So often when a patient goes to a plastic surgeon, he or she envisions a "new beauty" that is merely skin deep: a few less wrinkles, a more aesthetically pleasing nose, a tighter tummy. With the advances made in the art and science of plastic and reconstructive surgery over just the past few years, achieving these changes are certainly more possible than ever before to the skilled, experienced plastic and reconstructive surgeon. What I have always strived to give to my patients, however, is what we in Louisiana call "Lagniappe", that something extra. That something extra to me always means using my god-given talents and experiences to reconstruct not merely the flesh, but a rejuvenated inner spirit that comes with a more pleasing outer beauty. That goal is always appropriate, but perhaps never more so than at this time of year as we approach and make ready for the holiday season. It matters not whether one is Christian, Muslim, Hindu, Jewish ... we are all bound by the same spirit that leads us to seek peace, inner joy, accomplishment, generosity and concern for our brothers and sisters of many colors and many backgrounds, whether they live next door or on some faraway continent; in a mansion or a mud hut. Our kindnesses move outward like ripples on a pond to reach others as we attempt to build that theoretical matrix of one strong hand holding on to a weak hand, thus lifting up rather than tearing down. A more beautiful outer person is the first step toward a more beautiful inner person. When a person feels more confident about him or herself because of that outer beauty, it is then that they ripple out over the pond of the world to reach out to share that new found beauty and confidence with others. Bringing that to fruition has been the driving force in my life throughout my career. And so, as each of us runs about during these hectic days, preparing for the holiday season, the visits from family and friends, the joyous celebration, I would like to thank each of you, my patients and friends, for influencing my life by your faith in me. I wish each of you a joyous holiday season. - Dr. Hamid Massiha

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A program that works at the cellular level to give you the youthful, vibrant, healthy skin you've always wanted.
MegaPeel is the natural way to evenly and safely exfoliate your skin without extended periods of irritation and redness. Ideal for anyone who wants to improve skin appearance and reverse the aging process. From scarring and moderate wrinkles due to sun damage and acne, MegaPeel can make a beautiful difference to your skin.
Be clear for the holidays FDA approved, drug free acne treatment, no down time. Pain free.

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Your toughest wrinkles before after It took forty years to get them. And ten minutes to do something about them.

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DR. MASSIHA: "Some have called Botox miraculous."

Botox called "Miraculous"Botulinum toxin Botox'") has been hailed as nothing less than a "revolutionary" new treatment for the long-lasting elimination of facial wrinkles.

Recently approved for cosmetic application by the Food and Drug Administration, Botox has been used by ophthalmologists to treat nervous twitching of the eyelid since the early 1990's.

In its application as a facial cosmetic therapy, Botox has proven enormously successful in removing vertical "frown lines" between the eyes and horizontal "crow's feet" at the side of the eyes.

"Miraculous" "Some of my patients have called Botox miraculous'," Dr. Massiha says. "I can easily see how many of them feel that way. It's simple, quick and enormously effective. Results are immediate and usually last three to six months. Because Botox is used in extremely small amounts and because its effects are localized and do not spread to other parts of the body, the patient can come back for follow up therapy after that three to six month period."

And, Dr. Massiha says, unlike surgically invasive procedures that require a recuperative period patients who are administered Botox can return to full activity immediately.

"And," Dr. Massiha says, "Botox can be used by just about everybody except women who are pregnant or breastfeeding or anybody who has a neurologic disease."

Other applications of Botox In addition, research in Botox therapy is proving highly effective in treating other ailments in other parts of the body.

Scientific research has shown that approximately 80% of migraine and tension headaches sufferers have found relief from Botox injections. Similar relief has been found by patients suffering from back and neck pain.

Dr. Massiha explains: "Muscles in a natural state of relaxation produce no pain or deformity. This is true throughout the body. The brain controls the state of muscles causing them to tighten or relax. Often, where there is brain disease or injury, it cannot perform this function and there is involuntary muscle tightness which often causes pain. Botox injections have been shown highly effective as a therapy to involuntary muscle tightness.

"The same, of course, is true of the areas of the face where years of frowning and stress and the natural effects of aging form the common creases we see on cheeks, forehead and around he eyes. Over the years, these creases and valleys that we call wrinkles are formed by the frequent almost constant tightening of the muscles. Because Botox is a relaxant it does just that: relaxes the tightenened muscles that cause the wrinkles."

Dr. Massiha would be happy to discuss Botox therapy as a means of eliminating facial wrinkles. Simply give him a call to discuss your particular needs and desires.

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Breast surgery can offer more than you think

Often, breast surgery is thought of in only one dimension: enlargement. In fact, breast surgery in the 21st Century can mean so much more from correcting many abnormalities of the breast in women including breast reduction, breast reshaping and reconstruction following mastectomy or lumpectomy or dissatisfaction with earlier breast surgery. Dr. Massiha is a world renowned pioneer in the field of "small scar" breast surgery and has performed literally thousands of surgical breast procedures that have had enormous positive impacts on the lives of his patients. As always, the first step is a cost-free consultation with Dr. Massiha who will go over your individual needs and expectations and explain all facets of the surgery from risks (all surgery involves some risk, pre- and post-operative procedures, what you can expect, recuperative time, insurance coverage, available financing, and answers to all questions you may have.

DR. MASSIHA: "We've made great strides..."

Enormous strides "Over the years, the art and science of breast surgery has made great strides," Dr. Massiha says. "One of the things we've learned is that when a woman is dissatisfied with her breasts, whether that be size or shape, it can have an enormous negative physical and psychological impact on her life. I have had many women come to me saying she felt `less like a woman' because of a mastectomy or because a previous augmentation or reconstructive procedure by another surgeon fell far short of her expectations. Thankfully, because of my experience in this area I was able to help every one of them to regain what they once had."

A brief look at various procedures: Breast size enhancement: Many women choose to have their breasts enlarged in order to satisfy their desire for a fuller bustline. Their breasts may not have developed to a size that meets their expectations, or one breast may be noticeably smaller than the other. Often, after weight loss, childbirth or as a result of aging, the breasts lose volume and their shape changes. Breast augmentation can enhance breast size and shape, and give a woman the more proportional figure that she always wanted. Breast reconstruction can be the key to a new, fuller lifestyle. Dr. Massiha's reconstructive procedures have often produced results far beyond the normal expectations of his patients. In reconstruction, breast tissue lost during mastectomy or lumpectomy is replaced, thereby restoring the breast shape. The goal is to match as closely as possible the remaining natural breast by creating a breast size and shape with an implant which is placed beneath the skin and muscle that covers the chest or by using muscle from another part of the patient's body such as lower abdomen tissue to build new breasts. A combination of these techniques is used in some women. Not surprisingly, about half of all women who have undergone mastectomy or lumpectomy choose to have breast reconstruction surgery. Nipple reconstruction is also possible, generally as a separate operation once the reconstructed breast has settled into its final shape.

Breast reduction is designed for women with very large breasts they may have caused them medical or psychological problems.Women with very large breasts may experience a variety of medical problems. Common complaints are back and neck pain, breathing problems and irritation of the skin under the breasts. Breast reduction will provide a cure for some of these symptoms by reducing the size of large breasts. Women with very large breasts may also be extremely self conscious and reducing the size of the breasts will help them in this aspect. The procedure removes breast tissue, and skin from the breasts, making them smaller and firmer. Breast reduction is usually done as an inpatient procedure in a hospital. The surgery usually takes two to four hours. A hospital stay of two to three days is not unusual. Breast reduction surgery is usually performed under general anesthesia. Some women can return to a normal lifestyle in one to two weeks and others may take as long as two to three weeks depending on the nature of their job or responsibilities. Most of the patients are satisfied with the results of their surgery and most of them get rid of the symptoms associated with very large breasts. "With all the advances made in the field of breast surgery over just the past few years, there is hardly any need for any woman to suffer physically or psychologically any longer," Dr. Massiha says.

