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ABSTRACTS Free Communications Friday September 27th

Botulinum toxin A – hyper concentrated dilution with adrenalized local anesthetic S. Komitski Plastic surgery, Hospital Aleksandrovska Sofia, Sofia, Bulgaria Email : Purpose of this presentation is to describe a method of reconstitution of botulinum toxin A with adrenalized local anesthetic. The substances used (Botox and Ubistesin forte) are chemically analyzed and an exact step by step description of reconstitution is given. In addition a schematic facial anatomy (static and dynamic) is presented and some details of the injecting technique are mentioned. The indications for cosmetic use of botolinum toxin A are listed as well as the postoperative situation and the eventual complications. In this communication we focus on the use of hyper concentrated dilution of the lyophilized botulinim toxin powder (100 U in 1 ml or 50 U in 0,5 ml) and the application of an adrenalized local anesthetic as a solvent agent (Ubistesin forte which is atricaine hydrochloride 4% with adrenaline hydrochloride 1:100 000). The advantages are listed: relatively less volume of injected substance used, less risk of traumatic bleeding, less risk of local pain during and immediately after the procedure or post procedure headache, less risk of diffusion of the injected solution and minimizing the side effects as asymmetries, eyelids fatigue or ptosis, diplopia, dry mouth etc. The disadvantages and inconveniences are also given: risk of allergy to the atricaine, risk of tahicardia, need to use smallest possible syringes. NATURAL SCULPTING OF THE NOSE(TISSUE ENGINEERING CARTILAGE: STATE OF THE ART) IB EL ACHKAR PLASTIC department, MIDDLE EAST INSTITUTE OF HEALTH, BEIRUT, Lebanon Email : Rhinoplasty procedure is a big challenge; in this study we expose the importance of using sculptured cartilage graft in primary and secondary Rhinoplasty. Between January 2000 and 2009 around 4,300 patients have been operated with cartilage graft Rhinoplasty. In this study we discuss the cartilage graft in the treatment of the • Dorsum • Tip • Mid third • Columella • Several other parts of the nose • Secondary Rhinoplasty Cartilage graft in primary and secondary rhinoplasty provides an outcome of a natural nose shape.

MODIFIED TIP DOME DIVISION Dr. M.B. Bizrah,MD, DLO.RCS.Eng, FRCS Ed Consultant Facial Plastic Surgeon New Jeddah Clinic Hospital and the Bizrah Clinic Jeddah,KSA Email : The author following twenty five years’ experience and performing over twenty thousand Rhinoplasty procedures highly recommends the technique of endonasal new double dome creation, scoring, suture fixation, columellar strut and as indicated tip grafts. It has the most predictable results, because of the preservation of the continuity of the lateral crus and obtaining a strong tripod of conjoined lateral to medial crura supported by columellar and tip grafts, thus reducing very much the possibility of asymmetry, alar collapse, dropped tip, pinching, notching and alar retraction. However, because of the lateral crus marginal incision and lateral crus delivery, there may be unavoidable problems due to wound healing,fibrosis and contracture such as mild notching, pinching alar retraction, collapse, .asymmetry and dimpling. In order to avoid even these problems, the author has developed a new endonasal technique which is largely based on the Goldman's tip and the I-beam of medial crura but without lateral crus delivery;and lateral crus marginal incisions. This is in order to keep an intact alar rim and avoid any problems along the alar rim such as notching, retraction, collapse or asymmetry. The author has been applying this technique for the last 14 years. In his opinion this technique is very useful to achieve tip projection, definition and refinement in the following situations: Tip underprojection, Short columella , Mild tip bulbousity ,and In revision cases. The operative technique preoperative and the postoperative results will be fully discussed with timetables, photographs, illustrations and video presentation Dr .M.B. BIZRAH ,FRCS Auther of text book [ Rhinoplasty & Facial plastic Surgery ] 500 pages, > 1000 illustration pictures. The book also available free on web site:

Marginal Vermillontomy : surgical treatment of dysesthetic labial tatoos and iatrogenic labial hypertrophy Dr Laudoyer Head neck surgery, private office, NICE, France Email : The marginal vermillontomy was used by the authors with a purpose to remove dysesthetic labial tattoo and to improve iatrogenic labial hypertrophy due to permanent filler. This simple and effective surgical procedure is performed under local anesthesia as an outpatient surgical procedure. We are planning to use this surgical procedure for long white upper lip with thin red upper lip.

