The Anterior SMAS Approach for Facelifting and for Buccal Fat Pad Removal.

Having performed numerous varieties of SMAS advancement including: plication, resection, flap elevation with variable anterior deep dissection, the author has developed a direct approach to the mobile anterior SMAS which allows correction of midface descent, modest elevation of the modiolus, jawline correction, and, where indicated, direct access for buccal fat pad resection. 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 .

Venous thromboembolism after facelift surgery under local anesthesia: results of a multicenter survey.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication of cosmetic surgery, and studies have suggested that the incidence is not insignificant in facelift surgery. Use of local anesthesia over general anesthesia and shorter operative times are probable contributing factors to lower VTE incidence. Because there have been no large-scale assessments of VTE in facelifts as such, we investigated VTE incidence and relevant factors in facelift surgeries performed under local anesthesia only. METHODS: We conducted a retrospective multicenter survey of facelift surgeons who utilize the American Society of Anesthesiologists level 1 oral anxiolysis and local diluted lidocaine anesthesia technique. Anonymous online surveys were sent to surgeons with questions regarding facelifts performed and VTE incidence over the previous 19 months. RESULTS: Seventy-seven surgeons (93 % response rate) completed the survey, with 74 eligible surgeons reporting at least one facelift. Respondents reported five VTE events, for an overall VTE incidence of 1 event in 5,844 surgeries. Surgeons who reported performing facelifts at high volumes (>500 facelifts in 19 months) had a significantly lower VTE incidence than lower-volume surgeons (p = 0.011). High-volume surgeons also reported a significantly lower average operative time (p = 0.016), but for surgeries that did or did not result in VTE, there was no significant difference between surgeon-reported average operative times. CONCLUSION: The low VTE incidence in this facelift series supports prior understanding that there is a low risk of VTE in surgery performed under local anesthesia and in surgery with shorter operative times. Limiting ancillary procedures to the face likely reduces operative time and likely also contributes to a lower VTE rate. The data further suggest that physicians performing facelifts more frequently tend to have shorter average operative times and overall lower VTE incidence. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Barbed sutures in aesthetic plastic surgery: evolution of thought and process.

The evolution of barbed suture technologies and their application in the field of plastic surgery is now in its third decade. Much has been learned along the way. Initial excitement was often followed by disappointment as we learned more about the limited longevity of minimally invasive procedures and complications arising from various suture designs of the past. Some of the early designs, developed primarily for use in aesthetic facial procedures, included free-floating, bidirectionally barbed, nonabsorbable sutures; unidirectional barbed, nonabsorbable sutures; anchored, bidirectional, nonabsorbable double-threaded sutures; and a technology combining a nonabsorbable knotted thread and absorbable cones. More recently, a new, absorbable, unidirectional barbed suture design has become available. However, it should be noted that very limited data are available for any of the modified suture designs used in this field, and much of what has been published is based on the experience of a single user. The author has used the bidirectionally barbed Quill Knotless Tissue-Closure Device (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada), the most common barbed suture in both facial and other aesthetic plastic surgery procedures, with considerable success in various open aesthetic facial procedures, including suspension of the brow and midface, platysmaplasty, and lateral neck suspension. It is the author's experience that completion of 1 to 2 cases with this technology is sufficient to achieve competency in the closure techniques discussed in this article and that time savings can be realized using this device in various breast and body contouring procedures, including mastopexy, reduction mammoplasty, abdominoplasty, bodylift, and brachioplasty.

Infection risk from the use of continuous local-anesthetic infusion pain pumps in aesthetic and reconstructive abdominal procedures.

Postoperative pain control after abdominal procedures can be an area of significant concern. Continuous local-anesthetic infusion pain pumps have been clearly documented in recent literature to provide effective early postoperative pain control, in addition to other benefits. Our goal was to evaluate any increase in the risk of infection with the use of pain pumps with aesthetic and reconstructive abdominal procedures. A retrospective chart review evaluated 159 patients who underwent abdominoplasty (with or without suction-assisted lipectomy), panniculectomy, or a transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction. Information was collected on descriptive and demographic information, and the incidence of postoperative infection. Of the 159 patients who underwent abdominal procedures, 100 (62.9%) received the pain pump for postoperative pain control. None of those 100 patients developed an infection. Fifty-nine patients did not receive a pain pump, and 2 of those patients (3.3%) developed an infection. Overall, 1.3% (2 of 159) of patients in our study developed a postoperative infection. There is no increase in the risk of postoperative infection with the use of continuous local-anesthetic infusion pain pumps used after aesthetic and reconstructive abdominal procedures.

Using barbed sutures in open/subperiosteal midface lifting.

The author has found that the use of barbed sutures simplifies midface suspension not only by stacking elevated soft tissue, but also by providing the ability to adjust sutures postoperatively. Complications, such as breaking of sutures, malposition, and failure to maintain support have been rare in his practice.

Breast augmentation and abdominoplasty: postoperative management with pain pumps.

