Limited Delamination Modifications to the Extended Deep Plane Rhytidectomy: An Anatomical Basis for Improved Outcomes.

Background: This study introduces variations of a limited delamination approach to the deep plane face- and necklift. Objectives: To report surgeons' perceptions of limited delamination deep plane rhytidectomy, define the anatomical basis to support these modifications, and report complication rates. Methods: This retrospective multi-institutional chart review study of patients undergoing a modified classical deep plane face- and necklift. Surgeons' perception of outcomes and self-reported complications were collected. Results: In total, 3964 patients having undergone face- and necklift with six surgeons being included. Most patients were female (87.9%) with an age range of 31-83 years (mean 58 years). Most were primary procedures (2672/3964; 67.4%) with a median follow-up of 425 days (range 21-5470). Preliminary surgeon experience demonstrated increased ease of flap management, improved biomechanics, smaller perceived rates of skin discoloration, and telangiectasia of the skin and lower revisions rate (n = 11; 0.8%). Complication rates were low for hematoma (n = 24; 1.9%) and seroma requiring needle aspiration (n = 26; 2%) and minor infection (n = 18; 1.4%). Conclusions: A multicenter surgeon experience with the limited delamination extended deep plane rhytidectomy is based on anatomical evidence and demonstrates low complication rates and surgeon-perceived improved long-term outcomes. Prospective comparative outcomes of these evolving techniques are warranted.

Advanced Deep-Plane Rhytidectomy: Advantages For Neck Treatment and Volumization of The Midface.

The aged neck is the most common motivator for patients seeking facial rejuvenation. Unlike the deflated midface, surgical treatment is still the gold standard for optimal outcomes. It is our view that the majority etiology of both the aged neck and deflated midface is gravity's effects on the su-perficial soft tissue envelope, leading to soft tissue redundancy. It is also our view that the deep-plane rhytidectomy is supported by anatomy, embryology, and clinical evidence as the best meth-odology to treat soft tissue redundancy without producing the aesthetic and longevity issues asso-ciated with SMAS techniques. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane technique such as dissection entry point, flap design, and flap fixation concepts that allow aggressive approach to treating both the aged neck and deflated midface.

Advanced Deep-Plane Rhytidectomy: Advantages for Neck Treatment and Volumization of the Midface.

The aged neck is the most common motivator for patients seeking facial rejuvenation. Unlike the deflated midface, surgical treatment is still the gold standard for optimal outcomes. It is our view that the majority etiology of both the aged neck and deflated midface is gravity's effects on the superficial soft tissue envelope, leading to soft tissue redundancy. It is also our view that the deep-plane rhytidectomy is supported by anatomy, embryology, and clinical evidence as the best methodology to treat soft tissue redundancy without producing the aesthetic and longevity issues associated with superficial musculoaponeurotic system techniques. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane technique such as dissection entry point, flap design, and flap fixation concepts that allow aggressive approach to treating both the aged neck and deflated midface.

Deep-Plane Rhytidectomy: Pearls in Maximizing Outcomes while Minimizing Recovery.

The deep-plane rhytidectomy was first described in 1990 and has gained traction in the past decade as supported by anatomy, embryology, and clinical evidence. Consumer dissatisfaction in facial rejuvenation procedures often occurs because procedures are too conservative and are undone. From the consumer's perspective, an outcome is a combination of the esthetic result, predictability, and the length of the recovery process. The length of the recovery process is often the limiting issue affecting the consumer's willingness to proceed with the procedure. As one of the early pioneers in deep-plane rhytidectomy, the lead author will define contemporary advances in deep-plane techniques such as dissection entry point, flap design, and flap fixation concepts that allow an aggressive approach to treating both the superficial soft tissue envelope and deeper facial aging structures. These technique modifications and insights will provide the surgeon with an understanding of how to achieve significant, natural, long-lasting results with predictable short recovery periods-maximizing outcomes and minimizing postoperative processes.

The Submandibular Gland and The Aging Neck: A Longitudinal Volumetric Study.

