Evaluating the effectiveness and safety of radiofrequency for face and neck rejuvenation: A systematic review.

BACKGROUND: Radiofrequency technology has emerged as a treatment for aesthetic rejuvenation. OBJECTIVE: To examine radiofrequency for facial and neck rejuvenation, clinical studies were assessed on effectiveness and safety of radiofrequency for acne, acne scars, and facial aging by subjective and objective measures. METHODS: A systematic literature review was performed. Eligibility criteria included articles in English, primary literature, clinical or ex vivo studies, use of radiofrequency, and face or neck treatment. Ablative techniques, home-use devices, combined modalities, and studies unrelated to rejuvenation were excluded. All studies were appraised for quality and biases. RESULTS: We identified 121 articles. Radiofrequency effectively treated acne by reducing sebum levels and lesion count and improving acne scars. Radiofrequency demonstrated a volumetric reduction in facial fat, and improved skin laxity, elasticity, and global skin aesthetic. Patient satisfaction was higher for those desiring modest rejuvenation. There were histological changes consistent with repair response, neocollagenesis, and neoelastinogenesis. Radiofrequency was safe apart from one patient who developed a neck fistula. CONCLUSION: Most studies demonstrated radiofrequency treatment of acne, scars, or facial rhytids had positive subjective improvement ratings. Objective studies demonstrated reduction of acne, decreased scarring, lifting effect, improvement in elasticity and collagen, volumetric fat changes, and wrinkle reduction.

Subperiosteal Midface Lift with Sub-Superficial Musculoaponeuritic System Rhytidectomy.

The subperiosteal midface lift is a powerful tool that allows the surgeon to reposition the SOOF and malar fat pad in a vertical direction. Additionally, it significantly softens deep nasolabial folds. Its effect, however, is minimal with regards to addressing the jowl, jawline, gonial angle and cervicomental angle. Combining the subperiosteal midface lift with an extended sub-SMAS rhytidectomy addresses the pre-jowl sulcus by releasing the mandibular ligament. The jawline and gonial angle become more defined with the transposition and suspension of the SMAS flap. The SMAS transposition flap along with the suspension of the platysma flap to the mastoid fascia support the submandibular glands and deepen the cervicomental angle. These two approaches are valuable additions to the surgeons armamentarium and can yield excellent results in carefully selected patients.

The Selection of Facelift Approach on the Basis of Midfacial Ptosis.

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

Endoscopic Browplasty.

The endoscopic brow lift has become an established procedure that can safely and reliably rejuvenate the upper third of the face. The authors discuss relevant anatomy and considerations for patient selection to optimize surgical outcomes. A detailed review of surgical technique is presented, and the potential complications and means to reduce them are discussed.

Surgical Anatomy of the Upper Face and Forehead.

Aesthetic ideals regarding proportion and balance of the face have existed for centuries. The upper third of the face, including the brow, forehead, and temple, provides an important contribution to the overall facial aesthetic. This is especially true given how the brow frames the eyes, and the eyes serve as the key focal point in our interactions with others. There exists a variety of surgical and nonsurgical procedures aimed at improving the aesthetic of the upper portion of the face, and a thorough knowledge of the surgical anatomy of the upper face and forehead is critical to their successful execution.

Effects of the Tongue-in-Groove Maneuver on Nasal Tip Rotation.

BACKGROUND: A change in nasal tip rotation is a very common maneuver performed during rhinoplasty. Among the many techniques used to achieve this goal is the tongue-in-groove (TIG). OBJECTIVES: This study addresses the long-term effect of the TIG on the nasal tip rotation 1 year after rhinoplasty. METHODS: The authors prospectively identified patients who were submitted to a rhinoplasty with a TIG maneuver over a period of 1 year. The angle of rotation was measured along the nostril axis angle. The data were analyzed using the t test and a linear regression model. RESULTS: Seventeen patients were included. The average preoperative tip rotation was 93.95° (SD, 3.12°). Immediate postoperative tip rotation averaged 114.47° (SD, 3.79°). At the 1-year follow-up appointment, the tip rotation averaged 106.55° (SD, 3.54°). There was a significant loss of rotation at the 1-year postoperative visit (P < 0.0001), with an average loss of 7.9° (SD, 3.25°), which amounted to 6.8%. The preoperative rotation didn't affect the amount of loss of rotation (P = 0.04). It can be estimated that, for every degree of rotation that is changed at surgery, the tip can be expected to lose 0.35 degrees over the first year. CONCLUSIONS: TIG is a more dependable technique than the ones that rely on healing and contraction to obtain rotation. Our data demonstrated a significant loss of rotation during the first year. This suggests that the surgeon needs to slightly overcorrect the tip rotation to account for this loss.

