was asked to evaluate the cast for level of comfort after 1 week. RESULTS: There were no significant differences between study groups for adhesion (P =.18) and conformability (P =.35). Patient acceptability was good or excellent in both study groups. The fiberglass splint material was significantly easier to use (P<.001) and required less total preparation time (P<.001). The mean total preparation time for the Aquaplast and fiberglass splint materials were, respectively, 7 minutes 32 seconds and 2 minutes 37 seconds. CONCLUSIONS: Compared with the commonly used nasal splinting material Aquaplast, fiberglass splint material is not significantly more adhesive, conformable, or comfortable for the patient. Fiberglass splint material is significantly easier to use and requires less total preparation time than Aquaplast. These differences may provide advantages in the immediate postoperative period and for the long-term success of rhinoplasty surgery.

    Title Botulinum Toxin Type B (myobloc) in the Management of Hyperkinetic Facial Lines.
    Date July 2002
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVE: Our goal was to evaluate the safety and efficacy of botulinum toxin type B (BTX-B) in the management of hyperfunctional facial lines. STUDY DESIGN AND SETTING: Twenty-four patients from an academic faculty practice were treated with 400 to 800 units BTX-B in the corrugator, orbicularis oculi, or frontalis. Patients were evaluated with the Wrinkle Improvement Score (WIS) and Rated Numeric Kinetic Line Scale (RNKLS) and questioned about side effects and pain. Evaluations were made at 1, 2, 4, 8, and 12 weeks. RESULTS: Onset of effect was within 72 hours. WIS and RNKLS for all sites were statistically better after treatment, with the effect lasting 8 weeks. In general, patients noted a moderate improvement (grade 2) on WIS and a 2-point improvement on RNKLS. Injection was more painful than that of BTX-A. There were no complications. CONCLUSION: BTX-B is a safe and effective technique to eliminate wrinkles. Further studies are needed to elucidate dosage and duration. SIGNIFICANCE: BTX-B is stable for prolonged periods of time, requires no preparation before use, and is antigenetically distinct from BTX-A.

    Title Preliminary Experience with Botulinum Toxin Type B in Hyperkinetic Facial Lines.
    Date May 2002
    Journal Plastic and Reconstructive Surgery
    Title Total Nasal Reconstruction with Alloplastic and Autogenous Grafts.
    Date March 2002
    Journal Facial Plastic Surgery : Fps
    Excerpt

    The basic principles of successful total nasal reconstruction include providing a sufficient amount of tissue coverage, creating an adequate structural framework, and fashioning a viable inner lining. Relative uniformity of opinion exists regarding sources for tissue coverage and nasal lining. A variety of options exists, however, regarding the type of material used for nasal framework. Alloplastic metals, such as vitallium or titanium mesh, combined with autogenous soft tissue coverage, are reliable alternatives for use in total nasal reconstruction.

    Title Softform for Facial Rejuvenation: Historical Review, Operative Techniques, and Recent Advances.
    Date February 2002
    Journal Facial Plastic Surgery : Fps
    Excerpt

    The deep nasolabial fold and other facial furrows and wrinkles have challenged the facial plastic surgeon. A variety of techniques have been used in the past to correct these troublesome defects. Advances in the last five years in new materials and design have created a subcutaneous implant that has excellent properties. This article reviews the development and use of Softform facial implant.

    Title Synthetic Soft Tissue Substitutes: 2001.
    Date October 2001
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    The human face ages in a predictable fashion. Well-described changes in the lip and perioral region include progressive deepening of the nasolabial folds and atrophy of the lips. Conventional face lifting and endoscopic and resurfacing techniques do not adequately address many of these changes. As such, soft tissue filler materials are often used. This article outlines the history of soft tissue augmentation and discusses the risks and benefits of current synthetic materials.

    Title Bipolar Radiofrequency Resurfacing.
    Date October 2001
    Journal Facial Plastic Surgery Clinics of North America
    Excerpt

    Bipolar radiofrequency resurfacing is a new technology for the treatment of facial skin changes, including photoaging, rhytids, scars, and selected facial lesions. It is efficacious in the treatment of these problems and offers a quicker recovery than that of carbon dioxide laser resurfacing.