To set an appointment for a consultation about a breast surgical procedure, call Dr. Massiha's office at 455-9441.

Vitamins play important role in surgery

Facing surgery and wondering what you should do to prepare for it? One of the best preparations anybody who is facing surgery can make is the "Surgery Vitamin Supplement Program" offered by the Massiha Plastic Surgery & Skin Care Center.

But then, there is Vitamin A, Vitamin B-complex, Vitamin C, Niacin, Iron, synthetic vitamins, all natural vitamins ... Matching the right vitamin with the need along with dosage, brand names, cost ... What is a chelated mineral, anyway?

It can all be terribly confusing. And, let's face it, you're a busy person. You may know the important role vitamins play in a healthy life, but you just don't have time to inch you way through the maddening maze of options that are out there.

Well, you can stop pulling out your hair as you try to assess your own unique vitamin needs as you face surgery.

Massiha Plastic Surgery & Skin Care Center offers a complete line of VitaMedica vitamins and minerals to meet your needs.

Vitamins are vital "Often we don't connect vitamins and surgery" Dr. Massiha says. "We may think we have the surgery and then just let our bodies recuperate. But vitamin supplements prior to surgery play a vital role in just how our bodies recuperate. But a supplement such as Arnica Montana is designed to reduce discomfort, bruising and swelling following surgery. Bromelain with Quercetin is a supplement that has excellent anti-inflammatory properties. Vitamins A and C are very strong antioxidants that must be present for healing and proper immune system function and infection control.

"There are other considerations prior to any surgery such as alcohol consumption and smoking," Dr. Massiha says. "Overall health and intake of certain over the counter medications such as aspirin that is an anti-coagulant (blood thinner and can promote bleeding during surgery, must be considered. So must things such as drinking the proper amount of water and even proper relaxation techniques and support of family and friends. All of these things may seem unconnected to surgery or minor, but in fact, they all play a part in the success of the procedure and the length of recuperative time. We don't just schedule surgery then perform that surgery. We look at everything that can or will insure success and fast, proper healing."

Dr. Massiha works in conjunction with the highly successful VitaMedica Surgery Program and will be happy to discuss every phase - before, during and after - of your surgical procedure.

Someone once asked me, if I were proud of the work I did.

Naturally, I said that indeed I was. But the more I thought about it, the more I realized there was one word more appropriate to describe how I feel about the work I do: humbled. I am deeply humbled in knowing that I have been blessed with the honor of assisting God in his work of helping to create not just outer beauty, but the inner peace, joy and confidence that one of my procedures may bring to a patient. I remember the words of our late President, John F. Kennedy at his 1961 inaugural address urging us to go forth with our life’s work but: “…knowing that here on earth, God’s work must truly be our own…” and I have thought of how apt those words are for all of our undertakings. Recently I was blessed with the birth of a daughter – Maia Massiha. In addition, I was promoted to the position of clinical professor of plastic surgery at the LSU School of Medicine. Proud? Certainly. Any new father and professional would be. But again, I am humbled in the thought of being given the responsibility of nurturing new life in this world and of being thought of so highly by my colleagues. I have come to truly believe that humbleness expands our humanity. It opens an entire universe to us, one that brings us into total contact with those people we serve. I have found this to be true in the relationships I have with my patients. I find myself looking at an abdominoplasty or facelift or breast augmentation and seeing not just a patient with a cosmetic problem but a person of seeking a new level of confidence and joy in their inner beings. When I realize this patient has placed his or her complete trust in me, I am deeply humbled. And as such, I find myself no longer on only a physical or artistic level. I truly find myself at one with my patient, knowing their innermost desires as intimately as they do and giving them my best effort to help them fulfill those desires. To all of you who have humbled me by the trust you place in me, I say, ‘Thank you.’

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Blue Peel We are all ‘blue’ now and then. It’s part of the human condition. But did you know there’s a ‘blue’ that can change your life for the better? That blue is the revolutionary new Blue Peel skin treatment from Obagi that can give you healthier skin for a lifetime. The Obagi Blue Peel goes far beyond conventional alpha-hydroxy peels and other superficial procedures because it is a treatment ‘tailor-made’ for your own particular skin needs. The Blue Peel is simple, quick (about 20 minutes), in most cases, does not require sedation and can give a healthier, more attractive look to neck, chest, hands, back, arms and legs. What exactly is Obagi Blue Peel? The Obagi Blue Peel is an in-office procedure designed to significantly improve the appearance and health of your skin. It uses a low concentration of the chemical trichloroacetic acid (TCA) mixed with a special blue base or slow penetration. The Blue Peel allows Allison Muniz, the aesthetician of Massiha Plastic Surgery and Skin Care to monitor the appropriate depth to effectively remove the thin surface layers of aged and damaged skin from the face or other parts of the body. These dead skin cells are replaced by healthier ones, allowing the skin’s own clarity and tightness to resurface into a new and vitally appearance. Will I feel pain? The patient will usually experience a mild burning, tingling sensation that lasts only a minute or two (Allison can use a small fan to minimize the sensation). Following the procedure, a bluish tint will remain you’re the skin which will wash off within 12- to 24 hours. The skin will then swell slightly and will begin to peel within two to three days. This peeling will continue and should be completely healed in an average of seven to 10 days. What results can I expect? When the skin has completely finished peeling, the result will show through dramatically as you look into the mirror and see a beautifully improved complexion and the look of vitality you never knew possible. The skin will continue to improve over the next month to six weeks and your confidence and joy will grow, as your skin becomes firmer, clearer, smoother, healthier and more youthful looking. More than one? Allison will thoroughly discuss with you the number of Blue Peels that are necessary to achieve the desired results. In most cases, one to three Blue Peels can achieve dramatic improvements in most skin problems. Blue Peels can be performed in six to eight week intervals until those desired results are realized. Will the results last? That new healthy glow and youthful appearance of your skin is an ongoing process. The Obagi Nu-Derm restoration system is an at-home program designed to promote long-term overall skin health and works in perfect conjunction with the Blue Peel.

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Laser resurfacing Laser resurfacing can best be defined as a “renewal” of your face to the days before those fine wrinkles at the corner of your eyes, vertical lines around your mouth, acne scars, sun damage streaks on your cheeks, unattractive pigmentation that sometimes comes with age and even facial scars caused by injury or accident. The results of laser resurfacing are a smoother, more evenly toned complexion and are being enjoyed by men and women of all ages. Each year, thousands of men and women undergo laser resurfacing with greatly satisfying results and no major complications. However, prior to the procedure, you will meet in consultation with Dr. Massiha to discuss your medical history, specific cosmetic goals and pertinent information such as previous surgical procedures such as dermabrasion or facial peels, medications you are presently taking or have taken in the past, allergies, facial injuries and any other factors which may have a bearing on your laser resurfacing. How is laser resurfacing performed? Quite simply, a precision-directed beam of laser energy is used to vaporize the upper layers of damaged skin. As new cells form during the healing process, a smoother, tighter looking skin surface appears. The laser is carefully passed back and forth over the skin until Dr. Massiha reaches the safest level that will make the imperfection disappear or become less visible. If imperfections are deeply seated, Dr. Massiha may recommend that the procedure be formed in two or more stages. How long will the recovery period last? Dr. Massiha may cover the resurfaced area with a bandage which will be changed one or more times during the first seven days or he may have you cover your face with a protective ointment and give you additional ointment for home use to use for about a week during the healing process. During the first three weeks, your skin will be bright pink or red, as healing proceeds and new, healthy layers of collagen replace the heretofore-damaged area. During this healing period, you may wish to return to work and after about two weeks, you may safely apply makeup. After a month, the redness will begin to fade and you will begin to notice the visible improvement you seek. With each passing week, the pink tint of your skin will gradually diminish, but some pink tint may be slightly visible for three to four months. The results? The vast majority of patients are completely satisfied…even thrilled with the significant improvement in the tone and texture of their skin. And to show that beauty is not only “skin deep”, many say that their new look makes them feel more confident in work and social settings.