INTRODUCTION: The true effect of aging and other patient factors on submandibular gland (SMG) volume is unclear. We sought to evaluate the effects of age, body mass index (BMI), sex and race on SMG volume using computed tomography (CT) imaging. METHODS: We conducted a retrospective longitudinal study of adult subjects with multiple CT images of the neck at least 7 years apart. Subjects with history of salivary gland pathology, neck dissection, head and neck radiation, active infection or dental artifact were excluded. Three-dimensional volumes were measured. Age, BMI, sex and race data were analyzed to track their longitudinal effect on SMG volume. RESULTS: The study comprised 64 patients (Females n=36; Males n=28) with mean age of 47.1 and 58.5 at each respective time point (mean difference 11.4). Mean SMG volume increased from 10.1 ml to 10.5 ml (P < 0.05). Males had significantly greater SMG volume compared to females. Majority of growth occurred in the < 40 year age bracket (0.1 ml/year), more significantly in the male cohort. When controlling for aging and sex, a change in BMI was the only patient factor that predicted a change in SMG volume. An increase of 1.0 kg/m2 predicted a 0.17 ml increase in gland volume. Race had no significant effect. CONCLUSION: Our findings suggest that the majority of SMG volume change occurs in early adulthood ( < 40 years), especially in males. Among the factors we studied, a change in BMI was the only significant predictor of SMG volume change. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 . Genital Surgery.

The Aging Parotid Gland: A Longitudinal Volumetric Study and Implications for Treatment.

BACKGROUND: The parotid gland accounts for significant soft tissue volume in the face and is therefore of central relevance to facial and neck rejuvenation. OBJECTIVES: The aim of this study was to determine how parotid gland volume is predicted by age and other factors. METHODS: We conducted a retrospective longitudinal study of patients with multiple computed tomography (CT) scans of the neck performed at least 7 years apart. Parotid gland volumes were measured and multiple linear regression analysis was performed to model the relations between age, body mass index (BMI), and parotid volume. RESULTS: The study cohort comprised 70 patients. The mean [standard deviation] ages at initial and final imaging time points were 47.5 [12.6] and 58.8 [12.2] years, respectively, with an average of 11.3 years elapsed between CT scans. The mean parotid gland volume increased from 28.7 [10.0] to 32.2 [10.7] mL over the average 11.3-year period (P = 0.03). However, the results of the multiple linear regression analysis show that when controlling for BMI and sex, age alone does not predict parotid volume (P = 0.29). BMI was directly correlated with gland volume (P < 0.01). An increase of 1.0 kg/m2 in BMI predicted an increase in parotid volume by 1.1 mL. Male sex was also associated with significantly greater parotid volume. CONCLUSIONS: Mean parotid volume increased over time but these gains were driven by increases in BMI and not age alone. These findings are highly relevant to the treatment of the aging face and neck.

Deep-Plane Approach to the Vertical Platysma Advancement: Technical Modifications and Nuances over 25 Years.

In this article, we will provide the reader with the anatomical and embryologic evidence supporting the use of the deep-plane approach in rhytidectomy and insight into the evolution of the technique into the vertical platysma advancement. The original description of the deep-plane technique only described a basic superficial muscular aponeurotic system dissection in the midface with the ability to use tension on the flap without aesthetic consequences. This plane of dissection provides additional advantages not previously described, including access to deeper anatomical structures such as the buccal fat pad, and allows in vivo assessment and treatment of jowling. We describe how extension of this dissection and selective release of facial ligaments allows us to optimize treatment outcomes and longevity, especially in cases of difficult anatomy or revisions. Further advancements include case-specific facial volume enhancement, created by complex flap design, and facial narrowing by preauricular contouring and parotid hypertrophy treatment. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented.

From the Deep-Plane Rhytidectomy to the Vertical Platysma Advancement.

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

Deep Cheek Fat Volumes and Midfacial Aging.