    Title Epidemiology of Facial Injury in Female Blunt Assault Trauma Cases.
    Date September 2000
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    BACKGROUND: Etiology of trauma in the female population differs from that of the male population. To date, domestic violence has been researched extensively, but little has been published about the epidemiology of facial injury in the female population. OBJECTIVES: To analyze the differences in the circumstances under which males and females are injured, to identify gender-specific patterns of injury, and to assess whether differences in the demographics, health status, and drug-use profile exist between female and male assault cases and whether these factors lead to a difference in outcome. METHODS: A cohort of 91 female assault cases was compared with a control group of 706 males with similar injuries resulting from blunt assault trauma. Information was gathered by retrospective review of 797 consecutive cases requiring admission for facial injuries resulting from blunt assault trauma. Fisher exact, chi 2, and t tests were used to assess statistically significant differences between the male and female cohorts. RESULTS: The female cohort comprised 12% of all cases admitted for blunt assault facial trauma. One third of female blunt assault facial trauma patients were subjects of domestic violence. Statistically significant differences were found between males and females for the type of assault (rape, domestic violence, altercation, etc) with P < .0001. Females were more likely to be admitted with soft tissue injury only but no fracture (P < .05), less likely to be assaulted with a weapon, and unlikely to be involved in an altercation, gang violence, arrest, or robbery. Females were also less likely than males to be injured while intoxicated (P < .05). Incidence of specific injury patterns and outcomes, however, were similar between the 2 groups. CONCLUSION: The present data support the hypothesis that the female blunt assault facial trauma population represents a distinct epidemiological entity, with significant differences in the circumstances of injury, mechanism of assault, and role of intoxication in the incidence of injury. The prevalence of facial trauma in female assault cases makes it critical for the facial plastic surgeon to be vigilant in the evaluation and treatment of these patients.

    Title Temporal Brow Lift Using Botulinum Toxin A.
    Date March 2000
    Journal Plastic and Reconstructive Surgery
    Excerpt

    The objective of this study was to determine whether brow elevation occurs as a result of paralysis of brow depressors after botulinum toxin A injection. The study's design was a prospective case series with pretreatment and posttreatment outcome evaluation with statistical analysis at a university-based division of facial plastic surgery private clinic. Twenty-two patients of a consecutive sample desiring a cosmetic enhancement underwent injection of botulinum toxin A directed to brow depressors. Injections consisted of 7 to 10 units of botulinum toxin A (Botox, Allergan, Irvine, Calif.) into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. No patients withdrew for adverse effects. All patients were evaluated 2 weeks after treatment. The outcomes were measured by change in brow elevation along vertical axis extending from both midpupil and lateral canthus to the caudal row of brow hairs with eyes at neutral gaze and the head at Frankfort plane. Preintervention and postintervention brow height was measured by the primary clinical investigator. The average brow elevation from the midpupil observed after selected injection of brow depressors with botulinum toxin A was 1.02 mm (p = 0.038). The average brow elevation from the lateral canthus observed after selected injection of brow depressors with botulinum toxin A was 4.83 mm (p<0.0001). Significant temporal brow elevation occurs as the result of paralysis of brow depressors by using botulinum toxin A injection. This procedure may be considered an alternative to surgical brow elevation.

    Title An Anatomical Approach to Glabellar Rhytids.
    Date January 1999
    Journal Archives of Otolaryngology--head & Neck Surgery
    Excerpt

    OBJECTIVE: To identify surface landmarks that can serve as reference points to the underlying musculature in the treatment of glabellar rhytids. METHODS: Fifty cadaver hemibrows were dissected to assess the location, disposition, and relationships of the brow muscles, along with their variations at each of several consistent locations. Particular attention was paid to the corrugator supercilii, frontal belly of the frontalis, and procerus muscles. CONCLUSIONS: The information gained here may be applied to the pharmacological or surgical treatment of glabellar rhytids. Knowledge of the frequent location of the muscles involved, relative to easily identifiable surface landmarks, allows a more precise approach.