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Breast Augmentation As with many procedures in plastic surgery, the desire for and goal of breast augmentation is more than cosmetic beauty. Often, the feeling that their breasts are too small bothers women. Perhaps, weight loss, the birth of a child, genetic underenlargement and even age have left breasts smaller or less firm than they once were. Occasionally, a woman may have one breast smaller or of a different shape than the other. Whatever the case may be, the usual…and best motivation for breast augmentation surgery is simply wanting to feel better about oneself. Breast augmentation surgery (also called augmentation mammaplasty) can usually bring the desired results that leave a woman not only more physically attractive, but also more confident and self assured about herself. What is the first step? Consultation with Dr. Massiha is always the first step for any woman considering breast augmentation surgery. During the consultation, you will be asked about past and present medical conditions, medications (including nutritional supplements) and the results of past breast examinations and the history of breast cancer in your family. Also, your breasts will be examined and possibly photographed for your medical records. At this time, Dr. Massiha will consider the size and shape of your breasts and which procedure or procedures will bring the best results. In addition, Dr. Massiha will discuss with you preparations for your surgery. How is that procedure performed? The technique used for your surgery depends not only on Dr. Massiha’s preferences, but also on your desired results. The incision is small and usually made in one of three locations: under the breast, just at the crease; around the nipples (areolas) or within the armpit. Once the incision is made, Dr. Massiha creates a pocket into which the implant is inserted. This pocket is made either directly behind the breast tissue or beneath the pectoral muscle located below the breast tissue and above the chest wall. Is breast augmentation safe? Each year, thousands of women undergo breast augmentation surgery and have no major complications. However, as with all surgery, you must understand there are risks as well as the benefits. The risks are usually minimal and will be discussed with your during your initial visit. After surgery? Within a day or two after surgery, you should be up and around. Most of the discomfort you will feel can be controlled with medication prescribed by Dr. Massiha. A gradual healing process will have begun. The day following surgery, you will be permitted to shower. Since dissolving sutures are used under your skin, there will be no need to remove them. You may feel able to return to nonstrenuous work and resume gentle sexual relations within days. Also within a short time period of time, most of the swelling will have subsided, you may discontinue wearing your support bra and you will begin to see the final results. What will those final results be? Like most women, you will be very pleased with the final results. You will no longer need padded bras or other bust-enhancing undergarments and your new figure will open a world of new fashion to you. Most importantly, your self-confidence will soar. Also, Dr. Massiha may request that you return for period checkups in order that he may assess your long-term results and address any questions you may have. So there you have it. Breast augmentation is a procedure being sought by more and more women each day to build not only shapelier figures, but also heightened self confidence and deep inner joy. If you are considering breast augmentation, please feel free to call. Dr. Massiha will be happy to answer any questions you may have.

DR. MASSIHA: “Breast augmentation surgery (also called augmentation mammaplasty) can usually bring the desired results that leave a woman not only more physically attractive, but also more confident and self assured about herself.”

Massiha Plastic Surgery & Skin Care Center What better gift to give than a gift certificate for care for the skin? A gift certificate to pamper the skin is a tribute of love to that special person. Listed below are a few of the skin care techniques designed for long lasting beauty.

• Lunchtime MegaPeel with Vitamin C Treatment
• Deep Cleansing Facials
• Deep Cleansing Back Treatment
• Vitamin C/Glycolic/Lactic Acid Peel (Package of six)
• Obagi Blue Peel
• Skin Care Products
• Obagi Nu-Derm Skin Fitness System
• Theraderm Skin Care Products

For an appointment or information on Skin Care Gift Certificates, call 455-9441

Botox called "Miraculous"

nothing less than a revolutionary" new treat ment for the long-lasting elimination of facial wrinkle.

Recetly approved for cosmetic application by the Food and Drug Administration, Botox has bee used by ophthalmologists to treat nervous twitching of the eyelid since the early I990's,

In its application as a facial cosmetic therapy, Botox as proven enormously successful in removin vertical "frown lines" between the eyes an horizontal "crow's feet" at the side of the eyes.

"Miraculous"

"Some of my patients have called Botox 'miraculous’," Dr. Massiha says. "I can easily see how ill ny of them feel that way. It's simple, quick a d enormously effective. Results are immediate and usually last three to six months. Because Botox is used in extremely small amount and because its effects are localized and do not spread to other parts of the body. the patient can come back for follow up therapy after that three to six month period."

And, Dr. Massiha says, unlike surgically invasive procedures that require a recuperative period patients who are administered Botox can return t full activity immediately.

"And," Dr. Massiha says, "Botox can be used by just bout everybody except women who are pregnant or breastfeeding or anybody who has a neurologic disease."

Other applications of Botox In addition, research in Botox therapy is proving highly effective in treating other ailments in other parts of the body. Scientific research has shown that approximately 80% of migraine and tension headaches sufferers have found relief from Botox injections. Similar relief has been found by patients suffering from back and neck pain.

Dr. Massiha explains: "Muscles in a natural state of relaxation produce no pain or deformity. This is true throughout the body. The brain controls the state of muscles causing them to tighten or relax. Often, where there is brain disease or injury, it cannot perform this function and there is involuntary muscle tightness which often causes pain. Botox injections have been shown highly effective as a therapy to involuntary muscle tightness.

"The same, of course, is true of the areas of the face where years of frowning and stress and the natural effects of aging form the common creases we see on cheeks, forehead and around the eyes. Over the years, these creases and valleys that we call wrinkles are Formed by the frequency almost constant tightening of the muscles. Because Botox is a relaxant it does just that: relaxes the tightened muscles that cause the wrinkles."

Dr. Massiha would be happy to discuss Botox therapy as a means of eliminating facial wrinkles. Simply give him a call to discuss your particular needs and desires.

Beast surgery can offer more than you think

Often, breast surgery is thought of in, only one dimension: enlargement. In fact, breast surgery in the 21st Century can mean so much more from correcting many abnormalities of the breast in women including breast reduction, breast reshaping and reconstruction following mastectomy or lumpectomy or dissatisfaction with earlier breast surgery. Dr. Massiha is a world renowned pioneer in the field of "small scar" breast surgery and has performed literally thousands of surgical breast procedures that have had enormous positive impacts on the lives of his patients. As always, the first step is a cost-fee consultation with Dr. Massiha who will go over your individual needs and expectations and explain all facets of the surgery from risks (all surgery involves some risk), pre- and post-operative procedures, what you can expect, recuperative time, insurance coverage, available financing, and answers to all questions you may have.

There is an old saying that beauty is "skin deep". That's not the case at all. When one experiences beauty, particularly the beauty of oneself that joy permeates not only throughout the person's body, but deeply into that person's psyche and in his or her very own philosophy of life. I am fortunate in that I am able to spread that joy of beauty. In fact, it is why I chose the profession I did.

To see a patient come into my office, shy and retiring because of a facial imperfection, and leave glowing in happiness and confidence once that imperfection has been corrected. . . well, there are no words strong enough to express the reward I feel.

Over the many years of my practice of plastic surgery, I have seen countless men, women and children return, sometimes years later, to tell me how making a decision to correct a facial or bodily imperfection through plastic surgery has changed their lives. Again, no words can truly describe the awesome sense of fulfillment that permeates me.

That fulfillment brings joy not only to me, but to every person in our office. I've seen tears of joy fill eyes after such a visit from a former patient.

“I'm able to spread that joy of beauty”. Dr. Hamid Massiha

Whether that needed procedure is a lunchtime MegaPeel, breast augmentation, liposuction or any of the many other procedures we perform, the entire staff is dedicated to your comfort, confidence and to the lasting joy you or your loved one will experience.

