Suture Net Technique for Mid-face Superficial Fat Compartments Restoration.

BACKGROUND: Facial fold and groove formation is influenced by the ptosis of the superficial fat compartments in the mid-face region. OBJECTIVE: This study aimed to design a facial rejuvenation technique that targets sagging of the mid-face fat compartments and achieves a youthful facial configuration. MATERIALS AND METHODS: A total of 102 patients underwent suture net restoration. Each specific ptosis fat compartment was carefully lifted and held at the regional facial ligaments to effectively restore volume distribution. Patient outcomes were evaluated through preoperative and postoperative photography comparison, 3-D photographic analysis, and postoperative evaluations. RESULTS: Significant mid-cheek rejuvenation was observed. The procedure resulted in a remarkable, 10.89% increase in malar projection. The nasolabial fold improved by at least 1 grade in 61.43% of the patients and by at least 2 grades in 37.14%. A total of 87.65% of the patients expressed high satisfaction or satisfaction with the outcomes of the procedure. CONCLUSION: By specifically targeting the mid-face ptosis fat compartments, the technique demonstrated significant enhancements of both the nasolabial fold and the malar projection. The results indicate that this novel technique holds promise as an efficient approach for satisfactorily addressing facial aging concerns.

Free Dermal Fat Grafting: A Novel Technique for the Correction of Nasolabial Folds During Facelift Surgery.

BACKGROUND: Traditional facelift surgery does not behave well in the correction of nasolabial folds, which is a common clinical problem and needed to be improved. OBJECTIVES: To investigate the effect of free dermal fat grafting during facelift surgery for the treatment of nasolabial folds. METHODS: This prospective cohort study involved 80 patients with moderate to severe nasolabial folds and facial skin dermatolysis. Fifty of them underwent facelift surgery combined with free dermal fat grafting, and 30 of them underwent traditional facelift surgery. These patients were followed up 2 months, 6 months, and 1 year after the surgery to evaluate the effect. RESULTS: The difference in Wrinkle Severity Rating Scale (WSRS) scores, assessed at each follow-up, between the patients who underwent and did not undergo free dermal fat grafting during facelift surgery, was statistically significant. For patients who underwent free dermal fat grafting during facelift surgery, the WSRS scores assessed at 2 months, 6 months, and 1 year after the surgery were significantly different from those before the surgery. The analytic results of FACE-Q indicated a high level of overall satisfaction rate. No major complications were recorded. CONCLUSIONS: Free dermal fat as a filler for nasolabial folds can achieve excellent therapeutic effect. The combination of facelift surgery with free dermal fat grafting for the treatment of nasolabial folds can provide very good long-term results and a high patient satisfaction rate for patients with symptoms of facial aging such as facial dermatolysis, obvious wrinkles, and deep nasolabial folds.

Evaluating Predictors of Patient Satisfaction With Facial Appearance After Mohs Micrographic Surgery Using the FACE-Q.

BACKGROUND: Although patient satisfaction with reconstructive outcomes after facial skin cancer resection is an important consideration in Mohs surgery, there is limited information evaluating this concern using validated patient-reported outcome tools. OBJECTIVE: To characterize predictors that may be associated with increased postoperative patient satisfaction with facial appearance after Mohs surgery using the FACE-Q/Skin Cancer survey, a patient-reported outcome tool that has been validated in various studies. METHODS: A total of 202 patients who underwent Mohs surgery for facial skin cancer at the Brigham and Women's Faulkner Hospital between April 2017 and November 2021 were included after completing the postoperative Satisfaction with Facial Appearance scale (FACE-Q scale). RESULTS: Male patients were significantly more likely to have higher satisfaction scores compared with female patients (aOR 2.4, 95% CI 1.1-5.1). Increased preoperative facial satisfaction scores was directly correlated with increased postoperative facial satisfaction scores ( p < .01). Patients with tumors on the lower face/neck (aOR 3.88; 95% CI 1.4-10.7) had significantly greater satisfaction scores compared with those with tumors on their nose/nasolabial folds. CONCLUSION: Potential interventions and counseling methods can be tailored toward specific patient populations with lower satisfaction scores to increase their overall satisfaction with reconstructive outcomes.

Lifting the Anterior Midcheek and Nasolabial Fold: Introduction to the Melo Fat Pad Anatomy and Its Role in Longevity and Recurrence.

BACKGROUND: A limitation of current facelift techniques is the early postoperative reappearance of anterior midcheek laxity associated with recurrence of the nasolabial fold (NLF). OBJECTIVES: This study was undertaken to examine the regional anatomy of the anterior midcheek and NLF with a focus on explaining the early recurrence phenomenon and to explore the possibility of alternative surgical methods that prolong NLF correction. METHODS: Fifty cadaver heads were studied (16 embalmed, 34 fresh; mean age, 75 years). Following preliminary dissections and macrosectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination, and microcomputed tomography. Mechanical testing of the melo fat pad (MFP) and skin was performed to gain insight on which structure is responsible for transmission of the lifting tension in a composite facelift procedure. RESULTS: Anatomic dissections, sheet plastination, and microcomputed tomography demonstrated the 3-dimensional architecture and borders of the MFP. Histology of a lifted midcheek demonstrated that a composite MFP lift causes a change in connective tissue organization from a hanging-down pattern into a pulled-upward pattern, suggesting traction on the skin. Mechanical testing confirmed that, in a composite lift, despite the sutures being placed directly into the deep aspect of the MFP, the lifting tension distal to the suture is transmitted through the skin and not through the MFP. CONCLUSIONS: The usual method of performing a composite midcheek lift results in the skin, and not the MFP itself, bearing the load of the nondissected tissues distal to the lifting suture. For this reason, early recurrence of the NLF occurs following skin relaxation in the postoperative period. Accordingly, specific surgical procedures for remodeling the MFP should be explored, possibly in combination with volume restoration of the fat and bone, for more lasting improvement of the NLF.

Combination repair of nasal ala and nasolabial fold defects following Mohs micrographic surgery.

BACKGROUND: Repair of excisional defects involving the nose and cheek requires thoughtful planning to maintain the natural contour of the anatomical sites and optimize cosmetic outcomes. We aim to demonstrate that a combination repair of defects involving the ala and nasolabial fold with a full-thickness skin graft and a local flap can be used with good cosmesis and minimal complications. METHODS: This is a case report of a patient with skin cancer on the left ala and left nasolabial fold who underwent Mohs micrographic surgery for tumor extirpation. RESULTS: The patient and the Mohs surgeon reported satisfaction with the cosmetic and functional outcomes at the 6-month postoperative follow-up with no complications. CONCLUSION: The use of a full-thickness skin graft from a standing tissue cone and a cheek crescentic advancement flap is a viable repair option for Mohs micrographic surgery defects involving the ala and nasolabial fold.

Modified Lengthening Temporalis Myoplasty Using an Intraoral Approach.

BACKGROUND: Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure. METHOD: The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively. RESULTS: The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision. DISCUSSION: The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

Facelift Techniques: An Overview.

Facelift techniques can be classified according to the depth and extent of the dissection applied. Imbrication and plication of the superficial musculoaponeurotic system (SMAS) referred to as "SMAS lifts" or "classical facelifts" are the most commonly used techniques. Plication techniques involve in-folding of the SMAS and suture suspension without any SMAS incision whereas imbrication techniques involve a SMAS incision with a portion of the SMAS either removed or transposed with or without limited sub-SMAS dissection. Aging changes in the lower face and neck can be successfully treated with SMAS lift techniques. However, there is no lifting effect at midface level or improvement in the nasolabial folds since the retaining (zygomatic cutaneous and masseteric cutaneous) ligaments that prevent the transmission of traction to the malar portion of the facelift dissection are not released. Extended facelift techniques involve surgical release of these ligaments, and produce combined, balanced, and harmonious rejuvenation of the midface, cheek, and lower face without requiring a separate midface lift procedure. There are different techniques having similar extended midface dissections with some variations: The extended SMAS technique involves a long skin flap and a distinct SMAS flap dissected and pulled separately. The high SMAS technique has a similar dissection but involves a higher SMAS flap along the superior border of the zygomatic arch. The deep plane facelift involves undermining of skin-SMAS flap as a single unit following a more limited subcutaneous dissection. In the composite plane facelift, in addition to deep plane facelift dissection, the lower part of the orbicularis oculi muscle is also dissected and included in the flap. As they have a single unit, deep and composite flap facelifts allow excellent blood supply to the overlying skin. In this article, various facelift techniques are discussed in detail in line with the relevant surgical anatomy.

Cable-Stayed Face Lift: An Innovative Short-Scar Lift for Better Correction of Nasolabial Folds in East Asians.

BACKGROUND: The improvement of nasolabial folds by either lateral superficial musculoaponeurotic system rhytidectomy or minimal access cranial suspension lift alone is commonly performed, but patient satisfaction is often limited in East Asians. An innovative technique, termed the cable-stayed face lift, which combines the strengths of lateral superficial musculoaponeurotic system rhytidectomy and minimal access cranial suspension lift, was developed for improved results. METHODS: Between 2016 and 2019, 20 cable-stayed face lifts were performed in a single hospital. Two plastic surgeons independently evaluated postsurgery outcomes using a five-point Likert scale, where 5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse. Patient satisfaction was assessed by relevant items from the FACE-Q questionnaire. RESULTS: Twenty patients with a mean age of 51 years underwent face-lift surgery. The mean follow-up ± SD was 11.3 ± 9.8 months. The five-point Likert scale score evaluated by surgeons was 3.65 ± 1.08. Patient-perceived age visual analogue scale (7.8 ± 4.4) exhibited a difference between preoperative actual age and postoperative apparent age. Patients demonstrated high satisfaction with outcome (67.5 ± 16.2) and satisfaction with lower face and jawline (76.2 ± 14.9). No major complication, hematoma, or seroma was observed. CONCLUSION: The authors' approach-cable-stayed face lift-offers a good alternative to provide a more effective effacement of nasolabial folds, by lifting the nasolabial folds with parallel vector and lower face and neck with the vertical vector. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Rejuvenation with Concentrated Lipograft-A 12 Month Follow-Up Study.

Lipofilling is a popular technique to treat volume loss in aging patients. The isolated adipose tissue is composed of adipocytes and stromal vascular fraction cells, which include adipose-derived stem cells (ASC). We hypothesize that the patient's wrinkle severity scale (WSS) and patient's satisfaction on the global aesthetic improvement scale (GAIS) can be improved after using concentrated lipoaspirate. Fourteen patients (54 years ± 11.09 years) with volume loss in the midface area underwent waterjet-assisted liposuction (Human Med AG, Schwerin, Germany). Fat was centrifuged in an ACP Double Syringe (Arthrex GmbH, Munich, Germany) using Rotofix 32A centrifuge (Andreas Hettich, GmbH & Co.KG, Tuttlingen, Germany). Homogenization was performed using the double syringe and a 1.4 mm female-female luerlock connector. After a second centrifugation, patients received periorbital (PO) and nasolabial (NL) lipografting. ASC count was performed after enzymatical digestion. Vitality of cells was assessed using a resazurin assay. During long-term follow up (12 months, n = 10), we found a high patient's satisfaction (GAIS 1+/-0.52) and a good improvement of the WSS during short- and long-term follow-up. The ASC count of processed lipoaspirate was 2.1-fold higher than of unprocessed lipoaspirate (p < 0.001). The difference of ASC in sedimented and simply centrifuged lipoaspirate was also significant (p < 0.05). Facial rejuvenation with concentrated fat graft offers good results concerning objective aesthetic outcome and patient's satisfaction.

The feasibility of intranasal endoscopic microwave ablation on the removal of nasolabial cyst: Preliminary case series.

OBJECTIVE: The aim of this study was to investigate the clinical effect of the removal of nasolabial cyst via intranasal endoscopic microwave ablation (MWA). METHODS AND MATERIALS: The patients with nasolabial cyst were ablated through intranasal endoscopic MWA. Postoperative pain intensity was measured via visual analogue scale (VAS), post-operative complications were recorded. RESULTS: Of the 31 patients with unilateral nasolabial cyst, the main complaint was a gradually increasing mass in the nasal alar and upper lip, other complaint included nasal obstruction (11/31,35.5%), localized pain (21,67.7%), and erythema (13/31,41.9%). All 31 patients were successfully treated with the intranasal endoscopic ablation technique in outpatient. The mean ablation duration was 5.86 ± 0.71 min. The mean VAS pain score was 2.36 ± 1.08 on postoperative. None of infection occurred. All the patients complained of mild numbness in the upper lip with an average last duration of 28.5 ± 7.9 h in patients. In addition, 4 (12.9%) patients had facial/perinasal swelling, acid bilge of maxillary teeth in 7(22.6%), and toothache in one (3.2%). The patients were followed up for 12 months without recurrence and oronasal fistula. The nasolabial cyst had integrated into a part of the nasal cavity. CONCLUSIONS: The intranasal endoscopic MWA is feasible and alternative to conventional transoral sublabial approach for removal of the nasolabial cysts in outpatient.

Three-Dimensional Description of the Angular Artery in the Nasolabial Fold.

BACKGROUND: Due to its arterial vasculature, the nasolabial sulcus is one of the most challenging facial regions to treat when trying to ameliorate the signs of facial aging. OBJECTIVES: The aim of the present study was to provide data on the 3-dimensional course of the angular artery within the nasolabial sulcus in relation to age, gender, and body mass index to increase safety during minimally invasive treatments. METHODS: Thee hundred nasolabial sulci from 75 males and 75 females of Russian Caucasian ethnic background (mean [standard deviation] age, 45.7 [18.7] years; mean body mass index, 25.14 [4.9] kg/m2) were analyzed. Bilateral multiplanar measurements were based on contrast-enhanced computed tomography cranial scans. RESULTS: Up to 3 arteries could be identified within the nasolabial sulcus: ~90% contained 1 arterial trunk, ~9% had 2 trunks, and ~1% had 3 trunks; females had more arteries than men. The artery is located at mean depths of 21.6 mm at the oral commissure and 8.9 mm at the nasal ala. The angular artery was lateral to the nasolabial sulcus in 100% of cases; the smallest distance between the artery and the nasolabial sulcus was at the oral commissure (11.91 [7.9] mm) and the greatest was at the nasal ala (13.73 [3.9] mm). CONCLUSIONS: In contrast to current concepts, the angular artery is not located strictly subdermal to the nasolabial sulcus but at a variable depth, and in 100% of the investigated cases lateral to the nasolabial sulcus. With increasing age, the depth and lateral distance between arteries and sulci reduces significantly, underscoring the need for special caution when injecting this site.

Nasolabial fold dynamics: Implications for facial paralysis and facial reanimation surgery.

OBJECTIVES: In patients with facial paralysis, facial reanimation surgery may be needed to normalize facial soft tissue function/movements. Critical for this normalization is the dynamics of the nasolabial folds (NLFs). The objective of this prospective, observational study was to determine the 3D morphologic dynamics of the NLFs in patients with unilateral facial palsy and normal subjects. SETTINGS AND SAMPLE POPULATION: 3D facial soft tissue movement data collected from adults with unilateral, facial paralysis (Bell's Palsy, n = 36); and (2) an age- and sex-frequency matched control group (n = 68). MATERIALS AND METHODS: Movement data were collected during repeated animations from participants using a video-based motion capture system. Movement in terms of displacement and asymmetry of the NLFs, nasal and circumoral regions were analyzed in the lateral, vertical and depth planes; as well as movement of the commissure and NLFs relative to the lower lip midline. Two-sample t tests were used to test for significant group differences. RESULTS: Patients NLFs had less mean displacement, greater mean asymmetry and uncoordinated movements compared with the controls. For both groups during smiling, the NLF and commissure landmarks had approximately similar magnitudes of displacement (control range = 11-14mm; patient range = 7-10mm). CONCLUSION: NLF dynamics during smiling were as significant as oral commissure excursion. Thus, an immobile NLF is an unnatural feature of facial animations. Surgical treatments that address impaired NFL movements must be considered to create a more natural surgical outcome especially during smiling.

Face Lift Using Dual Deep Tissue Support.

BACKGROUND: Utilizing the concept of Barton's high superficial musculo-aponeurotic system (SMAS) technique, the authors performed the more extensive skin-attached SMAS/platysma flap elevation and the 'dual deep tissue support' technique involving multiple plications of the parotid-masseteric fascia, repositioning of the SMAS, and platysma muscle. Our aim was to demonstrate a specific surgical procedure for face and neck lift and offer its pitfalls and outcomes. METHODS: This study included 83 patients aged between 54 and 73 years. The pre- and 10-month postoperative photographs of all patients were used to assess the extent of the nasolabial folds, the labiomental fold, and the cervical band (platysma band). Each patient's subjective aesthetic satisfaction was also evaluated. RESULTS: At 3 and 6 months postoperatively, 94% (n = 3) of patients achieved "minimal" and "mild" nasolabial folds. Most patients (89.1%, n = 74) were satisfied with their outcomes. Two minor hematomas (2.4%) occurred locally over the temporal or retro-auricular area. No incidence of skin flap necrosis or permanent facial nerve injury was observed. CONCLUSIONS: Our extensive skin-attached SMAS/platysma flap elevation with dual deep tissue support, both by multiple parotic masseteric plication and SMAS/platysma repositioning, provided not only the definite lifting effect in the immediate postoperative period, but also resulted in long-lasting lifting outcomes without remission. LEVEL OF EVIDENCE: IV.

Stimulation of collagenesis by poly-L-lactic acid (PLLA) and -glycolide polymer (PLGA)-containing absorbable suspension suture and parallel sustained clinical benefit.

BACKGROUND: Though the collagen-stimulating capacity of poly-L-lactic acid (PLLA) is well established, no data are available on collagen stimulation by the PLLA/PLGA within absorbable suspension sutures used for tissue repositioning. AIMS: To characterize collagen stimulation by absorbable suspension sutures through examination of patient biopsies and assess severity of nasolabial folds (NLF) over time. PATIENTS/METHODS: Single-center, open-label, prospective study of 25 healthy volunteers treated with absorbable suspension sutures for descent of midface tissues. Punch biopsies were collected and evaluated for total collagen content. Subject and investigators evaluated NLF severity using the Nasolabial Fold Wrinkle Assessment Score (NLF-WAS). Seventeen of 25 patients completed the collagenesis portion of the study. RESULTS: Collagen deposition was apparent at day 90 and increased significantly compared with baseline at days 180 and 270 and between days 90 and 180. Subject- and investigator-reported NLF-WAS were significantly improved at all post-treatment time points through day 270. CONCLUSIONS: Absorbable suspension sutures stimulate collagen in areas immediately adjacent to the path of the PLLA/PLGA monofilament and cones, providing mechanistic support for improvement in appearance observed in clinical studies. This neocollagenesis, coupled with repositioning by the suture's cones, makes absorbable suspension sutures a valuable tool for patients seeking facial rejuvenation.

A nasolabial fold reset technique for enhancing midface lifts in facial reanimation: Three-dimensional volumetric analysis.

Despite successfully gaining excursion after free muscle transfer for facial palsy, soft tissue asymmetry, especially around the nasolabial fold (NLF) and medial cheek, is a troublesome problem in elderly patients. An NLF reset technique that enhances midface lifts has been introduced to overcome this problem. Our study included 43 consecutive patients who underwent facial reanimation surgery with free functional muscle transfer between March 2015 and July 2017. Of these, 20 patients underwent conventional procedures and 23 underwent our NLF reset technique. Postoperative oral commissure excursion and symmetry at rest and while smiling were quantified using FACEgram (Facial Assessment by Computer Evaluation) software. To detect soft-tissue changes after surgery, three-dimensional analysis was performed using Morpheus®, a 3D, LED-based, white-structured-light scanner. The NLF group had a significantly larger postoperative mean excursion at rest (control 25.32 ± 2.80 mm vs NLF 27.42 ± 3.60 mm; p = 0.047). The mean horizontal length ratios (affected-to-healthy) revealed better symmetry in the NLF group (resting 1.05 ± 0.22, smiling 0.97 ± 0.19; p = 0.201). The three-dimensional midface volume difference was significantly lower in the NLF group. The NLF reset technique produced improved surgical outcomes. An incision made along a mirrored NLF can influence midface lifting in patients with facial palsy, with the soft tissue concentrated in the lower face mobilized superomedially.

Comparison of Hamra's and Mendelson's Models of Midface Lift.

The aim of this study was to compare Hamra's and Mendelson's models of midface lift.The terms "Hamra ST" and "Mendelson BC" were used to search PubMed, yielding 35 and 48 papers, respectively. Of the 83 abstracts, 55 were excluded and 28 full papers discussing midface lift were reviewed. Among those 28 papers, 13 were excluded because they did not have sufficient content. Among the 15 full texts, 5 mined papers were added. Thereafter, 20 papers were analyzed.Hamra's description of his surgical technique changed twice. In 1990 (The Deep-Plane Rhytidectomy), he wrote that he performed Skoog-type subsuperficial muscular aponeurotic system (SMAS) dissection to the nasolabial fold. In 1992 (Composite Rhytidectomy), however, he cited a paper insisting that the SMAS does not exist in the cheek area. He wrote that his deep-plane rhytidectomy was not a sub-SMAS procedure, stating that he dissected the cheek fat that is attached to the zygomaticus major, then repositioned the skin. This was a substantially different explanation of the dissection plane. In 1997, he stated that instead of dividing the orbicularis oculi muscle from the zygomaticus major and minor, he elevated them together in a flap. Thus, his method returned to the sub-SMAS plane. Mendelson introduced the concepts of the prezygomatic space, orbicularis-retaining ligament, and zygomatic-retaining ligament, and proposed an anatomical model.If the authors explain Hamra's zygorbicular dissection using Mendelson's model, the dissection starts just beneath the roof of the prezygomatic space, traverses the floor, and then releases the zygomatic ligament (lower boundary of the space). The authors should consider the necessity and riskiness of this release.