    Title Correction of the Twisted Nose Deformity: a Surgical Algorithm Using the External Rhinoplasty Approach.
    Date September 1998
    Journal American Journal of Rhinology
    Excerpt

    Successful correction of the twisted nose is challenging due to the complex nature of the underlying anatomic deformity. Although the literature has in general supported endonasal rhinoplasty techniques for the twisted nose, we propose a surgical algorithm using the external rhinoplasty approach. The algorithm offer a stepwise, structured method that is adaptable to individual variations in anatomic deformity. The advantages and relative disadvantages of the external rhinoplasty approach are discussed, and a clinical experience of 30 patients is reviewed. Application of the external rhinoplasty algorithm in correction of the twisted nose can yield consistently satisfactory functional and aesthetic results.

    Title Implants in Rhinoplasty.
    Date July 1998
    Journal Facial Plastic Surgery : Fps
    Excerpt

    A variety of materials have been employed in rhinoplasty for augmentation and reconstruction. While autogenous tissue remains the mainstay of nasal implants and are the clear choice for structural and augmentation grafting of the nasal tip, limited availability and unpredictable resorption or remodeling have made homologous and synthetic implants important considerations for dorsal augmentation grafting. This section discusses categories of graft materials, their physical properties, harvesting and preparation technique, and advantages and disadvantages. An algorithm for nasal implants for specific indications in support and augmentation is presented.

    Title Evaluation of Expanded Polytetrafluoroethylene As a Soft-tissue Filling Substance: an Analysis of Design-related Implant Behavior Using the Porcine Skin Model.
    Date April 1998
    Journal Plastic and Reconstructive Surgery
    Excerpt

    Soft-tissue augmentation using the synthetic nonfluid biomaterial expanded polytetrafluoroethylene (ePTFE) has been supported by number of recent reports citing the favorable characteristics of biocompatibility, soft and natural feel, ease of use, and permanent augmentation. Concern has been expressed about this application for ePTFE material because of the proximity of the implants to the skin surface and potential problems with infection and extrusion. We evaluated the behavior of a series of specific ePTFE implant designs using a long-term subcutaneous augmentation model. By using a porcine model, 466 implants of ePTFE in the form of strips, rolls, or tubes were placed using a percutaneous insertion device subcutaneously over the dorsum and face. The animals were divided into three study groups by length of implantation (3 weeks, control; 6 months, intermediate term; and 12 months, long-term) and en-bloc tissue specimens, including skin, implants, and underlying soft tissue, were harvested for gross and histologic examination. Implants were removed at the earliest sign of infection, exposure, or extrusion and the difficulty of removal was ascertained and recorded. These data reveal that ePTFE material elicits acceptable levels of tissue activity with low extrusion rates over the short and long term supporting its use for soft-tissue augmentation. The data show a clear difference, however, in the host response and behavior of the implants for this application based on shape or design. A statistically significant difference in the low, but measurable, extrusion rates was observed amongst these implant designs. ePTFE tubes showed greater stability and predictable augmentation over other implant designs for soft-tissue augmentation and seem to represent a substantial improvement for this application.

    Title Complications of Injectable Synthetic Polymers in Facial Augmentation.
    Date November 1997
    Journal Dermatologic Surgery : Official Publication for American Society for Dermatologic Surgery [et Al.]
    Excerpt

    BACKGROUND: Injectable synthetic materials have been used for augmentation of soft tissue defects, correction of wrinkles, and augmentation of facial features such as the nasal dorsum. Success has been limited by inflammatory reactions, material migration, and the difficulty of removal should complications occur. OBJECTIVE: To evaluate complications resulting from soft tissue augmentation with injectable alloplastic materials. METHODS: Retrospective review of seven cases. Clinical history, treatment, histopathologic findings, and outcomes are assessed. RESULTS: Inflammatory reaction and tissue damage were refractory to antibiotics and steroids, and surgery was required to remove the foreign material. Histologic examination revealed giant cell foreign body reaction in all cases. CONCLUSION: Injectable synthetic polymers can produce significant complications including deformity and inflammatory tissue destruction, the control of which is complicated by the difficulty of removing the materials. Removable tissue fillers, such as e-PTFE, or natural materials such as collagen, autologous, fat, or Alloderm, should be considered instead.

