The Effect of a Novel Platysma Hammock Flap During Extended Deep Plane Facelift on the Signs of Aging in the Neck.

BACKGROUND: Aging changes in the neck, including platysma banding (PB), skin laxity (SL), and submandibular gland visibility (SGV), have a high degree of recurrence after rhytidectomy. OBJECTIVES: The authors sought to assess the long-term improvement in PB, SL, and SGV with addition of aplatysmal hammock flap to the extended deep-plane facelift and assess patient satisfaction. METHODS: This was a prospective study of 123 consecutive patients undergoing extended deep-plane facelift incorporating platysma hammock flap with or without midline platysmaplasty. Standard 2-dimensional patient photographs were employed to assess PB, SL, and SGV preoperative and >12 months postoperative. A 1-year postoperative patient satisfaction survey was conducted. RESULTS: The platysmal hammock flap without midline platysmaplasty cohort had a significant (P < 0.01) reduction in mean preoperative PB, SL, and SGV scores from 1.03, 1.88, and 1.21 to 0.06, 0.03, and 0.15 at 21 months. The platysmal hammock flap with midline platysmaplasty cohort had a significant (P < 0.01) reduction in preoperative PB, SL, and SGV scores from 1.81, 2.43, and 1.81 to 0.10, 0.15, and 0.48 at 18 months. The platysmal hammock flap with and without midline platysmaplasty cohorts had 96.2% and 88.9% satisfaction, respectively. CONCLUSIONS: Extended deep-plane facelift with a platysmal hammock flap achieves long-term, sustained improvements in PB, SL, and SGV; is well-tolerated; and results in substantial patient satisfaction.

Transcutaneous Blepharoplasty with Volume Preservation: Indications, Advantages, Technique, Contraindications, and Alternatives.

The aging appearance of the lower eyelids is multifactorial, involving changes in the skin, orbital fat, orbicularis muscle, soft tissue of the midface, and tear trough. The extent of these changes differs in each case and happens in a background of volume loss that occurs with facial aging. We present the indications, advantages, and technique for volumizing transcutaneous lower blepharoplasty with fat transposition. The absolute and relative contraindications to transcutaneous surgery are discussed, and surgical details of transconjunctival blepharoplasty with fat repositioning and autologous fat grafting as alternative approaches are included.

A Novel Volumizing Extended Deep-Plane Facelift: Using Composite Flap Shifts to Volumize the Midface and Jawline.

Traditional superficial musculoaponeurotic system (SMAS) facelifting surgery uses a laminar surgical dissection. This approach does not treat areas of facial volume loss, and requires additional volume supplementation with fat grafting or fillers. The novel volumizing extended deep-plane facelift uses a composite approach to the facelift flap. By incorporating a platysma myotomy in the extended deep-plane flap, a novel composite transposition flap can be created that revolumizes the posterior jawline, recreating a defined convex jawline of youth. Special attention is paid to the deep anatomy of the face, and the need for release of the facial ligaments.

Optimal Facelift Vector and its Relation to Zygomaticus Major Orientation.

BACKGROUND: The vector of superficial musculoaponeurotic system (SMAS) redraping in rhytidectomy is often described in relation to the zygomaticus major muscle (ZMM), so that suspension prevents distortion of the mimetic musculature and a "facelifted appearance." There are no data describing the true orientation of this muscle in the midface. OBJECTIVES: The aim of this study was to define the vector of the ZMM relative to the Frankfort horizontal plane. METHODS: One hundred patients underwent deep plane rhytidectomy. As part of this procedure the tissues overlying the ZMM are elevated, allowing muscle orientation to be measured as an angle relative to the Frankfort horizontal plane. RESULTS: Data for 200 hemifaces were aggregated. The average ZMM angle was 59° (standard deviation, 6°; range, 41-72°) relative to the Frankfort horizontal plane, and showed a statistically significant pattern of change with advancing age, becoming more acute with increasing age below the age of 60 years and more obtuse with age over 60 years. CONCLUSIONS: The native vector of the ZMM varies significantly between rhytidectomy patients as demonstrated by the high variance in this cohort. Assumptions about its orientation should not be made in rhytidectomy techniques that do not identify its course. Standard vectors of SMAS redraping, such as superior-lateral, vertically oblique, and purely vertical, should be reconsidered and a customized vector implemented in each case. Aging affects the orientation of the muscle, which can potentially be explained by soft tissue and bony changes at its attachments. This furthers the variability of the SMAS vector in each individual case.