Nothing means more to a plastic surgeon than a happy patient. I experience that happiness in the many letters and phone calls I receive from patients expressing their gratitude and happiness.

I send to each of you my special thanks for placing your trust in me. I also assure you again of my firm commitment to assist you.

The Truth about Lunchtime Peels

The lunchtime peel is the newest treatment in skin care today. Microdermabrasion is another term for this procedure. There are many different manufacturers of this machine, and they each have their own terminology: Dermapeel, MegaPeel, Power Peel, Crystal Peel, Diamond Peel, SmartPeel, Precision Peel, S. T: Peel Rejuvasilk, etc. These are all microdermabrasion machines. Most companies have esthetician models and physician models. The physician model, which is more aggressive, is only sold to physician's offices. I have not found two machines just alike. I demonstrated many of them prior to purchasing the MegaPeel Platinum series.

Microdermabrasion is one way to evenly exfoliate your skin. It is a procedure that lightly sands your skin with vacuum pressure. The sand and the vacuum are controlled and can be increased and decreased depending on the correction you are looking to achieve. This can be used to help stimulate your collagen, which helps with fine lines. It can help with discoloration ( uneven skin tones ), pigmentation problems ( dark spots ), blackheads, scarring, dull lifeless and sun damaged skin. This is not a painful procedure. You may experience some discomfort ( mild scratching sensations ). Once the procedure is complete there is no discomfort. Your skin will feel clean and tingly.

Women are always looking for ways to improve their skin without taking time from their busy schedule. This treatment is perfect for women who don't have the time to take off and need to go right back to work. The treatment takes approximately 30 minutes. You can apply your makeup right away and go back to work. It takes six to nine treatments. They can be done once a week or every other week depending on your skin type and what you are trying to correct.

Most microdermabrasion machines use aluminum oxide crystals only. However, pregnant women or nursing mothers cannot use these crystals. Our machine offers not only the aluminum oxide crystals, but sodium bicarbonate (baking soda) crystals.

At Massiha Skin Care Center we offer a Vitamin C treatment after a microdermabrasion procedure at no additional charge. A consultation with our licensed Aesthetician/ Plastic Surgery Skin Care Specialist is complimentary. As always you should be using good corrective skin care products in conjunction with your microdermabrasion treatments. Remember good skin care starts at home.

Hair Removal

Afraid of wearing the clothes you desire because of unsightly patches of dark, coarse hair that appears on your face, neck, abdomen, breasts, arms or underarms?

Fear no more.

Dr. Hamid Massiha, one of the worlds most renowned plastic surgeons has the answer to your problem: the revolutionary lightSheer Diode laser, the state-of-the-art system of hair removal.

In the past, remedies for unwanted and unattractive hair were painful plucking, repeated shaving, time-consuming waxing or chemical depilatories. After all of these methods, hair began growing back immediately.

Many seeking longer term hair removal relied on electrolysis. While effective and popular, electrolysis is often uncomfortable and slow.

Then came the lightSheer Diode laser method of hair removal.

"The results are phenomenal:' says the laser technician for the Massiha Plastic Surgery Center. It has opened up so many avenues, that nobody has to live with splotches of hair that is unattractive. In the past, dark skinned or tanned people, and African Americans were not good candidates for laser hair removal.

That is no longer the case. The results are excellent across the board. The painless process may last a few minutes to an hour or more, depending on the size of the area being treated.

It is very simple. The laser produces a beam of highly concentrated light. The color of the light produced by a particular laser is one of the keys to its effect on hair follicles. And during the procedure, the upper layer of skin is cooled before during and after each pulse of light while it directs the laser energy to the hair root.

Prior to the procedure, ethyl chloride is administered topically which further diminishes any discomfort which may be felt. Additional treatments are advised every 2-3 months with a maximum of 3-6 treatments.

Is the revolutionary hair removal treatment for women only? No, not all all. In fact, we have as many men as women seeking hair removal from various parts of the body. The results have been equally success flu. Anyone seeking hair removal is invited to call for consultation at no cost.

Liposuction

Liposuction is a procedure to remove stubborn pockets of fat in the body. Like all plastic surgery procedures, liposuction is constantly evolving and being improved upon with one goal in mind: A healthier, more attractive you. Traditional liposuction, successfully employed on hundreds of thousands of patients worldwide, now has an assist: "Ultrasound-assisted lipoplasty", commonly known as "UAL".

UAL, first employed in the early 1990s is no substitute for traditional liposuction, but has proved to be an effective tool for removing pockets of fat from fibrous body areas, such as the male breasts or back or for removing larger volumes of fat in a single procedure.

Ultimately, the patient and the physician will determine whether UAL or traditional liposuction is best suited.

"I have used both procedures with highly successful results," says Dr. Hamid Massiha.

"UAL allows us to expand those areas of fat removal from the body where perhaps we could not go before."

The best candidates for both traditional liposuction and UAL, Dr. Massiha says, have the same criteria: men and women of normal weight with firm, elastic skin who have pockets of excess fat in particular areas of their bodies.

Candidates for either procedure should be physically healthy, psychologically stable and have realistic expectations.

“Liposuction procedures are constantly evolving and being improved upon...”. Dr. Hamid Massiha

Dr. Massiha is quick to point out that while age is not generally a criterion for liposuction, elderly patients may have diminished skin elasticity and may not achieve the same results as a younger patient".

Dr. Massiha will be happy to discuss traditional liposuction and UAL and whether you are a candidate for either procedure.

A guideline for liposuction. Who is a candidate?

• If you have excess subcutaneous fat, which is resistant to diet and exercise.
• If you wish to change the contours of your body. Commonly involved areas are the anterior part of the neck ( under the chin ), upper arms and armpits, male chest/breasts, trunk, abdomen, waist, hips, thighs, inner knees, calves and ankles.
• Most patients are near normal weight and ease permanent contour changes.
• Improved techniques such as Ultrasound Assisted Liposuction, allow larger amounts of fat removal. Liposuction can be useful to heavier persons as well.
• A permanent improvement in the contour and proportion of the treated areas.
• A more flattering figure or physique, in or out of clothing.
• The procedures as done on an outpatient basis.
• General anesthesia is usually used for safety and comfort.
• Small suction tubes are insert through very short incisions placed in inconspicuous locations near the fat deposits, and excess fat is removed.
• With the tumescent technique used today, blood loss in the operating room is minimal making the operation much safer than before.
• The patient goes home with a compression garment covering the treated areas.
• Compression is advised for about 2-3 months as it helps reduce swelling and helps you achieve the final result more quickly.
• Swelling usually subside in two to four weeks. The final results take shape over 2-3 months as the skin naturally shrinks.

Massiha Plastic Surgery & Skin Care Center

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Reconstruction of the Submammary Crease for Correction of Postoperative Deformities in Aesthetic and Reconstructive Breast Surgery

Hamid Massiha, MD, FACS

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This article discusses a method of reconstruction of breast crease for correction of postoperative deformities. These deformities are usually the result of implant insertion for the purpose of breast enlargement or reconstruction. The operation is performed by creating a new crease in the appropriate site by suturing capsular and soft tissue structures from the anterior to the posterior wall of the pocket to eliminate excess space at the lower, medial, or lateral breast. This article will detail crease reconstruction through an internal approach. Patient selection, technique, and results are discussed.

Massiha H. Reconstruction of the submammary crease for correction of postoperative deformities in aesthetic and reconstructive breast surgery. Ann Plast Surg 2001;46:275-278

From the Louisiana State University Medical Center, New Orleans, LA.

Received Sep 19, 2000, and in revised form Oct 11, 2000 Accepted for publication Oct 11, 2000.