    Title Refinement in the Rehabilitation of the Paralyzed Face Using Botulinum Toxin.
    Date October 1997
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    A number of surgical procedures exist to improve facial symmetry for patients with facial paralysis. Whereas static symmetry is often improved, dynamic asymmetry frequently persists because of the imbalance of complex coordinated movements of facial expression. The paralyzed face is often distorted by the excessive pull of the normal contralateral face during emotional expression. This study reports an expanded clinical indication for botulinum toxin in patients with unilateral facial paralysis. Ten patients with facial paralysis and markedly asymmetric smiles were treated with botulinum toxin A injections into the contralateral zygomaticus major, levators labii superioris and angulii oris, or risorius muscles. Eight of the 10 patients noted improvement in the symmetry of their smiles and underwent repeat injections. The onset and duration of effect averaged 5.9 days and 3 months, respectively. Botulinum toxin therapy provides a safe and efficacious modality for refining the appearance of the paralyzed face during mimetic activity.

    Title Epidemiology of Facial Injury in Blunt Assault. Determinants of Incidence and Outcome in 802 Patients.
    Date October 1997
    Journal Archives of Otolaryngology--head & Neck Surgery
    Excerpt

    BACKGROUND: Facial assault trauma has reached epidemic proportions. While the biomechanics of injury, methods of repair, and general demography of blunt facial trauma are well known, statistical associations between epidemiological factors, incidence, and outcome are poorly understood. OBJECTIVES: To provide a comprehensive epidemiological survey of this patient population. To assess factors determining outcome and pattern of injury. DESIGN: Retrospective review of 802 patients admitted with blunt assault facial trauma. Statistical analysis of associations between epidemiological factors, incidence, and outcome with chi 2 test, 2-tailed t test, and Fisher exact test. SETTING: Urban university and county hospital. RESULTS: Statistically significant associations are demonstrated between gender and the context of assault, incidence of armed assault, presence of fracture, and rate of intoxication at injury. Poor prognostic indicators for outcome include use of tobacco and presence of a mandible fracture. Open reduction and internal fixation were found to bear a higher complication rate only in mandible fractures. CONCLUSIONS: While choice of treatment carries a statistically significant association with outcome, social variables, including gender, tobacco use, intoxication, and low socioeconomic status, produce dramatic worsening of both injury incidence and outcome.

    Title Nasal Reconstruction Using a Combination of Alloplastic Materials and Autogenous Tissues: a Surgical Alternative.
    Date September 1997
    Journal The Laryngoscope
    Excerpt

    Re-creation of a functional and aesthetically acceptable nose after partial nasal defect requires accurate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near-total nasal defects combining both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue-expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near-total nasal defects.

    Title Biomechanical Effects of E-ptfe Implant Structure on Soft Tissue Implantation Stability: a Study in the Porcine Model.
    Date August 1997
    Journal The Laryngoscope
    Excerpt