BACKGROUND: Midfacial volumizing procedures are increasingly common in facial rejuvenation. However, the changes that occur in midfacial fat with aging are poorly understood. OBJECTIVES: The aim of this study was to determine how deep cheek fat volume is predicted by age. METHODS: We conducted retrospective cross-sectional and longitudinal studies of patients based on facial computed tomography (CT) scans. In the cross-sectional cohort, multiple linear regression analysis was performed to model the relations between age and deep cheek fat volumes. In the longitudinal analysis, changes to deep cheek fat volumes were tracked among subjects who underwent multiple facial CT scans. RESULTS: The cross-sectional cohort comprised 109 patients. The mean (SD) age of the subjects was 59.7 (15.0) years (range, 21.7-91.1 years). A linear regression analysis showed that increasing age was associated with increasing deep cheek fat volume (ß = 0.015, P < 0.001). Additional regression analyses showed that the gain of fat with aging was more pronounced in the caudal aspect of the cheek (ß = 0.007, P < 0.001) than in the cephalad (ß = 0.005, P < 0.001). Twenty-three subjects were identified for longitudinal analysis. The mean (SD) ages at initial and final imaging time points were 50.0 (5.8) and 60.3 (5.2) years. In the deep fat compartment, there was an average gain of 0.23 mL over 10.3 years (P = 0.03). CONCLUSIONS: Age is an important predictor of midfacial deep cheek fat volume. In this study, there is no evidence of adipose volume loss in the deep cheek compartment. Rather, aging was associated with an increase in deep cheek fat, possibly reflecting pseudoherniation of buccal fat.

Neck Deformities in Plastic Surgery.

This article provides facial plastic surgeons with the insight to avoid and address common pitfalls in neck procedures. Many aesthetic issues are created from overtreatment or undertreatment of components of the neck. Using the platysma muscle as the divide, ease of access to superficial anatomy leads to overtreatment problems, whereas difficulty of access to deeper structures leads to undertreatment problems and to overall imbalances. Strategies to accurately assess and treat all structures of the neck proportionally can be used to both avoid and treat any neck aesthetic issues. The advent of minimally invasive techniques has resulted in new complications.

Patterns of Change in Facial Skeletal Aging.

IMPORTANCE: Research in facial aging has focused on soft-tissue changes rather than bony changes despite evidence of the importance of underlying bony structural changes. Research has also been limited by comparing different patients in separate age groups rather than the same patients over time. OBJECTIVE: To longitudinally document patterns of change in the facial skeleton and determine a consistent methodology for measuring these changes. DESIGN, SETTING, AND PARTICIPANTS: Case series study of university hospital system records using facial computed tomographic (CT) images timed at least 8 years apart in adults initially aged 40 to 55 years with no history of facial surgery who required repeated facial imaging that included the entire midface and cranium. MAIN OUTCOMES AND MEASURES: Face CTs were analyzed for 3-dimensional constructions and 2-dimensional measurements to document changes in glabellar, piriform, and maxillary angles and piriform height and width. RESULTS: Fourteen patients (5 men, 9 women; mean [SD] age, 51.1 [5.8] years) with mean (SD) follow-up of 9.7 (1.4) years were eligible for 2-dimensional analysis, which revealed statistically significant decreases in mean (SD) glabellar angles (from 68.8° [7.6°] to 66.5° [8.6°]) and maxillary angles on both the right (from 82.5° [6.3°] to 81.0° [7.1°]) and left (from 83.0° [5.8°] to 81.0° [7.0°]), as well as increases in mean (SD) piriform width (from 24.5 [1.6] mm to 25.5 [1.3] mm). Nine patients (3 men, 6 women; mean [SD] age, 51.4 [6.3] years) with mean (SD) follow-up imaging at 9.6 (1.5) years were eligible for 3-dimensional analysis, which revealed statistically significant decreases in mean (SD) maxillary angles (from 56.5° [6.6°] to 51.6° [7.6°]) and piriform angles (from 50.8° [3.4°] to 49.1° [3.4°]). Statistically significant differences between the sexes were also noted: Initial mean (SD) glabellar angle for men was 61.7° (5.7°) vs 72.7° (5.4°) for women, with final values of 57.9° (4.9°) vs 71.2° (6.0°). Mean (SD) maxillary angle initial values were 87.8° (6.1°) (right) and 87.1° (4.9°) (left) for men, with 79.6° (4.3°) and 80.6° (5.0°) for women, respectively. Final values were 87.0° (4.4°) and 86.9° (4.1°) for men and 77.7° (6.1°) and 77.7° (6.2°) for women, respectively. Mean (SD) piriform height for men was 35.0 (2.0) mm initially and 35.5 (2.1) mm finally, vs 31.3 (2.8) and 31.6 (3.0) mm for women, respectively. CONCLUSIONS AND RELEVANCE: Our pilot study of repeated CT images of patients over several years supports previous studies of bony facial aging and further characterizes these changes. This study is the first, to our knowledge, to document bony changes of the face in the same group of patients at different time points to better characterize facial aging. We also detail an improved methodology to study bony aging to contribute to additional research in the field. LEVEL OF EVIDENCE: NA.