Endoscopic-assisted facelifting.

Over the past two decades the use of endoscopes for facial rejuvenation gained wide popularity due to its reliable and reproducible results and limitation of the morbidity related to the open approaches. A thorough knowledge of the anatomy is of paramount importance to safely release all the fascial attachments while avoiding injuries to the facial nerve. The authors find the endoscopic forehead midface lift to be a reliable and safe procedure for facial rejuvenation.

Creating elegance and refinement at the nasal tip.

Enhancing nasal tip definition requires a three-dimensional approach encompassing both form and function. Dome refinements achieved during surgery should be created with sufficient integrity to withstand postoperative healing forces. Stabilizing the nasal base is the first component of dome alterations and prevents loss of tip rotation and projection. Structural grafting can be used to enhance tip definition and at the same time adds support to the cartilaginous framework. Tip shield grafts camouflage dome asymmetries, establish the tip-defining point, and enhance the supratip break. Shield grafts can be placed in all skin types with appropriate contouring and camouflaging techniques.

Management of the aging nose.

As a growing segment of our population, mature patients seeking rhinoplasty for both functional and aesthetic reasons will increasingly be encountered by the facial plastic surgeon. The aging process is characterized by a gradual derotation and deprojection of the nasal tip. This article provides an overview of versatile and proven techniques that may be applied to the majority of aging nose rhinoplasty cases and that have been found to yield predictable and lasting results.

Lower eyelid aesthetics after endoscopic forehead midface-lift.

OBJECTIVE: To assess and quantitate the immediate effect of endoscopic forehead midface-lift on infraorbital hollowing and lower eyelid skin excision. METHODS: Twenty-five patients who underwent an endoscopic forehead midface-lift with a lower eyelid blepharoplasty or lower eyelid blepharoplasty without a midface-lift between January 1, 2005, and May 15, 2005, were included in the study. Preoperative and immediate postoperative measurements of the vertical height of the lower eyelid were taken in all patients. The change in the vertical height of the lower eyelid after endoscopic forehead midface-lift with blepharoplasty was compared with the change in lower eyelid height after either transconjunctival or lower eyelid skin pinch blepharoplasty or skin muscle flap blepharoplasty alone. The amount of lower eyelid skin excised after endoscopic forehead midface-lift with blepharoplasty was compared with both transconjunctival or lower eyelid skin pinch blepharoplasty and skin muscle flap blepharoplasty when a midface-lift was not performed. RESULTS: The average change in the vertical height of the lower eyelid after the endoscopic forehead midface-lift was 5 mm. Lower eyelid blepharoplasty alone, whether transconjunctival with skin pinch or skin muscle flap, did not affect the vertical height of the lower eyelid. The change in the vertical height of the lower eyelid with midface surgery over blepharoplasty alone was statistically significant (P < .001). The average amount of lower eyelid skin excised after endoscopic forehead midface-lift and lower eyelid skin pinch was 7.0 mm compared with 5.5 mm for both the transconjunctival lower eyelid skin pinch and the skin muscle flap techniques. The difference in skin excision when a midface-lift was performed compared with blepharoplasty alone was statistically significant (P = .008). CONCLUSIONS: The endoscopic forehead midface-lift can reduce the vertical height of the lower eyelid by an average of 5 mm and allows more skin excision over blepharoplasty alone. The endoscopic forehead midface-lift is a powerful tool for decreasing the vertical height of the lower eyelid, lessening infraorbital hollowing, and improving dermatochalasis.

Synthetic facial implants.

This article presents a range of synthetic implant materials for use in facial plastic surgery. The authors discuss alternatives to autogenous tissue transfer in terms of biocompatibility, technique, complications, controversies, and cautions. The reader is presented information about a range of synthetic implant materials such as silicone, polyester fiber, polyamide mesh, metal, polyethylene, polyacrylamide gel, hydroxyapatite, polylactic acid, collagen, and others.

The Korean American woman's nose: an in-depth nasal photogrammatic analysis.