A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques.

BACKGROUND: Sub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection. OBJECTIVES: The authors sought to aggregate and summarize data on complications among different SMAS facelift techniques. METHODS: A broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: A total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01). CONCLUSIONS: There are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile.

A Novel Extended Deep Plane Facelift Technique for Jawline Rejuvenation and Volumization.

BACKGROUND: Jawline aging is a complex process. We believe loss of posterior jawline definition and volume depletion is an underappreciated factor in the aging face. OBJECTIVES: The aim of this study was to describe a novel composite, rotational flap modification of an extended deep-plane rhytidectomy. We evaluated long-term efficacy on improving jawline contour and volumization of the posterior mandibular region overlying the gonial angle. METHODS: We performed a prospective study on patients who underwent our modification of extended deep-plane rhytidectomy. We define and introduce the mandibular defining line, a new anatomic metric in evaluating the mandibular contour. We define the area of the posterior lower face overlying the gonion and mandibular angle as the gonial area. Using 3-dimensional photography, we quantify contour changes along the mandibular border and volume change along the gonial area. RESULTS: Eighty-nine patients (178 hemifaces) were analyzed. The mean gonial area volume gained was 3.5 cc. Average follow-up was 19 months. There was a statistically significant change in the mean mandibular defining line from 7.1 cm preoperatively to 9.8 cm postoperatively. This represents a lengthening of the visual perspective of the mandibular contour of 2.7 cm. CONCLUSIONS: Composite, rotational flap modification of extended deep-plane rhytidectomy provides significant long-term augmentation of volume to the posterior mandibular region and lengthens the visual perspective of the inferior mandibular contour, creating a more youthful jawline. In selected cases, this may obviate the need for other volumization procedures used to improve jawline contour, such as autologous fat grafting.

Characterization of the Cervical Retaining Ligaments During Subplatysmal Facelift Dissection and its Implications.

Background: The cervical retaining ligaments anchor the platysma and soft tissues of the neck to the deep cervical fascia and deeper skeletal structures. The cervical retaining ligaments tether the platysma and prohibit free mobilization and redraping of the platysma muscle in rhytidectomy. This ligament system has previously been described in the literature only qualitatively. Objectives: To define the anatomic dimensions of the cervical retaining ligaments and their relation to the platysma muscle in order to better understand the cervical retaining ligament system and how it limits motion of the platysma during rhytidectomy. Methods: Extended deep plane rhytidectomy was performed on 20 fresh cadaveric hemifaces. The extent cervical retaining ligaments were dissected and measured. The anterior extent (width) of the cervical ligament were recorded at three anatomic points on each hemiface: (1) at the level of the inferior border of the mandible; (2) at the top of the thyroid cartilage at the thyroid notch; and (3) at the level of the cricoid. Results: The average width of the cervical retaining ligaments in the neck was 15.3 mm. The width significantly decreased as they became more inferiorly positioned from the top of the neck at the anatomic measurement points, measuring 17.1 mm, 16.1 mm, and 12.6 mm (P < 0.05). Conclusions: The cervical retaining ligaments are the support mechanisms of the platysma muscle in the neck. While previously described in only a qualitative manner, this study quantifies the anterior extent of these ligaments and how they invest the lateral platysma muscle. As these ligaments tether the platysma for an average of 1.5 cm, lateral platysma elevation of this distance during rhytidectomy surgery can improve platysmal redraping during rhytidectomy and potentially improve neck rejuvenation.

Nonsurgical Facial Rejuvenation Procedures in Patients Under 50 Prior to Undergoing Facelift: Habits, Costs, and Results.