Illusion of volume loss.

Facial aging can create an appearance of volume loss and responds to volume enhancement in certain clinical scenarios. Actual fat loss is an illusion created by the inter-relationship of the different tissue types. The purpose of this article is to provide the anatomical, clinical, and research evidence to differentiate the contributions to facial aging from gravity's effects on soft tissue, fat loss, and skeletal remodeling, explaining the illusion.

Deep plane face lifting for midface rejuvenation.

The deep-plane midface lift offers many advantages in midface rejuvenation. Anatomic analysis of aging and embryologic evidence both support surgical facial "degloving" in the sub-SMAS plane and resuspension of the platysma/SMAS unit. This approach offers more complete repositioning of facial soft tissue compared with nonsurgical techniques, delivering accurate, direct treatment of deeper anatomic aspects of facial aging. The well-vascularized deep-plane flap minimizes complications. Outcomes can be maximized because tension exists "invisibly," only at the fascia level. Consistent, natural,and long-lasting aesthetic results are achieved.

The deep-plane approach to neck rejuvenation.

This article provides the facial plastic surgeon with anatomic and embryologic evidence to support the use of the deep-plane rhytidectomy for optimal treatment of the aging neck. An anatomic basis is established that demonstrates this technique's ability to maximize neck rejuvenation through its direct relationship to midface soft-tissue mobilization. A detailed description of the procedure, aimed at providing safe and consistent results, is presented with insights into anatomic landmarks, technical nuances, and alternative approaches to facial variations.

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

OBJECTIVE: To define whether duration of anesthesia is an indicator of patient morbidity and mortality in facial plastic surgery performed in an accredited office-based surgical facility. DESIGN: A prospective and retrospective outcomes analysis of 1200 consecutive patients who underwent facial plastic surgery from July 1995 to February 2005. Outcomes of patients who underwent surgery with anesthesia for less than 240 minutes were compared with those of patients who underwent surgery with anesthesia for more than 240 minutes. RESULTS: Of the 1200 cases analyzed, in 1032 (86%), duration of anesthesia was longer than 240 minutes. There were no deaths and no cases of myocardial infarction or pulmonary embolism in this study group. Morbidity in the 1200 cases was reported as follows: 1 case of respiratory failure, 1 case of central nervous system deficit, 1 case of adverse reaction to medication, and 1 case that required transfer to a hospital. There were 6 cases of prolonged recovery from anesthesia. Incidences of major morbidity in the group of 168 patients (14%) whose anesthesia lasted less than 240 minutes were the same as in the group whose anesthesia lasted more than 240 minutes. CONCLUSIONS: In an accredited office-based facial plastic surgery facility, anesthesia duration is not an indicator of patient morbidity and mortality. Combined facial plastic surgery procedures, using general anesthesia, can be accomplished safely in the office-based environment, and inpatient care would not have altered morbidity in this study group.