OBJECTIVES: To assess the differences in nasal anthropometric measurements between Korean American women and North American white women and to perform an in-depth nasal index calculation. METHODS: This anthropometric survey included a volunteer sample of Korean American women (n = 72) aged 18 to 35 years with Korean parents and no previous nasal surgery or trauma to the nose. Standardized and referenced frontal, lateral, and basal photographs of the nose were taken of the subjects and 22 standard anthropometric measurements of the nose were determined. Results were compared with published standards for North American white women. In addition, 18 nasal indices were calculated and compared with the published standards for North American white women. RESULTS: The Korean American woman's nose did not fit the neoclassic facial canons. Compared with North American white women, 20 of 22 nasal measurements in Korean American women were found to be significantly different. Nasal indices also revealed significant differences in 16 of the 18 that were calculated. The Korean American woman's nose exhibits less rotation, has a flatter dorsum, and is more flared at the alae, with less definition of the nasal tip. CONCLUSIONS: The average Korean American and North American white female nasal anthropometric measurements are very different. As cosmetic surgery becomes more popular among Asian Americans, our findings bolster the need for a broader view of facial analysis and transcultural aesthetics.

Microtia reconstruction.

Success in microtia surgery requires meticulous patient education, planning, technique, and follow-through. When these principles are followed, excellent results as well as tremendous satisfaction are achievable for both the patient and surgeon.

Effects of endoscopic forehead/midface-lift on lower eyelid tension.

OBJECTIVE: To evaluate and quantify the increase in lower eyelid tension (stress) after endoscopic forehead/midface-lift in a cohort of patients with normal lower eyelid function preoperatively. METHODS: A prospective nonrandomized study was conducted at a private facial plastic surgery practice and ambulatory surgical center on 22 patients who underwent subperiosteal endoscopic forehead/midface-lift from October 2000 to June 2002. Patients were evaluated preoperatively, 4 to 6 months postoperatively, and approximately 12 months postoperatively. RESULTS: Compared with preoperative lower eyelid tension, there was a 4- to 5-fold increase in lower eyelid tension at 3 and 5 mm of distraction immediately after the operation. Four to 6 months after the operation, lower eyelid tension decreased but was still 2 to 3 times that of preoperative values. Twelve-month measurements for the 15 patients who remained in the study (the other 7 patients were lost to follow-up or refused to have measurements taken) showed that lower eyelid tension was 1.7 to 1.9 times preoperative values. CONCLUSIONS: Our results show that lower eyelid tension increases following endoscopic forehead/midface-lift and that this increased tension is long lasting and quantifiable 12 months after surgery.

Pitfalls of midface surgery.

The endoscopic forehead midface lift is perhaps the most powerful tool has been made available to the facial aesthetic surgeon in the last 10 years. Although this technique can reap the greatest rewards, it is also fraught with the greatest peril. A difficult dissection, prolonged period of edema, and numerous other pitfalls have tempered enthusiasm among facial aesthetic surgeons for this powerful technique. Nonetheless, the midface lift can be performed both safely and effectively. Through careful analysis of the pitfalls of midface surgery, one can adopt principles that help prevent or minimize potential complications. Such an approach can maximize the surgical benefit to the patient and lessen the anxiety surrounding the procedure for the patient and surgeon alike.

Transtemporal midface lifting to blend the lower eyelid-cheek junction.

When examining the results of this technique, improvement is noticed in the infraorbital hollowing, midface tissue ptosis, depth of nasolabial folds, and degree of jowling. The greatest overall improvement is the extent of midface ptosis and infraorbital hollowing at the lower eyelid-cheek junction followed by improvement in the nasolabial region. Improvement in jowling was common but less significant than the improvement of the midface structures. The authors think that this dramatic improvement is owing to multiple factors. With wide and complete release of the central and lateral midfacial structures, the en bloc suspension of the SOOF and malar fat pad is thoroughly accomplished. Unlike other midfacial techniques, the transtemporal midface achieves pull in 2 vectors, directing the repositioning of tissuesboth superiorly and laterally. The superior vector repositions the SOOF and malar fat pad over the bony infraorbital rim and malar/zygomatic complex, whereas the lateral pull effaces the nasolabialfold. This superior vector more accurately reverses the forces of aging displayed on the ptotic midface. Lastly, although this technique is not designed primarily to eliminate jowling at the mandible, it has been noted that elevation of 1.0 to 1.5 cm of skin overlying the mandible is typical. Although the endoscopic forehead midface lift is not without its complications or pitfalls, all of these can be minimized, easily managed, or avoided completely through the intraoperative techniques and postoperative care. Careful and deliberate preoperative counseling of patients regarding the possible bumps in the road to recovery is critical. By using the techniques available to limit and manage complications and setting appropriate patient expectations should these complications occur, the endoscopic forehead midface lift can become an extremely powerful and safe technique in the facial cosmetic surgeon's armamentarium to efface the lid-cheek junction with a high degree of patient satisfaction.