Background: Facial rejuvenation in patients younger than 50 years of age has experienced an unprecedented growth with multimodality nonsurgical and less invasive rhytidectomy techniques. Objectives: To analyze the nonsurgical treatment habits of patients prior to undergoing rhytidectomy at <50 years of age. Methods: Retrospective study to enlist patients who underwent primary rhytidectomy at age <50 years between January 1, 2003 and December 31, 2013 by the senior author (AAJ) to complete a survey. Results: One hundred and fifty-seven patients were surveyed. Patients had nonsurgical rejuvenation starting at an average age of 37 years and rhytidectomy at an average age of 44 years. Thirty-two percent of responders had injectable treatments prior to their facelift, reporting a mean of 7 rounds of injectable treatments prior to pursuing rhytidectomy. Sixteen percent of responders had laser skin resurfacing undergoing 4 separate treatments prior to rhytidectomy, and 10% had energy-based facial tightening treatments one time prior to their rhytidectomy. Average expenditure on nonsurgical treatments prior to rhytidectomy was $7000 cumulatively. Fifty-nine percent of patients who went on to rhytidectomy did not report regret over this cost expenditure. Patients reported that they appeared 4 years younger after nonsurgical intervention, and 8 years younger after their facelift, a statistically significant difference (P = .048). Conclusions: Patients undergoing rhytidectomy <50 years old begin less invasive facial rejuvenation treatments at an even earlier age. The majority of these patients did not regret the costs associated with noninvasive treatments, even though they saw that rhytidectomy provided a greater rejuvenation effect. Rhytidectomy surgeons should incorporate nonsurgical techniques into their practice to best serve the needs of the modern aging face patient.

The Effect of Midline Corset Platysmaplasty on Degree of Face-lift Flap Elevation During Concomitant Deep-Plane Face-lift: A Cadaveric Study.

IMPORTANCE: The evaluation of the effects of midline platysmaplasty concomitant with rhytidectomy. OBJECTIVE: To determine whether midline platysmaplasty limits the degree of lift during deep-plane face-lift. DESIGN, SETTING, AND PARTICIPANTS: Deep-plane rhytidectomy was performed on 10 cadaveric hemifaces. The redundant skin for excision after performing the face-lift was measured with and without midline platymaplasty. EXPOSURES: Deep-plane rhytidectomy. MAIN OUTCOMES AND MEASURES: The redundant skin was measured preauricularly in the vertical and horizontal dimension, and postauricularly after deep-plane face-lift and after adding a midline platysmaplasty. RESULTS: Concomitant midline platysmaplasty significantly reduced the amount of lift during concomitant deep-plane rhytidectomy preauricularly in the vertical dimension by 40.5% (from 37.0 mm excess skin redraped to 22.0 mm) and postauricularly by 23.9% (from 40.6 mm excess skin redraped to 30.9 mm) (P < .001 and P < .001, respectively). The 19.7% reduction in the horizontal skin redraping after midline platysmaplasty (from 14.7 mm excess skin redraped to 11.8 mm) did not reach statistical significance (P = .15). CONCLUSIONS AND RELEVANCE: Concomitant midline corset platysmaplasty significantly limits the ability to lift the neck as well as the jawline and midface during rhytidectomy. LEVEL OF EVIDENCE: NA.

Three-Dimensional Analysis of Long-Term Midface Volume Change After Vertical Vector Deep-Plane Rhytidectomy.

BACKGROUND: Facial aging is a complicated process that includes volume loss and soft tissue descent. This study provides quantitative 3-dimensional (3D) data on the long-term effect of vertical vector deep-plane rhytidectomy on restoring volume to the midface. OBJECTIVE: To determine if primary vertical vector deep-plane rhytidectomy resulted in long-term volume change in the midface. METHODS: We performed a prospective study on patients undergoing primary vertical vector deep-plane rhytidectomy to quantitate 3D volume changes in the midface. Quantitative analysis of volume changes was made using the Vectra 3D imaging software (Canfield Scientific, Inc, Fairfield, New Jersey) at a minimum follow-up of 1 year. RESULTS: Forty-three patients (86 hemifaces) were analyzed. The average volume gained in each hemi-midface after vertical vector deep-plane rhytidectomy was 3.2 mL. CONCLUSIONS: Vertical vector deep-plane rhytidectomy provides significant long-term augmentation of volume in the midface. These quantitative data demonstrate that some midface volume loss is related to gravitational descent of the cheek fat compartments and that vertical vector deep-plane rhytidectomy may obviate the need for other volumization procedures such as autologous fat grafting in selected cases. LEVEL OF EVIDENCE: 4 Therapeutic.

Bilateral Transposition Lip Flaps: A Novel Single-Stage Reconstruction of Central Upper Lip Defects Involving Cupid's Bow.

IMPORTANCE: Defects of the central upper lip present a challenge. A variety of techniques have been described, but most tend to efface the natural contours present in the philtrum and the cutaneous-mucosal vermilion border (Cupid's bow). Furthermore, the techniques typically require a second-stage procedure to improve the upper lip aesthetic. We discuss a novel technique using bilateral transposition flaps to reconstruct central defects of the upper lip that violate Cupid's bow while maintaining normal aesthetic landmarks in a single stage. The mean angle of the transposition flaps was calculated. OBSERVATIONS: A retrospective review of 7 patients was performed to identify those who underwent reconstruction of central upper lip defects at a Mohs reconstruction referral practice. Medical records from January 2009 to December 2013 were evaluated. The mean diameter of the final defect was 1.4 cm (range, 1.2-2.1 cm). The mean angle of the transposition flaps used was 50°. All defects were closed in a single stage with no secondary defect remaining. There was no need for a second-stage procedure. CONCLUSIONS AND RELEVANCE: The use of bilateral transposition flaps is a viable and preferred method for a single-stage reconstruction of the Cupid's bow and philtrum in central defects of the upper lip.

An algorithmic approach to multimodality midfacial rejuvenation using a new classification system for midfacial aging.

Midfacial aging is the result of the complex interplay between the osseous skeleton, facial retaining ligaments, soft tissues envelope, facial fat compartments, and the overlying skin elasticity. As a result of the many anatomic components involved in midfacial aging, the authors proposed a classification system based on distinct anatomic factors to direct surgical treatment. Evidence based data suggest that midface rejuvenation often requires a multimodality approach to obtain desired results, especially in patients with more advanced aging and poor tissue elasticity, or those with hypoplastic midfacial skeletal structure.

Vertical neck lifting.

The authors' vertical neck lifting procedure is an extended deep plane facelift, which elevates the skin and SMAS-platysma complex as a composite unit. The goal is to redrape cervicomental laxity vertically onto the face rather than laterally and postauricularly. The authors consider this an extended technique because it lengthens the deep plane flap from the angle of the mandible into the neck to release the cervical retaining ligaments that limit platysmal redraping. This technique does not routinely use midline platysmal surgery because it counteracts the extent of vertical redraping. A majority of aging face patients are good candidates for this procedure in isolation, but indications for combining vertical neck lifting with submental surgery are elucidated.

Comparing rates of distal edge necrosis in deep-plane vs subcutaneous cervicofacial rotation-advancement flaps for facial cutaneous Mohs defects.

IMPORTANCE: The cervicofacial rotation-advancement flap is commonly used for facial defects. Decreasing the rate of distal edge necrosis (DEN) encountered with this flap would help prevent complications in sensitive areas such as the eyelid, lip, and nose. OBJECTIVE: To compare the untoward occurrence of DEN between 2 surgical dissection methods for reconstructive cervicofacial rotation-advancement flaps. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: A review was conducted of 88 patients who underwent cervicofacial flap reconstruction for Mohs ablative surgery between January 1, 2003, and June 30, 2012, by the senior author (A.A.J.). All patients had periorbital, midfacial, cervical, and/or lateral temporal/forehead defects following Mohs surgical ablation. Patients were categorized into 1 of 2 groups on the basis of the surgical technique used: subcutaneous (SC) cervicofacial elevation or deep-plane (DP) cervicofacial elevation. Subcategories of smokers and nonsmokers within each group were further reviewed. Statistical analysis of DEN between categories and subcategories was performed. RESULTS: Sixty-nine patients were in the SC group and 19 were in the DP group. The mean defect size among both groups was 14.3 cm(2). The rate of active or recent smokers was 23% in the SC group and 11% in the DP group. The rate of DEN among nonsmokers in the SC group was 23% (n = 53) compared with 0% in the 17 DP nonsmokers (P = .03). The rate of smokers with DEN in the SC group was 75% and 0% in the DP group (P = .09). The mean area of DEN in the SC group was 0.8 cm(2). CONCLUSIONS AND RELEVANCE: Our statistically significant data indicate that DP dissection is a superior technique for avoiding DEN in nonsmokers. We found better outcomes in smokers as well. Thus, we strongly advocate the use of the DP approach as the criterion standard in cervicofacial flap elevation. LEVEL OF EVIDENCE: 3.