Address correspondence to Dr Massiha, 3939 Houma Boulevard, Suite 216, Metairie, LA 70006

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The submammary crease is a very important landmark with regard to aesthetics of the female breast. In asymmetry of the breast after augmentation mammaplasty, it may be necessary to reconstruct a new crease to correct asymmetry and any resulting deformity. Also, in reconstructive breast surgery, having a reliable means of reconstructing a crease anywhere that is appropriate would be a great asset in the surgeon's armamentarium . For example, an expander can be used to expand tissues of the lower chest somewhat below the ideal submammary crease. At the time of placement of a permanent implant, the submammary crease can be reconstructed in the desired location.

Technically, the desired site, of the crease is marked preoperatively with the, patient in a sitting position (Figs 1A, B).

Fig 1. (A) Preoperative marking in a patient with a palpable implant that is located too medially, (B) Markings of the area of capsular contracture and adhesion to be opened. Notice the double-bubble deformity medially and inferiorly as well. (C) Preoperative view of the left breast deformity with medial displacement and lateral contracture. ID) Postoperative view with correction of the deformity. (The patient did not desire to undergo right crease elevation.)

During surgery, after removal of the implant or the expander, the crease is created by suturing the anterior capsular tissue to the posterior part of the capsule at the Hamid Massiha, MD, FACS anterior chest wall. Nonabsorbable sutures are used after implant insertion. The patient then is placed in a semisitting position. If correction is not adequate, sutures are placed in a more proper location. I have used this technique in the last 20 years with good, long-lasting results. The submammary crease, and its continuation laterally and medially, is the most important determining factor in beauty and contour of the female breast. Irregularities in this area of anatomy are detected easily by simple observation. Asymmetry after breast augmentation is frequent (Fig 1C), not only in the submammary crease, but frequently at the lateral boundaries of the mammary pocket and less frequently at the medial aspect. At times we have seen cases that have transgressed the mid-line, creating a severe deformity. In any and all of these kinds of deformities, this method of correction works well (Fig 1D). Patients and Methods The patient is marked carefully in a sitting position (see Figs 1A, B). The patient is then anesthetized (I use general anesthesia in my practice), and proper prepping and draping are completed. Entry is made into the breast capsule area using previous incisions. The implant is removed and the capsule is evaluated. The capsule is then incised and the pocket is expanded. The capsule is then deeply sutured to the chest wall at the appropriate site, preferably with 2-0 Prolene sutures. As much subscapular soft tissue is incorporated as possible. Incising the capsule along the line of repair may be helpful. Suture placement is guided by preoperative markings. Although interrupted sutures can be used, I find running sutures easier to place and fully functional After completion of the repair, the old implant is introducedto the newly formed pocket, If the shape is satisfactory and the new crease is in a desirable location, the old implant is replaced with a new one, and the wound is closed (Figs 2-4).

Fig 2. (A) Lateral view showing the lower breast with a low submammary crease. (B) Desired correction. (C) The correction is made by lifting the submammary crease and decreasing the distance from the nipple to the crease.

Fig 3. (A-C) The sutures at the top of the new crease are all internal

Fig 4. (A, B) Shown is how the capsule and surrounding soft tissue at the lower parts of the pocket are sutured to the chest wall. The capsule is incised superficially to create a better healing surface before suturing.

Whether the implant is too high [Fig 5A] or otherwise improperly situated, the capsule may be revised into a more satisfactory shape with this technique. In the case of an implant being too high, simply dissecting the inframammary crease area is not enough. Because the skin is usually tight in the inferior chest wall area, it does not have enough laxity to accept and maintain a filled implant. An excessively large pocket at the inframammary crease (or lateral or medial crease, as needed) must be created, and the expander placed there (see Fig 5B). After a few weeks and after the expander is expanded adequately, the patient is taken to the operating room, the expander is removed, a new submammary or lateral crease is created, and a permanent implant is placed (see Fig 5C).

Fig 5. (A) Preoperative view of the deformity after multiple attempts at breast reconstruction on the right side. (B) The same patient after removal of her implant and expansion to an extremely low level. (C) Postoperative view with the new crease and lower breast, with enough skin pulled up for the breast to stay relaxed and full.

Fig 6. (A) A patient after multiple unsuccessful attempts at breast reconstruction. (B) Crease reconstruction.

Resultshave used this technique in a diverse group of deformities in 200 cases ranging from postaugmentation deformities to severe deformities (Fig 6A) resulting from breast reconstruction with implants. This is an effective and reliable method. In the past 20 years that I have used it, no failures have been observed. With careful attention to detail, this simple method is suitable for all sorts of breast deformities that result from capsular malformations (see Figs 5 and 6). Discussion This paper expands on a previous article on postimplantation breast deformity. In the correction of certain kinds of postaugmentation double-bubble deformities, reconstruction of a new submammary crease is essential. In addition, this technique has proved to be very simple and useful in correcting a variety of deformities that result from the breast reconstruction and augmentation. Whether these deformities are the result of the patient's own soft-tissue defect is uncertain, though it is readily observed that some people have more elastic skin than others, even in youth. Regardless, this technique is effective in ameliorating the problem. During the correction of these deformities, careful marking is essential. After the crease is reconstructed it will not "give" in terms of stretch nor will it self-correct. Thus, no overcorrection is needed and should be avoided. This method is also needed in some cases of mastopexy in breasts with previously inserted implants. In these patients, if the capsule is not modified from the inside, mastopexy alone will not render excellent results. For example, if the implant is already too medial, mastopexy alone is not capable of bringing the implant to a more normal central location. I prefer sub mammary and periareolar incisions. Although the operation may be performed through a 5 to 6-cm submammary incision, exposure through a periareolar incision is superior , especially for medial and lateral suturing. In patients in whom the implant is too high, conventional opening of inferolateral space is prone to failure or overcorrection. The current technique opens up a larger space and creates a new crease in the desired location. Also, if needed, inframammary skin from the area can be mobilized to increase the nipple-to-crease distance. In severe high-implant deformities after breast reconstruction, use of an expander is necessary, especially in the inframammary area. The new crease is reconstructed at the second stage at the time of implant replacement. Adding inframammary skin to the lower portion of the breast improves roundness at the same time. Sometimes sutures placed into the capsular tissue may cause dimpling. However, in the inframammary area, they are rarely visible and usually improve with time. It is possible that incising the capsule at the proposed suture site may enhance breast configuration, although this has been difficult to confirm. Conclusion This technique of reconstructing submammary and perimammary creases for correction of deformities after breast augmentation and reconstruction is a very simple and useful. No additional external incisions are needed. Results are permanent, although further stretching of the breast tissue will continue as years go by. This technique has worked well in my hands. It is easy to do and it is easy to teach.

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Presented at the Southeastern Society of Plastic and Reconstructive Surgeons. Bermuda, June 4-8, 2000.

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Reference 1 Massiha H. Augmentation in ptotic and densely glandular breast: prevention, treatment, and classification of double- bubble deformity. Ann Plast Surg 2000;44(2):143-146 Open Discussion Felmont F. Eaves, MD (Charlotte, NC): Concerning inframammary fold control, some of the newer suture materials will give tensile strength . for up to a year and a half. Do you think there is any advantage in a patient like this in fixing the fold? And how long do you think you actually have to be able to control that level postoperatively? Is permanent suture material really part of that? Dr Massiha: I have not seen one of these from the inside after surgery. But from my experience on redo facelifts, when I identify the 3-0 Prolene sutures I have previously placed into the SMAS and remove them, nothing falls back. Applying that knowledge to this situation, I would imagine that something that lasts 6 months or more would be enough. Also, please be certain that the knots don't face toward the implant or they may erode the implant. Be certain they are buried.