    Successful implantation of biocompatible materials depends on physical aspects of its structure. Meshed implants are stable but cannot be easily removed. Nonporous materials are easily removed, but subject to extrusion. We hypothesized that the microporous structure of expanded polytetrafluoroethylene (e-PTFE) would permit limited fibrous ingrowth into the substance of the material, and that tubular implant shape would increase tissue integration while preserving ease of removal. A two-tailed in vivo study was done comparing implant retention, strength of fixation, and removability between tubular and solid-strip e-PTFE implants. Differences in implant retention within tissues were assessed by implanting 396 implants subcutaneously in five swine for observation periods ranging from 3 weeks to 12 months. Strength of implant attachment to host soft tissues was measured at 52 sites by extraction with a tensiometer with forces both parallel and perpendicular to the implant used. Implant porosity was assessed with scanning electron micrography of tubular and solid-strip e-PTFE implants. Measurements of the force and stress tolerances of the implant-tissue interface demonstrated significantly stronger attachment in tubular than strip-shaped implants (P < 0.005). The 11 N (2.75 lb) force sustained by the tubular implant exceeded the 3.4 N (<1 lb) force for the e-PTFE strip by a statistically significant margin on two-tailed Student's t-test (P < 0.005). Even greater forces were tolerated when applied at right angles to the axis of the tubular implant, emulating tissue suspension (21 N, 5.25 lb). The forces and stresses tolerated by both e-PTFE implants far exceeded the fracture stress measured for the implants. Implant extrusion rates were significantly smaller in tubular (0.85%) than in strip-shaped (4.4%) e-PTFE implants (P < 0.05). Standard error of the mean (SEM) demonstrated lesser porosity in tubular than strip implants, suggesting lesser direct tissue attachment. Tubular e-PTFE implant structure facilitates ingrowth of soft tissue through the tube's lumen. This increases the attachment to surrounding soft tissues, increasing fixation strength, decreasing extrusion rate, but still allowing easy removal. These properties may improve clinical applications in facial implantation.

    Title Eptfe (gore-tex) Facial Augmentation.
    Date June 1996
    Journal Plastic and Reconstructive Surgery
    Title The Human Immunodeficiency Virus and Facial Plastic Surgery.
    Date July 1995
    Journal Ear, Nose, & Throat Journal
    Excerpt

    The Human Immunodeficiency Virus (HIV) has imparted a number of concerns involving patient care and management as well as health care worker safety upon most surgical practices. Although these concerns are not often discussed in the context of facial plastic surgery (or particularly cosmetic surgery), they remain important issues. These issues are discussed with respect to public health policy, ethics and legality. The pathophysiological considerations for decision-making and care for HIV disease in the facial plastic surgery practice are addressed.

    Title Primary Surgical Management for Rehabilitation of the Paralyzed Eye.
    Date April 1994
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Protection of the eye is the primary concern in managing the patient with facial paralysis; however, the aesthetic consequences cannot be overlooked. Lagophthalmos has traditionally been treated with frequent ocular lubrication, medical eye care, and tarsorrhaphy. This approach is fraught with the difficulties of poor patient compliance and unacceptable cosmesis. We suggest a protocol for the complete ocular management with emphasis on immediate rather than delayed surgical rehabilitation as a primary therapy in facial paralysis. Gold weight implantation to the upper lid and tightening of the lower lid at the lateral canthus are simple and reliable procedures that provide immediate functional and aesthetic improvement. This surgical technique has extremely low morbidity and is reversible should facial function return. We have used this protocol in more than 30 patients with excellent results.

    Title Three-dimensional Video Imaging in Otolaryngology--head and Neck Surgery.
    Date November 1993
    Journal The Laryngoscope
    Title Expanded Polytetrafluoroethylene (gore-tex Soft-tissue Patch) in Facial Augmentation.
    Date September 1993
    Journal Archives of Otolaryngology--head & Neck Surgery
    Excerpt

    BACKGROUND: Expanded polytetrafluoroethylene (EPTFE) (Gore-Tex soft-tissue patch) has received favorable clinical reports for use in facial augmentation procedures. We evaluated the EPTFE soft-tissue patch in short-term (3-week), intermediate-term (6-month), and long-term (12-month) animal models. METHODS: Nine pathogen-free male and female New Zealand white rabbits weighing 2 to 4 kg were used. After implantation of the EPTFE soft-tissue patch, the animals were carefully observed on a daily basis for signs of wound infection, seroma, or hematoma formation. The stability of the implant was evaluated and graded after the animals were killed. Tissue specimens, including skin, implant, and underlying bone, were removed en bloc. These blocks were sectioned and stained for histologic evaluation. A portion of these blocks were used for scanning electron microscopy. RESULTS: The material increased in stability over time and showed minimal inflammatory cell response and only a delicate fibrous capsule, even in long-term implants. Ultrastructural analysis demonstrated close apposition of the material to tissue, suggesting good interface bioactivity. CONCLUSIONS: The EPTFE soft-tissue patch appears to be safe and reliable material for augmentation, demonstrating high biocompatibility, low tissue reactivity, and increasing stability over time.

