Facelift: Assessment of Total Platysma Muscle Transection to Prevent the Recurrence of Platysmal Bands.

INTRODUCTION: Determining which facelift technique yields the most effective long-term rejuvenation results and ensures optimal stability over time remains a significant question in cosmetic surgery: Does the most invasive surgery lead to the best long-term outcomes? This study aims to evaluate the authors' approach using total platysma muscle transection to prevent platysma band recurrence, and to provide anatomical observations supporting and justifying their procedure. MATERIAL AND METHODS: A preliminary study in anatomical basic sciences was conducted to establish the rationale for our method. A prospective single-blind study was conducted, involving eighty patients seeking facial rejuvenation with platysmal band correction. They underwent face and neck-lift procedures with total platysma transection by the same surgeon between May 2013 and May 2016. Cosmetic outcomes were assessed using the Face and Neck-Lift Objective Photo-Numerical Assessment Scale. Scores by three blind evaluators before surgery, at 1 and 5 years postoperatively, were compared using a matched T Test (p < 0.05). RESULTS: The preliminary anatomical study revealed a consistent anastomotic system between the cervical branch of the facial nerve and the branches of the cervical plexus. Incomplete platysma section during a facelift might contribute to platysma band recurrence. The clinical study demonstrated satisfactory outcomes, with significant overall appearance improvement (p < 0.00001) and no platysma band recurrence. Complication rate was low. CONCLUSION: The authors' technique achieved satisfactory long-term results with minimal complications. However, due to the lengthy operating time and steep learning curve, it should be reserved for highly motivated patients. LEVEL OF EVIDENCE II: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comprehensive Assessment of Lower-Face Volume Reduction Using Laser-Assisted Liposuction as an Additive Procedure in Asian Rhytidectomy.

The most important factor that distinguishes a youthful appearance from an aged one is the shape of the lower face. This study aimed to examine the outcome of volume reduction of the lower face using laser-assisted liposuction (SmartLipo) at the time of rhytidectomy in Asians. There were 20 patients (Group 1) for whom only extended deep-plane rhytidectomy were performed, while extended deep-plane rhytidectomy with laser-assisted liposuction was performed on 42 patients (Group 2). This study was performed retrospectively. The FACE-Q questionnaire was given to evaluate the subjective result of the patient. Efficacy was evaluated by measuring the fat quantity at the midpoint and anterior border of the masseter muscle on each side by using an ultrasound scan in Group 2. Then, the correlation between the change in the quantity of fat and the FACE-Q was investigated. The overall satisfaction, and satisfaction for the lower face, jawline, and the area under the chin were significantly higher for Group 2 for which the procedure was concurrently performed in comparison to Group 1. In Group 2, change in the fat was reduced by 21.2% (Rt.) and 22.5% (Lt.) at the mid-point and 24.5% (Rt.) and 26.4% (Lt.) at the anterior border of the masseter muscle. Changes in the fat quantity and lower face satisfaction displayed a significant correlation. With a greater reduction in fat quantity, the score of lower face satisfaction was higher. In addition, with a higher level of satisfaction for the lower face and jawline, the overall satisfaction score displayed a higher positive correlation. Laser-assisted liposuction was useful for the additive procedure at the time of rhytidectomy and improved patient's satisfaction after surgery.

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study.

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p < 0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

The Face- and Neck-Lift Objective Photo-Numerical Assessment Scale: A Complete Scale for Face-Lift Evaluation.

BACKGROUND: Success or failure of plastic surgery procedures relies on cosmetic results. Understanding the objective perception of favorable aesthetic results is critical to ensure patient satisfaction. The aim of this study was to develop and validate a new facial rating scale that could objectively assess face- and neck-lift outcomes: the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale. METHODS: One thousand White patients were included in the authors' study and assessed. To validate the authors' scale, the interrater reliability and the test-retest reliability were analyzed. The Rasch model was used as part of the scale validation process. RESULTS: Eleven scales for face- and neck-lift outcomes assessment were developed. All scales exceeded criteria for acceptability, reliability, and validity. The interrater and intrarater reliabilities were good, with a substantial or virtually perfect interrater reliability for the total score ( P = 0.15). CONCLUSIONS: The authors' results allowed us to validate the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale as a reliable and reproducible tool to assess face- and neck-lift outcomes. This scale could be also considered as an important new metric to be used in facial rejuvenation surgery clinical research.