Superior Positioning of the Ptotic Umbilicus in Abdominoplasties and TRAM Flaps Hamid Massiha, MD, FACS

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The author finds that higher positioning of the umbilicus in cases of abdominoplasty and other similar operations such as transverse rectus abdominis musculocutaneous flap breast reconstruction is a useful technique. The operation renders better aesthetic results and also increases the margin of safety in lower abdominal flap circulation because tension is transferred from the lower abdomen to the upper abdomen. Technically, the procedure is easy to do and teach. The umbilicus is fixed to a higher point in the abdominal wall and the new umbilicus is reconstructed in a reasonably higher position with a safe degree of tension at the upper abdominal flap while trying to decrease tension in the lower part of the abdominal flap.

Massiha H. Superior positioning of the ptotic umbilicus in abdominoplasties and TRAM flaps. Ann Plast Surg 2002;48:508-510

From the Department of Surgery, Louisiana State University School of Medicine, Metairie, LA.

Received Oct. 2, 2001. Accepted for publication Oct. 8, 2001.

Address correspondence and reprint requests to Dr Massiha, Department of Surgery, Louisiana State University School of Medicine, 3939 Houma Boulevard, Suite 216, Metairie, LA 70006.

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During the past several years, I have used a higher position for the umbilicus in cases of abdominoplasty and transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction of the breast. This approach has multiple advantages: First, there is a transfer of tension from the lower abdominal distant part of the flap to the well-supplied upper part of the abdominal flap. Second, the reconstructed umbilicus is not too close to the incisions, which, in addition to compromising distal flap circulation, is highly unsightly and looks misplaced anatomically. And third, the high position of the umbilicus is a sign of a youthful abdomen. The higher location is an aesthetic advantage. In the case of true ptosis of the umbilicus, it is necessary to recreate the normal position.

Studying flap necrosis in cases of abdominoplasty and/or abdominal closure in TRAM flap reconstruction often shows a triangular area starting at or below the umbilicus with the base at the lower abdominal incision. Furthermore, these cases are usually the ones in which the umbilicus is too close to the incision line in the lower abdomen. In some cases, although the lower abdomen looked well, the upper abdomen seemed to have too much fat and, at times, even too much skin

I have also observed that in most abdomens with large amounts of fat, the umbilicus is ptotic, with a long stalk pulled down by gravity. In the youthful, muscular abdomen, the umbilicus appears to be much higher than in the obese abdomen.

To encourage the idea of placing the umbilicus in a higher position, I published my previous experience with the umbilicus with hidden scars.' In this procedure I suggest moving the scar around the umbilicus posteriorly to the level close to the linea alba, with a natural-looking umbilicus. In some cases with an umbilicus with a long stalk, even after most of the excess stalk was excised, the remaining umbilicus bulged out anteriorly and looked unsightly. A simple solution to the problem is to move the umbilicus slightly upward, which produces better results (Fig 1).

Anatomy

The umbilicus is a distinct landmark of beauty of in the abdominal region. In patients in whom the umbilicus is removed because of surgical procedures, the abdomen looks abnormal and shapeless. The location of the umbilicus is determined to be at a level that corresponds to the disk between the third and fourth lumbar vertebrae.' This is its location site in a healthy young patient. However, as the person ages and osteoporosis shortens the vertebral column, and as the torso shortens, the umbilicus moves inferiorly. If we assume a triangle base by connecting two points on the anterior superior iliac spine to a point corresponding to the disk between the third and fourth lumbar vertebrae, this triangle is approximately 3 cm high (Fig 3). I suggest that as a person ages, this triangle flattens and may even become inverted downward. This downward migration is in addition to the inferior movement of the umbilical opening as a result of gravity. I suggest restoring the umbilicus to its normal position or just slightly higher.

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Fig 1. (A) The umbilical stalk is fixed to the abdominal wall so that its opening ends up at a higher position. (B) Defatting around new umbilical site is necessary to create a depressed area so that the scar around the umbilicus is hidden in the bottom of this depression. Notice also the sculpting effect in the upper abdomen that could be achieved by defatting the midline and, in some cases, even suturing the midline to the rectus sheath.

Fig 2. (A) Preoperative view of a patient with a ptotic umbilical opening (downward tilt of the umbilical stalk). (B) Postoperative view with the elevated umbilical opening. Notice the result by comparing the umbilical site to the curvature of the waistline and also the underwear markings in the preoperative and postoperative views.

Fig 3. (A) Normal relationship of umbilicus to third and fourth intervertebral space and triangle formed by connecting this point to right and left anterior superior iliac spine. (B) With osteoporosis as a result of aging, especially in female patients, the vertebral column shortens. Thus, the upper body migrates down. Notice how the distance from A to D is reduced.

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Materials and Methods

During the repair phase of an abdominoplasty or a TRAM flap reconstruction, after placement of guide sutures in the lower abdomen, the site of the umbilicus is marked as usual on the midabdominal flap. At this point, it usually looks like the umbilicus site is too close to the incision line. If this is the case, a decision is made to place the umbilicus at a higher position. The amount of elevation of the new umbilicus depends on the severity of the ptosis of the umbilicus, and the length of the stalk and its degree of mobility. The operating surgeon's judg ment is a determining factor. The technique of umbilicoplasty with hidden scars that has been described previously' is used to fix the umbilicus to the linea alba and the rectus sheath, but in a higher position (Fig 1A). One should note that some tension in the flap from the umbilical incision site to the xiphoid region is necessary. After fixation of the umbilicus to the linea alba, the flap is pulled down and incisions are made, and defatting around the new umbilical incision is performed (Fig 1B).' At times, defatting of the midline sections of the superior abdominal flap up to the xiphoid is done to create a midline recess that resembles anatomically and aesthetically strong abdominal muscles. Sutures are placed at the location of the new umbilical depression in the level of the linea alba/rectus sheath. The operation is then concluded as usual, with the exception that lesser tension on the lower abdominal flap may now be feasible. This technique helps to remove the site of the previous umbilicus safely and still provides a relaxed lower abdominal flap with a good blood supply.

Results

This technique had helped remedy the unsightly, too-low umbilicus. Also, it is my impression that it has helped lower abdominal flap circulation. I believe that a higher position of the umbilicus is aesthetically more pleasing and renders a more youthful look (Fig 2).

Discussion

Youthful abdominal surface anatomy portrays a muscular underlying structure with definition of the upper abdominal muscles (even in the modern female figure). The umbilicus appears to be higher in these individuals compared with their obese counterparts, although admittedly this could be visual perception. In older individuals with a longstanding panniculus, this is definitely not a visual perception, but a true anatomic ptosis of the umbilicus signified by a long stalk. Actually, I believe any stalk that has turned from posterior-anterior to an inferior direction is considered ptotic. This operation helps to create an overall more youthful appearance by: 1) placing the umbilicus in a higher position; 2) creating a depression from the xiphoid to the umbilicus, which is especially important when reduction of fat in the midline upper abdomen is performed; and 3) by increasing the distance from the umbilicus to the incision line in the lower abdomen, it enhances further the aesthetics of this key anatomic site in the human figure. In addition to its aesthetic considerations, this procedure is beneficial in: 1) protecting lower abdominal flap circulation by transferring most of the tension from the lower abdomen to the upper abdomen; and 2) in some cases more tissue is available for a safe resection in the lower abdomen.

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Presented at the Southeastern Society of Plastic and Reconstructive Surgeons; Orlando, FL; June 2001.

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References

1 Massiha H, Montegut W, Phillips R. A method of reconstructing a natural-looking umbilicus in abdominoplasty. Ann Plast Surg 1997;38:228 2 Basmajian JV. Grant method of anatomy. 1971;8:200

Elliptical Horizontal Excision and Repair of Alar Cartilage in Open- Approach Rhinoplasty to Correct Cartilaginous Tip Deformities

H. Massiha (East Jefferson General Hospital, New Orleans, LA; Louisiana State University, New Orleans)

Reprinted from YEARBOOK OF PLASTIC, RECONSTRUCTIVE & AESTHETIC SURGERY St. Louis pp. 239-241, 1999 (Copyright 0 1999 by American Society for Aesthetic Plastic Surgery, Inc. (Printed in the U.S.A.)