Upper blepharoplasty: a paradigm for precision J Vandeputte Plastic surgery, Algemeen Ziekenhuis Oudenaarde, Oudenaarde, Belgium Email : Eyebrow position, eyelid fullness and supratarsal crease anatomy are the three selection criteria for blepharoplasty techniques, regardless of the amount of skin excess. The impact on eyelid appearance of lifting the lateral aspect of the eyebrows for a few millimetres is the first step in the paradigm. Given the simplicity, the reliability and the safety of suture lifts of the lateral aspect of the brows and of their volumetric support, there is little excuse to compensate low set eyebrows by extra skin excision. The choice for skin removal alone versus surgery on deeper layers depends on the two other parameters. Eyelid fullness may be due to orbicularis muscle mass, protruding fat or fat excess. Orbicularis reduction, orbital fat repositioning or its excision require deep exposure. A localised, medial fat deposit is an exception. As it can be removed through a very small muscle incision, it does not warrant an “open sky” approach. If the “supratarsal” skin crease, in fact a high pretarsal crease, is absent, or if it slides down the tarsus more than half the distance from its original position to the eyelid margin, deep eyelid exposure is also required. The subsequent surgery should provide well-fixed pretarsal skin, a well-defined high pretarsal crease and proper eyelid skin invagination. The majority of Caucasian candidates for blepharoplasty do not have excess eyelid volume and do have a well-defined and reasonably well-positioned high pretarsal skin crease. They do well with skin excision plus microcoagulation of the orbicularis muscle in the high pretarsal position in an office setting. The scar induced by the latter part of the procedure prevents the tissues behind the attenuated orbital septum to slide too low, preventing an inverted V deformity. The highest precision for the skin incision can be achieved with a 4 MHz current, administered through a wire electrode, without any tension being applied on the skin. A 4 MHz cut/coag current to excise skin often provides a dry operative field, without prolonging postoperative oedema. Microcoagulation of the high pretarsal area is an old surgical trick. However, performed with a monopolar 4 MHz current, it produces a more advantageous temperature gradient in the tissues than with conventional current, with a high temperature in the intended area of coagulation and minimal thermal damage at short distance. Thus fusion between the orbicularis oculi muscle, the levator expansion and the upper aspect of the tarsus by scar tissue can be achieved without negative impact on swelling and recovery time. Given the variability of levator anatomy, even a small orbicularis muscle trim may interfere with the levator expansion. Any deeper exposure requires identification of the suborbicularis fascia, the orbital septum and the levator aponeurosis. Entering the eyelid at the lower blepharoplasty incision holds a risk to dissociate the different layers of connective tissue that make up the distal part of the levator expansion. A transorbicularis (open sky) approach exposes the deeper structures through the upper incision line. It is a reliable way to unequivocally identify the aforementioned

structures and to better assess the quantity of pre- and retroseptal fat, at the expense of more postoperative oedema and a longer recovery time. Operating theatre working conditions are required. Whereas a localised, medial, preseptal fat deposit is preferentially removed, orbital fat in general should only be excised if there is frank bulkiness unrelated to ageing. After opening the septum over its entire width, retroseptal fat can accurately by repositioned in the orbit after opening the septum by 1,7 MHz bipolar coagulation of the connective tissue membrane surrounding the lobules. The distal end of the levator aponeurosis is severed by en bloc resection of the tissue in between the upper and lower “open sky� incision. It is sutured anterosuperiorly to the tarsus with 6/0 poliglecaprone 25. This deep suture line is taken up in the skin sutures with a running 6/0 polybutester suture, (re)creating a well-defined, high pretarsal skin crease. The intentional interposition of the skin scar in between the margins of the severed orbicularis provides more stability. Following a well-defined paradigm applied to clinical parameters makes the choice between minimalistic or invasive upper lid blepharoplasty more consistent. Modern technology can enhance our precision in either case.

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