Using pain pumps, the author has been successful in reducing postoperative pain after breast augmentation and abdominoplasty. Further, patients ambulate sooner, which reduces the risk of deep vein thrombosis, and more fully expand their lungs, which averts a compromise in pulmonary function.

Blending the lid/cheek junction.

BACKGROUND: Rejuvenation of the periorbital area requires an understanding of the morphologic changes that occur with aging. Blending the lid/cheek junction is a goal of periorbital rejuvenation. OBJECTIVE: Transblepharoplasty techniques are proposed to achieve aesthetic periorbital rejuvenation with predictable improvement and minimal morbidity. METHODS: Techniques of blending the lid/cheek junction are presented that include septal advancement with both septal tightening and subseptal fat pad contouring when indicated, or complete release of the orbital orbicularis oculi muscle, along with vascularized and/or free fat transfer over the inferior orbital rim, to produce a youthful contour. Lid support was enhanced with a medially based orbicularis oculi muscle sling, which further improves the contour of the lid/cheek junction through muscle release to the medial inferior orbital rim. RESULTS: Fifty-eight consecutive cases were reviewed that included lower lid blepharoplasties with or without a concomitant midface lift. Four cases of midface lift did not require any lower eyelid procedures. Septal reset or aggressive orbicularis oculi release with fat transfer were performed in 30 patients. A medially based orbicularis oculi flap was developed to support the lid, and canthopexy or canthoplasty was performed as indicated. Complete release of the medial fibers of the orbital orbicularis oculi muscle allowed for tension-free placement of vascularized fat or free fat grafts and a more profound blending of the lid/cheek junction, since the flap advancement acted as a handle to carry the upper midface soft tissues. CONCLUSIONS: Transblepharoplasty options for repositioning periorbital soft tissues are reliable means for blending the lid/cheek junction.

Assessing the options for lip augmentation.

The author prefers autologous tissue from a combined SMAS/fat graft for lip augmentation. However, he considers Alloderm the best alternative. Here he describes his technique and compares Alloderm with other available materials.

Brow lift fixation.

One of the more difficult and controversial aspects of forehead and brow lift is fixation with control and stabilization of the result. Aesthetic Surgery Journal has invited Robert W. Bernard, MD; Robert S. Hamas, MD; Peter McKinney, MD; and Malcolm D. Paul, MD to share their preferred brow lift techniques. Here are their responses to questions posed by "Comparing Notes" editor, Alan H. Gold, MD. (Aesthetic Surg J 2003;23:217-219.).

Face expressive lifting (FEL): an original surgical concept combined with bipolar radiofrequency.

BACKGROUND: Aging can lead to changes in facial expressions, transforming the positive youth expression of happiness to negative expressions as sadness, tiredness, and disgust. Local skin distension is another consequence of aging, which can be difficult to treat with rejuvenation procedures. The "face expressive lifting" (FEL) is an original concept in facial rejuvenation surgery. On the one hand, FEL integrates established convergent surgical techniques aiming to correct the age-related negative facial expressions. On the other hand, FEL incorporates novel bipolar RF technology aiming to correct local skin distension. METHODS: One hundred twenty-six patients underwent FEL procedure. Facial expression and local skin distension were assessed with 2 years follow-up. RESULTS: There was a correction of negative facial expression for 96 patients (76 %) and a tightening of local skin distension in 100 % of cases. CONCLUSIONS: FEL is an effective procedure taking into account and able to correct both age-related negative changes in facial expression and local skin distension using radiofrequency. Level of Evidence: Level IV, therapeutic study.

An overview of cosmetic medicine and surgery: past, present, and future.

The evolution of thought and process in cosmetic medicine and surgery has united specialists from various backgrounds with the goal of providing safe, reproducible techniques to improve the various elements of the aging face from within and without. The realization that the aging face is both vector and volume based has dramatically altered the approach to reversing the signs of aging. Ultimately, it was the joining of forces from multiple specialties that provided a blueprint for impressive improvement in the return of a youthful, natural look.

Lifting and wound closure with barbed sutures.

The advent of barbed sutures has been a novel and useful adjunct for the aesthetic plastic surgeon in properly selected patients. The deployment of a barbed suture minimizes the risks of cheese wiring and stress relaxation, facilitating the minimally invasive repositioning of soft tissue in the head and neck, as well as optimizing and enhancing traditionally long and potentially tedious procedures in body contouring. This article highlights the advances, advantages, and efficacy associated with the use of barbed sutures in lifting and wound closure.

Noninvasive body contouring with radiofrequency, ultrasound, cryolipolysis, and low-level laser therapy.

Noninvasive body contouring is perhaps one of the most alluring areas of esthetic surgery today. This article discusses current noninvasive body-contouring modalities, including suction massage devices, radiofrequency energy, high-frequency focused ultrasound, cryolipolysis, and low-level light laser therapy devices. It also discusses imminent technologies awaiting approval by the Food and Drug Administration, reviews the basic science and clinical effects behind each of these existing and emerging technologies, addresses patient selection and clinical applications of each modality, and discusses the applicability and economics of providing noninvasive lipolysis services in office.