Evaluating, Purchasing, and Incorporating High-Tech Equipment into a Facial Plastic Surgery Practice.

In this article the authors discuss and analyze technological devices also known as energy-based devices and their use in skin rejuvenation, facial contouring, skin tightening, and other applications in facial plastic surgery. Energy has been applied in some form to tissue since the beginning of recorded history. The practice of applying heat to tissue with the use of cauters was used for thousands of years as an invaluable method of controlling hemorrhage. Continuous improvement of methods for using the beneficial effects of heat on tissue eventually led to the development of the basic concepts of electrosurgery we know today.

Regenerative application of stromal vascular fraction cells enhanced fat graft maintenance: clinical assessment in face rejuvenation.

OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of the use of FG-SVFs in face rejuvenation for esthetic improvement. METHODS: 33 female patients affected by face's soft-tissue defects with loss of volume, study group (SG), were treated with FG-SVFs, comparing results with a control group (CG) (n = 30) treated with fat graft not enhanced (FG). Clinical evaluation, a photographic assessment, magnetic resonance imaging (MRI), and ultrasound (US) were performed. Post-operative follow-up was performed at 1, 3, 7, 12, 24, 48, weeks, and then annually. RESULTS: SG patients showed 61% maintenance of the contour restoring and of volume after 3 years compared with the CG treated with FG, who showed 31% maintenance. 60.7% (n = 20) of SG patients, presented an increase of 6.6 mm in the soft tissue volume after 36 months, which was reported in only 33,3% (n = 10) of the CG. Volumetric persistence in the SG was higher than that in the CG (p <. 0001 vs. CG). MRI and US moreover confirmed the absence of important side effects, as fat necrosis, and cytosteatonecrotic areas. CONCLUSIONS: The use of FG-SVFs was safe and effective in this series of a case treated.

Readability Assessment of Online Rhytidectomy Patient Information.

Patients frequently access online resources for medical information. The National Institutes of Health and the American Medical Association recommend that to be understood by the average American, patient information should be presented at or below the sixth to seventh academic grade level. The popularity of rhytidectomy (facelift) is rising, and providers are frequently using the Internet to attract patients. All rhytidectomy information provided by 100 private practice Web sites in New York City, Los Angeles, Chicago, Houston, and Phoenix was analyzed using Readable.io software. The information was also assessed using the Flesch-Kincaid Grade Level, Gunning-Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook, Automated Readability Index, Flesch Reading Ease Score, and Fry Reading Graph tools. Analyzed material was written at a higher academic grade level than recommended for the average American. The overall average grade level was 10.99 ± 1.39. Online patient education materials about rhytidectomy provided by private practice clinics in 5 major cities of the United States were written at academic grade levels above the National Institutes of Health and American Medical Association recommended levels. This may lead to rhytidectomy patients having unrealistic or inaccurate expectations related to their surgical procedure.

Assessment of the Impact of Perioral Rejuvenation With Hyaluronic Acid Filler on Projected First Impressions and Mood Perceptions.

BACKGROUND: Small-particle hyaluronic acid filler is approved for lip augmentation and correction of perioral rhytides. Treatment with this product may improve facial aesthetics, projected first impression, and self-perception of mood. OBJECTIVE: To determine the effect of perioral rejuvenation with hyaluronic acid on patient perception of mood and projected first impression. MATERIALS AND METHODS: Seventeen subjects underwent perioral rejuvenation treatment with small-particle hyaluronic acid filler. Each subject underwent photography and completed 2 surveys measuring self-perception of mood before treatment and after achieving an optimal cosmetic result. Aesthetic improvement with treatment was assessed using the Global Aesthetic Improvement Scale and the Oral Commissure Severity and Perioral Line Severity scales. Seventeen hundred blinded evaluators rated pre-treatment and post-treatment photographs of the subjects using a First Impressions Questionnaire. RESULTS: Perioral filler treatment significantly improved pre-treatment and post-treatment scores for happiness within the Happiness Measures Scale. This treatment was found to significantly improve projected first impression across all categories. CONCLUSION: Small-particle hyaluronic acid filler treatment for perioral rejuvenation is an effective method for improving physical appearance as well as first impressions. Larger studies are necessary to verify whether perioral rejuvenation with hyaluronic acid offers enhanced self-perception of mood.