Quantitative analysis of lip appearance after V-Y lip augmentation.

OBJECTIVE: To quantitatively analyze the changes in the 3-dimensional appearance of the lips after V-Y lip advancement for lip augmentation. DESIGN: A retrospective single-blinded study of patients who had a V-Y lip augmentation from January 1999 to December 2001. Standardized anterior and lateral preoperative and postoperative digital photographs of patients were analyzed using digital imaging software to quantify postoperative changes. RESULTS: There were statistically significant increases in the vertical height of the upper red lip (75%) and in the area of the upper red lip (66%). The upper and lower lip projection increased by approximately 40%. The vertical distance from the apex to the trough of Cupid's bow increased by 56.7%. CONCLUSIONS: The V-Y lip advancement for lip augmentation increases the parameters that characterize the fullness of the upper lip and enhances the vermilion "pout" and projection of the upper and lower lip. It also increases the curvature of Cupid's bow.

Anatomical guides to precisely localize the frontal branch of the facial nerve.

OBJECTIVE: To define the relationship between the frontal branch of the facial nerve and a series of blood vessels that are encountered during endoscopic forehead procedures. DESIGN: Anatomical study using 6 fresh cadavers (12 sides). RESULTS: In 11 of 12 dissected specimens, the blood vessels in the temporal region were found to lie within 2 mm of the frontal branch of the facial nerve. CONCLUSIONS: We believe that a series of veins encountered during endoscopic forehead procedures provide the surgeon with the ability to identify the precise location of the frontal branch of the facial nerve. During endoscopic surgery, these vessels are found in a plane between the deep temporal fascia (below) and the superficial temporal fascia (above). We believe that these vessels can be thought of as arrows pointing superiorly to a frontal branch of the facial nerve as it courses through the superficial temporal fascia.

Surgical management of concavities of the distal nose.

Normal topographic anatomy of the distal nose is a reflection of the delicate integration between the lower lateral cartilage, the upper lateral cartilage, the sep-tum, and skin. Understanding these relationships will help the rhinoplasty surgeon diagnose and treat con-cavities of the distal nose. Most patients present with a hybrid of these defects. For example, the patient in Fig. 19 presented for a primary rhinoplasty. A variety of concavities can be noted and include dorsal septal deflection, upper lateral cartilage avulsion on the left,bilateral lower lateral complete concavities, and the beginning of a dorsal depression (Fig. 19A-I). The nasal skeleton and the skin and soft tissue are normally in equilibrium, but trauma and reduction rhino-plasty disrupts this equilibrium. Skeletal distortion can lead to septal deflection, middle vault collapse, or alar buckling [20]. It is important to realize that correction of deflection or depression by excision needs to be balanced with augmentation, which provides balance for the previously disequilibrated skeletal and soft tissue forces. Augmentation can be done with spreader grafts, tip grafts, columellar strut, and dorsal grafts. A patient's soft tissue envelope will also play a major role in the success of a septorhinoplasty. The surgical principles of septorhinoplasty such as judicious resculpting of the cartilaginous framework, respect of major tip support, tip grafting technique, and postoperative tissue contraction still apply and must be placed in conjunction with repairing a pathological topographic concavity.

Midface lift: panel discussion.

UNLABELLED: What is the most efficient dissection plane to perform midface lift? What is the best incision/approach (preauricular, transtemporal, transoral)? Why? What specific technique do you use? Why? What is the best method/substance for adding volume to midface lifting? In approaching the midface, how do you see the relationship of blepharoplasty versus fillers versus midface lifting? ANALYSIS: How has your procedure or approach evolved over the past 5 years? What have you learned, first-person experience, in doing this procedure?