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Elliptical Horizontal Excision and Repair of Alar Cartilage in Open- Approach Rhinoplasty to Correct Cartilaginous Tip Deformities Massiha H (East Jefferson Gen Hosp, New Orleans, La; Lousiana State Univ, New Orleans) Plast Reconstr Surg 101: 1 77-184, 1998 4-59

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Introduction. - Open-approach rhinoplasty has significantly improved correction of nasal tip deformities, particularly bulbous tip deformities. Like double-dome deformities, bulbous deformities are usually cartilaginous in nature, rather than fibrous. Patients with these deformities may need direct alterations of the cartilage, traditionally by resection of the cephalic part of the lateral crura of the lower lateral cartilage.

FIGURE l.-Above, basic concepts of elliptical excision and repair of the lateral crura of the lower lateral cartilage. Below, reduction convexity of the lateral crura. (Courtesy of Massiha H: Elliptical horizontal excision and repair of alar cartilage in open-approach rhinoplasty to correct cartilaginous tip deformities. Plast Reconstr Surg 101:177-184, 1998.)

The authors report an experience with elliptical, horizontally directed excision of the central segment of the lower lateral cartilage for the correction of nasal tip deformities (Fig 1).

Technique.-Elliptical excisions are placed in a horizontal direction in the central segment of the lower lateral cartilage. The width and shape of the elliptical excisions are determined by the anatomy and extent of the deformity, but a 2-3 mm excision is sufficient in most cases. The upper and lower edges of the remaining cartilage are repaired with 3-4 5-0 nylon sutures. These excisions eliminate the most protruding and bulbous portions of the lateral crura. Suturing of the upper and lower portions results in a flatter and narrower lateral crura. The bulge of the dome can be changed at the top, if necessary, with preservation of the relationship between the upper and lower lateral cartilage. The author presents 2 cases in which this procedure corrected bulbous deformities of the nasal tip.

Conclusions.-An elliptical horizontal excision approach to correction of cartilaginous deformities of the nasal tip is reported. In the author's experience, this technique provides consistently satisfactory clinical results. With any shape of central excision, no free or loose edges of cartilage are left to warp or deform during healing. This is an interesting approach because it follows the principal of the diagnosis of the anatomy as the shown pictures indicate that the maximum amount of bulk is in the midportion of the alar cartilage. The necessity for a long taper to prevent buckling of this cartilage, however, means that the incision must be tapered toward the piriform. This is probably what causes alar retraction seen in the lateral photographs. Reshaping techniques would not leave a space, and hence, no retraction. Cephalic resections limited to the domal area leave a space, but that technique has less cephalic retraction unless it too is carried toward the piriform. This type of resection also changes the angle that the cephalic border makes with the septum.

P.W. McKinney, M.D.

ANNUALS OF PLASTIC SURGERY / VOL 25 / NO 6 / DECEMBER 1990

Combined Skin and Skin-Muscle Flap Technique in Lower Blepharoplasty: A 10-Year Experience Hamid Massiha, M.D. Because of the important function of the pretarsal orbicularis muscle in blinking and tear drainage, the skin and skin-muscle flap technique for lower blepharoplasty was conceived to preserve the anatomical integrity of this muscle as well as its intimate relationship with the tarsal plate. The procedure involves elevating a skin flap over the pretarsal part of the orbicularis muscle followed by a skin-muscle flap at the preseptal part of the orbicularis muscle. This technique permits easy access to orbital fat pads while leaving the pretarsal orbicularis muscle intact and, in turn, facilitates the lateral suspension of the preseptal orbicularis muscle only. Trimming of the excess muscle is performed at the level of the preseptal orbicularis muscle, which is much less important functionally than the pretarsal orbicularis muscle, the part removed in the McIndoe-Beare muscle flap technique. This procedure, which has been performed on 700 eyelids (350 patients) from 1979 to the present, has successfully corrected lower eyelid defomiity as a result of aging, particularly lower eyelid atonicity and infrapalpebral crease. The method also offers a safe and fast approach to the infraorbital bony structures in patients undergoing trauma operations or other suzgical procedures. Massiha H: Combined skin and skin-muscle flap technique in lower blepharoplasty: a 10-ym experience. Ann Plast Surg 25:467, 1990 Reprinted from Annals of Plastic Surgery, Volume 25, Number 6, December, 1990. Published by Little, Brown and Company, Boston, Massachusetts. Copyright (C) 1990. All rights reserved. No part of this reprint may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without the publisher's written permission.

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From the Department of Plastic Surgery, Louisiana State University Medical Center, New Orleans, LA Presented at the Seventeenth Annual Meeting of the American Society of Aesthetic Plastic Surgery, Washhigton, DC, 1984, and also as a videotape presentation at the Nineteenth Annual Meeting of American Society of Aesthetic Plastic Surgery, New Orleans, LA, 1986. Address correspondence to Dr. Massiha, 3939 Houma Blvd., Suite 216, New Orleans, LA 70006.

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For a number of years, the two accepted methods used to treat the aging eyelid surgically have been the skin flap technique, with excision of excess skin and removal of herniated fat pads [2, 7, 8], and the skin-muscle flap technique, with excision of herniated fat pads and excess skin and muscle [1]. Although both procedures have produced excellent results in selected patients, the disadvantages associated with each are numerous (Tables I and 2). The combined skin and skin-muscle flap technique described in this article is a very conservative approach to lower blepharoplasty that involves minimal anatomical disturbance and that effectively corrects anatomical derangement associated with aging. The intention in devising this variation in lower blepharoplasty was to create a skin flap over the pretarsal segment of the orbicularis oculi muscle, preserving the intimate anatomical relationship between the muscle and the tarsal plate (Fig 1).

	Fig 1. (A) Basic concept of skin and skin-muscle flap technique. (Dashes indicate lines of dissection.) (B) Dissection of skin flap over pretarsal portion of the orbicularis muscle and skin-muscle flap over the septum orbitale. (C) Excess muscle excised or (D) excess muscle overlapped (see text). (E) Front view showing the pretarsal part of the orbicularis muscle intact and preseptal muscle raised together with the skin, over the septum orbitale.
Table 1. Lower Blepharoplasty Skin Flap Tecbnique Advantages Disadvantages 1. Maintains the anatomical relationslup of the tarsus to the orbicularis muscle. 2. Necessary amount of skin may be excised independently of muscle. 3. Decreases tendency to produce pretarsal flatness. 1. Involves difficult and tedious dissection. 2. Irregularities, bumps, and muscle bulges may be visible under the thin skin flap. 3. No muscle toning can be done. 4. Results in hyperpigmentation.
Table 2. Lower Blepharoplasty Skin Flap Tecbnique Advantages Disadvantages 1. Provides for easy and fast dissection (except for pretarsal portion) and less bleeding during dissection. 2. Decreases chance of skin slough, hyperpigmentation, and subcutaneous hematoma. 1. Destroys anatomical relationship of tarsus to orbicularis muscle. 2. May produce pretarsal flatness. 3. Causes ectopion if required amount of skin is removed (too much muscle is removed). 4. Creates possibility of epiphora because of orbicularis muscle pump disturbances.

Fig. 2. Operative technique. (A) Horizontal incision at the lateral canthal area. (B) Elevation of skin flap over pretarsal part of the orbiculazis muscle with tenotomy scissors. (C) Subciliary incision completed, (D) Skin flap completed. (E) Muscle incised and skin muscle flap raised (F) Excess orbital fat removed. (G), (H) Excess muscle excised laterally and superiorly; lateral toning of the preseptal orbicularis muscle done. (I) if the operation has been done correctly, opening the mouth, pressing the orbit, and similar maneuvers will not change the position of the skin flap appreciably. (J) Excess skin removed along the margin of the lower eyelid (not at the incision line). (K) Lateral excision. Usually more skin is removed laterally than at the infraciliary area. (L) Repain completed with 6-0 continuous nylon sutures.

Operative Technique >A lateral canthal incision is made, with dissection of the skin overlying the pretarsal portion of the orbicularis muscle to a width of approximately 6 mm (Fig 2A). Elevation of the skin flap is completed with an incision directly beneath the eyelashes, usually with a pair of small tenotomy scissors (Fig 2A-D). At the level of the inferior edge of the tarsus, this skin flap is converted to a skin-muscle flap (Fig 2E), leaving intact the part of the orbicularis muscle corresponding to the tarsus. The pretarsal portion of the muscle is separated from the preseptal portion of the muscle, and the skin flap becomes a skin and skin-muscle flap. Dissection under the muscle is done quickly; herniated fat pads become accessible, and are removed as in conventional blepharoplasty (Fig 2F). In the lateral canthal area, the portion of the orbicularis muscle corresponding to pretarsal muscle fibers is not cut. However, the portions corresponding to the septal portion are cut to facilitate excision of the fat pads (see Fig 2E, F). Repair begins with draping of the entire flap upward and laterally over the eye and upper eyelid (Fig 2I, J). This flap usually rests at an appropriate level without traction. The laterally cut edge of the preseptal portion of the orbicularis muscle is lifted with forceps and moved laterally and superiorly. Toning and tightening of the preseptal portion of the orbicularis muscle are accomplished by removing part of the muscle laterally and suspending it from the lateral canthal area with deep sutures (5.0 Vicryl; Ethicon Co., Somerville, NJ) to the periosteum and stump of the muscle (Fig 2H). This suturing should be done very carefully to avoid excessive tension on the muscle; however, there should be sufficient toning to achieve a youthful concavity in the preseptal area. At this point, maneuvers such as opening the mouth or putting pressure on the orbit will not pull the flap downward if the amount of the lateral traction is correct (see Fig 2I). The pretarsal portion of the muscle and the frame of the eye are left intact with no cuts. If, in an older person, tarsorrhaphy shortening or a similar procedure appears necessary, it is done at this time. With appropriate caution, excess skin, muscle, or both may be excised from the infraciliary and lateral canthal areas. As a safety measure, excision of the excess tissue is performed at the level of the lower lid margin (not the incision line) to prevent excessive excision (Fig 2J, K). Although it may be tempting to remove all of what appears to be excess flap tissue to the incision line, 2 to 3 mm of skin should be left intact to account for the depression created under the lower eyelid. Skin repair is performed with no tension (Fig 2L). Closure is completed with 6-0 nylon sutures. Results The combined skin and skin-muscle flap technique has been used to perform bilateral inferior blepharoplasty in 350 patients ranging in age from 30 to 75 years. It is a safe, fast, and easy procedure that produces consistently satisfactory results with fewer complications than previously employed techniques. Table 3 lists the improvements achieved by this technique.

Table 3. Lower Blepharoplasty Skin Flap Tecbnique
Advantages	Disadvantages
1. Maintains anatomical relationship of the tarsus to orbicularis muscle. 2. Enables removing varying amounts of skin and muscle independently of each other. 3. Avoids lacrimal system. 4. Gives surgeons a choice of creating or decreasing pretarsal fullness. 5. Reduces chance of skin slough, hyperpigmenta\tion, subcutaneous hematorna, and buttonhole on the skin flap. 6. Decreases chance of ectropion, possibly because of preservation of the frame of the eyelid.	1. Offers temptation to overcorrects. 2. Dogear laterally may require longer incision.

Discussion The combined skin and skin-muscle flap technique is a conservative and anatomically sound approach to lower blepharoplasty. The pretarsal portion of the orbicularis muscle is responsible for blinking and for pumping to drain the lacrymal system. This technique demonstrates that adequate blepharoplasty may be accomplished without detaching the orbicularis muscle from the tarsus, while maintaining access to the preseptal portion of the orbicularis muscle. This is the portion of the muscle that becomes lax with aging and that usually needs toning (Fig 3). Leaving the pretarsal muscle intact not only preserves the anatomical function of the muscle but also saves time, because detaching the muscle from the tarsal plate is tedious and somewhat bloody. Another important aspect of this method is preservation of nerve supply to the pretarsal orbicularis muscle. (Nerve supply is lateral and will usually be preserved with the bridge of the intact muscle, laterally.) This technique has some of the advantages of both previously reported methods of lower blepharoplasty [2-5]. The combined skin and skin-muscle flap technique permits independent treatment and reduction of muscle and skin. Because the redundancy of skin and muscle varies from one patient to another, the ability to handle and reduce each structure independently is self-evident. In my experience, complete separation of the skin flap and muscle flap is unnecessary [6]. Complete skin and muscle flap separation has the inherent disadvantages of both skin flap and muscle flap techniques, violates pretarsal muscle anatomy, and involves unnecessary dissection between the preseptal muscle and skin. The technique of skin and skin-muscle flap blepharoplasty also has some incidental advantages. Overlapping of the pretarsal and preseptal orbicularis muscle, if desired, could create infraciliary fullness more safely and easily than the method suggested by Sheen [9, 10]. This fullness could be considered desirable by patients in some ethnic groups, as well as patients with atrophic lid margin (see Fig 1D). Furthermore, because the lid margin becomes independent of the preseptal orbicularis muscle in the course of the procedure, satisfactory toning of the preseptal muscle laterally can be achieved (see Fig 3, Fig 4). Lateral suspension also lifts the ptotic cheek from the nasolabial fold to a varying degree. It should be emphasized that this effect on the cheeks is incidental, and overenthusiastic attempts to lift cheeks with this method should be avoided.

A	B
C	D
E	F
G	H
	Fig. 3. Preoperative (A, C, E, G) and postoperative (B, D, F, H) views of patient with atonic orbicularis muscle. Notice the marked improvement in the orbicularis muscle tone.

Since 1984, when the skin and skin-muscle flap technique was initially presented, a number of plastic surgeons around the United States have adopted the technique. Their comments have reiterated that this technique is easy to perform and teach. In fact, some consider it the safest method of lower blepharoplasty (Carraway JH: personal communication, 1989).

A	B
C	D
E	F
G	H
I	J
	Fig. 4. Preoperative (A, C, E, G, I) and postoperative (B, D, F, H, J) views of patient with herniated orbital fat and atomic orbicularis muscle and skin excess. Postoperative views show improved appearance and function. (Improvement in eyelid aperture is the result of blepharoplasty only.)

References 1. Beare R: Surgical treatment of senile changes in the eyelids: the Mclndoe-Beare technique. In Smith B, Converse JM (eds), Proceedings of the Second International Symposium on Plastic and Reconstructive Surgery of the Eye and Adnexia. St Louis, Mosby, 1967 2. Castenares S: Eyelid plasty. In Goldwyne RM (ed), The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Boston, Little, Brown, 1982, p 267 3. Courtiss EH: Selection of alternatives in aesthetic blepharoplasty. In Rees TD (ed), Modern Trends in Blepharoplasty. Clin Plast Surg 8:739, 1967 4. Edgerton MT: Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 49: 367, 1972 5. Flowers RS: Blepharoplasty. In Courtiss EH (ed), Male Aesthetic Surgery. St Louis, Mosby, 1982, p 207 6. Klatsky SA, Manson PN: Separate skin and muscle flaps in lower lid blepharoplasty. Plast Reconstr Surg 67: 151,1981 7. Rees TD: Aesthetic Plastic Surgery. Philadelphia, Saunders, 1980 8. Rees TD (ed): Modern Trends in Blepharoplasty. Clin Plast Surg 8:643, 1967 9. Rees TD: The voice of polite dissent: comment on [10]. Plast Reconstr Surg 62:295, 1978 10. Sheen JH: Tarsal fixation in lower blepharoplasty. Plast Reconstr Surg 62:24, 1978