Assessment of efficacy and safety of a fractionated bipolar radiofrequency device for the treatment of lower face wrinkles and laxity.

Skin aging, as a natural course, is a gradual process. It can be classified as either intrinsic or photo-aging. In recent years, as the attention to lower face wrinkles and laxity has raised significantly, the demands to facial rejuvenation also increased, along with a variety of technologies coming into being. Fractional bipolar RF as a novel means of rejuvenation has been used in clinical practice, but questions remain in terms of its efficacy and safety. Considering a large population in our country and huge demands for skin tightening, we did this research to evaluate the efficacy and safety of fractional bipolar radiofrequency.

Two years' outcome of thread lifting with absorbable barbed PDO threads: Innovative score for objective and subjective assessment.

BACKGROUND: Thread-lifting rejuvenation procedures have evolved again, with the development of absorbable threads. Although they have gained popularity among plastic surgeons and dermatologists, very few articles have been written in literature about absorbable threads. This study aims to evaluate two years' outcome of thread lifting using absorbable barbed threads for facial rejuvenation. METHODS: Prospective comparative stud both objectively and subjectively and follow-up assessment for 24 months. RESULTS: Thread lifting for face rejuvenation has significant long-lasting effects that include skin lifting from 3-10 mm and high degree of patients' satisfaction with less incidence rate of complications, about 4.8%. Augmented results are obtained when thread lifting is combined with other lifting and rejuvenation modalities. CONCLUSION: Significant facial rejuvenation is achieved by thread lifting and highly augmented results are observed when they are combined with Botox, fillers, and/or platelet rich plasma (PRP) rejuvenations.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients.

INTRODUCTION: Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure. METHODS: We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates. RESULTS: A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of - $1331 (95% CI - $2032 to - $631). CONCLUSION: Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy. LEVEL OF EVIDENCE V: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients.

BACKGROUND: Although the literature is replete with favorable facelift results, there are few validated facial rejuvenation outcome measures. Apparent age (AA), a visual estimate of age by objective observers, has been utilized in several studies; although attractive, AA lacks validation. OBJECTIVE: The aim of this study is to examine the reliability of AA, highlighting the importance of the exclusive use of validated outcome measures in future studies. METHODS: Ten blinded reviewers assessed pre- and postoperative photographs of 32 patients who underwent facelift. Each reviewer completed 3 surveys at 3-month intervals composed of 40 randomly ordered photos; totaling 1200 photographs assigned an AA. The intra-class correlation coefficient was classified as "excellent," "good," "fair," or "poor." The accuracy of assigned AA, agreement within 5 years, and reduction in AA were also evaluated. RESULTS: The mean difference of preoperative true age from assigned AA was 2.74 ± 4.36 years. Forty-three percent of raters were within 5-years (±2.5) of the mean. Intra-rater reliability preoperatively and postoperatively were 0.77 (95% CI, 0.82-0.72) and 0.75 (95% CI, 0.79-0.71), respectively. Inter-rater reliability preoperatively was 0.98 (95% CI, 0.99-0.96), while postoperatively was 0.95 (95% CI, 0.99-0.95). Mean AA reduction was 5.23 ± 2.81, with an intra-rater reliability 0.15 (95% CI, 0.03-0.34) and inter-rater reliability 0.65 (95% CI, 0.84-0.38). CONCLUSION: Using current statistical measures and analysis, AA is an acceptable tool for pre- and postoperative facial evaluation when assessed by a group of 10 reviewers. Therefore, apparent age represents a reliable and valid objective observer assigned measure for evaluation of facelift outcomes.

The Role of Injectables in Aesthetic Surgery: Financial Implications.