    Title Comparison of Biomaterials for Facial Bone Augmentation.
    Date May 1990
    Journal Archives of Otolaryngology--head & Neck Surgery
    Excerpt

    We compared the gross behavior of and microscopic response to implant materials currently in clinical use for facial bone augmentation at different sites in dogs. Materials evaluated include porous polytetrafluoroethylene carbon (Proplast), large-pore high-density polyethylene (Medpor), solid medical-grade silicone rubber (Silastic), polyamide mesh (Supramid), and autogenous rib bone. The subjects were 12 mixed-breed dogs and the materials were implanted directly on bone with periosteum removed at one of three sites in the dog's face (malar eminence, nasal dorsum, and chin). Animals were killed 3 months after surgery and stability of the implants was graded by manual manipulation. Blocks of tissue, including the study materials and underlying bone, were examined microscopically after sectioning. Stability results are tabulated and histologic appearance is described by site for each material evaluated. These data demonstrate marked variability of stability and cellular response depending on the site of implantation. From these data one may conclude that the site of implantation and implant movement are essential factors in determining the nature of the tissue response and fate of an implant. Solid and porous alloplastic materials show an acceptable tissue response, but neither demonstrates the ability to consistently provide an implant that is stable on underlying bone.

    Title The Predictive Efficacy of the Müller Maneuver in Uvulopalatopharyngoplasty.
    Date August 1989
    Journal The Laryngoscope
    Excerpt

    Flexible pharyngoscopy with the Müller maneuver has been proposed as a method for selection of uvulopalatopharyngoplasty candidates. In this prospective study, its predictive efficacy has been evaluated in 24 consecutive obstructive sleep apnea patients undergoing uvulopalatopharyngoplasty. FPMM enabled us to accurately predict the uvulopalatopharyngoplasty outcome in 12 of the 24 patients (50%). Although flexible pharyngoscopy with the Müller maneuver appears to be helpful in the selection of candidates for UPP, its distinct predictive efficacy is low.

    Title Breast Cancer Within a Pectoralis Major Myocutaneous Flap.
    Date April 1989
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Title Determination of Shear Strength of Periosteum Attached to Bone with Bioglue Surgical Adhesive.
    Date
    Journal Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc. and the International Federation of Facial Plastic Surgery Societies
    Excerpt

    OBJECTIVE: To determine the shear strength of BioGlue Surgical Adhesive (Cryolife Inc, Kennesaw, Georgia) for use in periosteal fixation in endoscopic browplasty. METHODS: In a controlled design, the shear strength of periosteal attachment to native bone and that of dissected periosteum affixed to bone with BioGlue surgical adhesive was physiologically determined. Twenty-one periosteum and bone samples were harvested from 3 human cadavers. These samples were tested for maximum shear strength using an Instron Model 5500 universal materials testing machine. Native samples consisted of periosteum still attached to the bone surface, while BioGlue samples consisted of dissected periosteum reattached to the bone surface using BioGlue surgical adhesive. The maximum shear strength attained for each sample was recorded and used to determine if native samples differed from those using BioGlue surgical adhesive. RESULTS: The mean (SD) maximum shear strength values obtained during testing were 57.8 (31.7) kPa and 45.9 (27.4) kPa (589.4 [323.3] gram force [gf]/cm(2) and 468.0 [279.4] gf/cm(2)) for native (n=8) and BioGlue (n=9) samples, respectively. There was no statistical difference between the native and BioGlue samples (P> .05) using analysis of variance. CONCLUSION: This study demonstrates that the adhesive properties of BioGlue are similar to the strength of attachment of native periosteum to bone and supports the use of BioGlue as an alternative method of fixation for use in endoscopic brow-lifting.


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