Dermabrasion.

This review presents skin anatomy, dermabraders, indications for dermabrasion and microdermabrasion, and dermabrasion techniques for the face, along with potential complications. Dermabrasion is a minimally invasive technique used for skin resurfacing. Its applications include treatment of rhytids, abnormal scarring, and premalignant lesions. The risks of complications are low and include pigment changes, hypertrophic scarring, and infection. Despite the introduction of newer therapies, such as lasers and chemical peels, dermabrasion remains an effective tool for physicians to combat the effects of aging without the downtime required for surgery.

A safety and feasibility study of a novel radiofrequency-assisted liposuction technique.

BACKGROUND: The feasibility, safety, and efficacy of a novel radiofrequency device for radiofrequency-assisted liposuction were evaluated in various body areas. METHODS: From July to December of 2008, 23 subjects underwent radiofrequency-assisted liposuction using the BodyTite system. Information regarding aesthetic results and local and systemic complications was collected immediately after the procedure and at 6- and 12-week follow-up. RESULTS: The mean age of the patients was 38.8 +/- 12.4 years, and 87 percent were women. Radiofrequency-assisted liposuction was performed successfully in all cases; volume aspirated per patient was 2404 +/- 1290 ml, whereas operative time was 158 +/- 44 minutes. All patients underwent liposuction at the hip and low abdominal areas, bilaterally. Body contour improvement was observed postoperatively in all patients and there were no severe systemic or local complications, although postoperative pain was minimal in all patients. Weight and circumference reductions were significant at both 6-week and 3-month follow-up. Skin tightening was judged optimal by the surgeon in all patients. CONCLUSIONS: The authors' study suggests that the removal of moderate volumes of fat with concurrent subdermal tissue contraction can be performed safely and effectively with radiofrequency-assisted liposuction. Additional benefits of this technique are excellent patient tolerance and fast recovery time. Nonetheless, a larger sample is required to confirm the authors' results and guarantee the efficacy and safety of the procedure. Direct comparison with traditional liposuction or energy-assisted liposuction techniques may provide some insights to tailor future indications of this novel technique.

Bidirectional barbed sutures for wound closure: evolution and applications.

Traditionally, wound closure sutures have in common the need to tie knots with the inherent risk of extrusion, palpability, microinfarcts, breakage, and slippage. Bidirectional barbed sutures have barbs arrayed in a helical fashion in opposing directions on either side of an unbarbed midsegment. This suture is inserted at the midpoint of a wound and pulled through till resistance is encountered from the opposing barbs; each half of the suture is then advanced to the lateral ends of the wound. This design provides a method of evenly distributing tension along the incision line, a faster suture placement and closure time with no need to tie knots, and the possibility of improved cosmesis. Bidirectional barbed sutures, which are available in both absorbable and nonabsorbable forms, can be used for simple closures, multilayered closures, and closure of high-tension wounds in a variety of surgical settings.

Barbed sutures for aesthetic facial plastic surgery: indications and techniques.

This article describes the indications and techniques related to the use of barbed sutures in facial aesthetic plastic surgery. The principle applications for barbed sutures in facial aesthetic plastic surgery are those involving lifts of the brow, midface, and the lower face and neck. Usually all three areas require surgical maneuvers to create a harmonious rejuvenation. Regardless of where in the face bidirectional barbed sutures are planned, five essential steps are needed: (1) making the incision or incisions, (2) dissecting soft tissue, (3) proximal anchoring, (4) deploying threads, and (5) molding soft tissue.

Continuous-infusion local anesthetic pain pump use and seroma formation with abdominal procedures: is there a correlation?

BACKGROUND: Seroma formation is the most commonly occurring complication in plastic surgery abdominal procedures. Continuous local anesthetic pain pump delivery systems are often used to decrease postoperative pain. An unreported concern with use of these devices in abdominal procedures is the effect of continuous fluid infiltration of the surgical site and a possible increase in the incidence of seroma formation. METHODS: The authors performed a retrospective chart review to evaluate all patients (n = 159) who underwent abdominal procedures (abdominoplasty, panniculectomy, and transverse rectus abdominis myocutaneous flap harvest) over a 3-year period. Patient charts were evaluated for sex, age, body mass index, procedure performed, surgeon, operation length, pain pump use, postoperative seroma formation, and any complications. In cases with pain pump use, catheter placement location, anesthetic medication and strength, continuous-infusion rate, and duration of pain pump use were also reviewed. If a postoperative seroma formation was identified, treatment and outcomes were also recorded. RESULTS: The overall seroma formation rate was 11.3 percent (18 of 159 patients). Other complications occurred at a rate of 2.5 percent (four of 159). The incidence of seroma was 11.0 percent (11 of 100) in patients with pain pump use versus 11.9 percent (7 of 59) in those who did not use a pain pump. There was no statistically significant difference (p = 0.9) in the incidence of seroma formation between those who did and did not use a pain pump device. CONCLUSION: There was no correlation between increased rate of seroma formation and use of a continuous-infusion local anesthetic pain pump system in our patient population.