Background: The plastic surgeon competes with both core and noncore physicians and surgeons for traditional cosmetic procedures. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) joined efforts to form a Cosmetic Medicine Task Force to further analyze this trend. Objectives: Our objective is to document and quantify the patient capture and total collections generated in a single surgeon's practice exclusive from Botulinum Toxin A and filler injections over a 10-year period. We subsequently identified the effect and importance that fillers and Botulinum Toxin A have on an active cosmetic practice. Methods: A retrospective chart review of all male and female patients who received Botulinum Toxin A or soft tissue filler injections (noninvasive aesthetic treatment) in a single surgeons practice from January 2004 to December 2013 was undertaken. Only those patients new to the practice and who were exclusively seeking out Botulinum Toxin A or fillers were included in the study. Chart review then identified which of these selected patients ultimately underwent invasive aesthetic surgery during this 10-year period. Noninvasive and invasive aesthetic surgery total collections were calculated using billing records. Results: From January 2004 to December 2013, 375 patients entered the senior surgeon's practice specifically requesting and receiving noninvasive aesthetic treatments. Of these 375 patients, 59 patients (15.7%) subsequently underwent an aesthetic surgery procedure at an average of 19 months following initial noninvasive aesthetic treatment. Of these 375 patients, 369 were female and 6 were male. The most common initial invasive aesthetic procedure performed after injectable treatment included 22 facelifts (18.5%), 21 upper eyelid blepharoplasties (17.6%), and 15 endoscopic brow lifts (12.6%). Total collections from noninvasive aesthetic sessions and invasive surgery combined represented US$762,470 over this 10-year span. This represented US$524,771 and US$396,166 in total collections for injectables and surgery respectively. Conclusions: Noninvasive aesthetic surgery is a critical part of a plastic surgery practice. A measurable and significant number of patients who sought out a single plastic surgeon exclusively for noninvasive treatment ultimately underwent traditional invasive cosmetic surgical procedures.

Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Midface.

This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Also, treatment of the frontonasal angle, the dorsum, the nasolabial angle, and the columella may be used to shape and contour the nose. Neuromodulators may be used to treat bunny lines and for elevation of the nasal tip. The midface is considered an advanced area for treatment, and injectors are advised to obtain specific training, particularly when injecting fillers near the nose, because of the risk of serious complications, including blindness and necrosis. Injections made in the midcheek must be performed with caution to avoid the infraorbital artery.

Interface Between Cosmetic and Migraine Surgery.

This article describes connections between migraine surgery and cosmetic surgery including technical overlap, benefits for patients, and why every plastic surgeon may consider screening cosmetic surgery patients for migraine headache (MH). Contemporary migraine surgery began by an observation made following forehead rejuvenation, and the connection has continued. The prevalence of MH among females in the USA is 26%, and females account for 91% of cosmetic surgery procedures and 81-91% of migraine surgery procedures, which suggests substantial overlap between both patient populations. At the same time, recent reports show an overall increase in cosmetic facial procedures. Surgical techniques between some of the most commonly performed facial surgeries and migraine surgery overlap, creating opportunity for consolidation. In particular, forehead lift, blepharoplasty, septo-rhinoplasty, and rhytidectomy can easily be part of the migraine surgery, depending on the migraine trigger sites. Patients could benefit from simultaneous improvement in MH symptoms and rejuvenation of the face. Simple tools such as the Migraine Headache Index could be used to screen cosmetic surgery patients for MH. Similarity between patient populations, demand for both facial and MH procedures, and technical overlap suggest great incentive for plastic surgeons to combine both. Level of Evidence V 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Assessment Tools for Facial Rejuvenation Treatment: A Review.

BACKGROUND: In the field of cosmetic medicine, patient satisfaction is an important and common indicator used to measure the efficacy of the treatment. However, it is insufficient to prove objectively that the benefit of the specific factors involved in the cosmetic outcomes. The practitioner should be aware of these assessment tools, in particular in case of demanding or litigious patients. OBJECTIVE: The aim of this review was to establish a list and discuss the subjective and objective methods used to assess facial aesthetic rejuvenation treatments. METHODS: A systematic literature search was performed using the Pubmed search engine. Studies published over the last 5 years, i.e. between January 2010 and January 2015 were considered for review. The following keywords were used: "aesthetic treatment", "facial rejuvenation", and "subjective evaluation" or "objective evaluation". RESULTS: Of the 446 articles identified by the search strategy, 47 articles focused specifically on facial rejuvenation and on the efficacy of aesthetic medical treatments were retrieved for review. Thirty-seven articles used quantitative methods to assess aesthetic treatment outcomes and only 12 used subjective methods. The different assessment methods were listed according to the tools used and treatment indications. CONCLUSION: This review will help in choosing adequate methods to assess facial rejuvenation medical treatment. It is important to combine these tools adequately to improve the assessment. There is no current consensus on assess facial rejuvenation treatments but we noted that objective assessment methods seem helpful. NO LEVEL ASSIGNED: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .