Supraperiosteal fat repositioning with midface lift in lower eyelid blepharoplasty: an 18-year experience.

PURPOSE: To assess the clinical outcomes of fat repositioning via supraperiosteal dissection with midface lift for correction of tear trough deformity in a large Asian patient population. METHODS: Retrospectively review 1152 Asian patients who underwent fat repositioning to the supraperiosteal plane with a midface lift between 2005 and 2022. Surgical technique, postoperative course, and complications were recorded. At the 6-month postoperative follow-up, the degree of patient satisfaction was assessed. RESULTS: A total of 2304 eyes from 1152 patients with an average follow-up of 10 months. These procedures were performed using a transforniceal approach in 185 patients (16%) or a transcutaneous skin excision approach in 967 patients (84%). Among the patients who underwent the transcutaneous technique, seven individuals (0.6%) experienced effective treatment of lower lid ectropion through lateral tarsal strip procedures. Nine patients (0.7%) required revision surgery to address the remaining lateral fat pad due to inadequate lateral orbital fat excision during the initial procedure. At the 6-month follow-up, most patients reported a high level of satisfaction, with 800 patients (78%) expressing extreme satisfaction and 196 patients (19.1%) reporting satisfaction with the improvement in their appearance. No one reported facial numbness, lower eyelid or cheek paralysis, newly developed diplopia or granuloma formation. CONCLUSION: The procedure of fat repositioning involving supraperiosteal dissection and a midface lift, whether performed using a transforniceal approach or a transcutaneous skin excision approach, in lower eyelid blepharoplasty proves to be a secure and auspicious surgical technique for rectifying tear trough deformity and attaining a pleasing aesthetic outcome.

Basic concepts in facial and neck thread lifting procedures.

In this review article, our objective is to elucidate fundamental principles and offer practical illustrations concerning the procedures involved in facial and neck thread lifting. Moreover, we aim to explore associated concepts such as the fixing point, hanging point, and anchoring point terminologies, along with the elucidation of vectors. Additionally, we will provide anatomically oriented explanations of the lifting process required for each facial region using thread lifting methods like V, U, and I techniques using floating type threads (Secrete line, Hyundai Meditech., Inc., Wonjusi, Republic of Korea). Furthermore, our intention is to delve deeply into the concepts of tensile strength, anchoring strength, and holding strength, contextualizing their practical applications within this specific field.

What are filling (volumizing) threads?

Facial aging prompts a shift in the demands for lifting procedures, transitioning from targeted improvements in younger individuals to overall facial contour enhancements as skin elasticity declines in later years. This paper examines the evolution of PDO volumizing threads, delineating their development from initial limitations to contemporary innovations aimed at addressing tissue deformation and maintaining thread integrity post-insertion. Categorizing these threads based on elasticity, shape, and functionality underscores their versatility and application nuances, catering to specific wrinkle correction, contour sculpting, and facial volume restoration. The discussion emphasizes the pivotal role of thread characteristics in achieving optimal outcomes while minimizing potential complications. By delving into historical contexts, mechanisms, effectiveness, and thread classification, this paper equips practitioners with a comprehensive understanding to make informed decisions in selecting threads for volumizing thread procedures. Recommendations for future research directions, including long-term safety assessments and patient-specific outcomes, seek to enhance the clinical utility and applicability of this analysis.

SMAS repositioning technique utilizing cog thread: Anatomical perspectives.

INTRODUCTION: Face-lifting surgeries were once common among individuals over 60 years old due to skin laxity, but recent trends favor thread lifting in this age group. Understanding dynamic changes in facial anatomy during postural shifts is essential. METHOD: Fresh cadaver studies have demonstrated the passage of threads through the superficial musculoaponeurotic system (SMAS) layer, confirming the efficacy of the technique. Proper insertion depth targeting SMAS repositioning, rather than superficial skin layers, is crucial. RESULT: The natural movement of tissues secured by thread (N-Cog and N-Fix, N-Finders Inc., Korea) insertion results in lifting effects. However, complications may arise if threads affect deeper facial muscles, leading to discomfort. Fibrous septa play a significant role in guiding thread placement, with different densities influencing thread maneuverability and tissue response during lifting. CONCLUSION: Procedures targeting SMAS repositioning using threads aim to maintain the new position of relocated tissues. Understanding structural variations in facial regions informs thread selection and placement. Aligning threads with tissue movement and the intended SMAS layer positioning is vital to prevent complications. Balancing thread insertion depth and tissue traction is critical for successful outcomes. Modern thread lifting techniques prioritize SMAS repositioning, enhancing lifting effects while ensuring procedure safety and efficacy.

Evaluation of Physical Properties of Coated Polydioxanone Threads.

BACKGROUND: Using a thread for wound closure promotes healing and minimizes contamination by foreign substances. Threads have also been employed in esthetic surgery; however, functional threads that can improve wrinkles and rejuvenate the skin are required. OBJECTIVE: To evaluate the suitability of polydioxanone threads coated with polyethylene glycol, hyaluronic acid, and amino acids for use in the medical field because such formulations are expected to promote regeneration and collagen synthesis. MATERIALS AND METHODS: Physical properties (diameter [ n = 20], tensile strength [ n = 20], strength retention rate [ n = 10], and scanning electron microscopy images) and cytotoxicity (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide and lactate dehydrogenase assays) of polydioxanone threads coated with polyethylene glycol, hyaluronic acid, and amino acids were assessed and compared with those of uncoated polydioxanone threads. Analyses were performed using IBM SPSS Statistics (Statistical significance; p values <.05). RESULTS: The size standards for tensile strength (≥63.5 N) and diameter (average 0.570-0.610 mm) were met. There were no differences in the physical properties of the coated and uncoated threads; however, the biocompatibility of coated threads was high owing to low cytotoxicity. CONCLUSION: Threads coated with materials that can promote regeneration are suitable for use in the medical field.

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.

Comparing the Safety and Effectiveness of Microfocused Ultrasound: Standard vs Targeted Tissue Protocol in Lifting and Tightening the Lower Face and Upper Neck.

BACKGROUND: Micro-focused ultrasound with visualization (MFU-V) delivers energy to specific soft tissue layers beneath the epidermis with the ability to lift and tighten the lower face and neck.  Objective: To determine the efficacy of microfocused ultrasound with visualization (MFU-V) using a standard treatment line protocol versus a customized treatment line protocol based on the patient's unique anatomy targeting the superficial muscular aponeurotic system and fibrous septae for lifting and tightening of the lower face and neck. METHODS: This was a single-center, prospective, randomized, investigator-blinded clinical trial. 51 subjects were randomized to receive a single treatment of MFU-V targeting the lower face and neck using either a standard or custom treatment protocol.   Results: Subjects in both standard and custom treatment groups noted a greater than one-point improvement in jawline laxity. Three-dimensional photography measurements also demonstrated lifting of the lower face and neck in both treatment groups. CONCLUSION: Custom and standard treatment MFU-V protocols produce a safe and effective treatment for tightening and lifting the lower face and neck. Custom treatment protocols aid in maximizing results for patients with variations in the anatomy of the lower face and neck.  J Drugs Dermatol. 2024;23(4):7647.     doi:10.36849/JDD.7647.

Is Bipolar Radiofrequency-Assisted Liposuction Equivalent to Open Anterior Platysmaplasty in Facelift Surgery?

BACKGROUND: During facelift surgery, anterior platysmaplasty (AP) has been used for decades, but it limits lateral advancement and can induce contour irregularities. Radiofrequency (RF)-assisted-liposuction in the anterior neck can avoid these disadvantages by tightening skin without open surgery. PURPOSE: The purpose of the study was to compare the esthetic outcomes of facelift surgery with those of AP and RF. STUDY DESIGN, SETTING, SAMPLE: A 5-year retrospective cohort study was performed on facelift patients treated by a single surgeon. Exclusions were single-side surgery, previous facelift, chin/lip augmentation/reduction, and inadequate data. PREDICTOR VARIABLE: The predictor variable was neck management technique (AP vs RF). MAIN OUTCOME VARIABLES: The primary outcome variable was the change in cervicomental angle (CMA) following surgery as measured on facial photographs. Secondary outcomes included distance changes from the central CMA point in vertical and horizontal planes to repeatable reference planes. COVARIATES: Covariates were age, body mass index, American Society of Anesthesiologists classification, smoking, and simultaneous procedures. ANALYSES: The statistical analysis was performed using Wilcoxon rank-sum, Fisher's exact, Kruskal-Wallis tests, Pearson's correlation, and linear regressions. The level of statistical significance was P < .05. RESULTS: There were 132 patients included in the study; 67 received AP and 65 received RF. AP trended toward better performance in CMA change in the unadjusted analysis (-18.7° ± 13.8° vs -22.3° ± 13.7°, respectively, P = .08). AP and RF performed similarly in the adjusted analysis (P = .29). Techniques were similar in horizontal distance change to the CMA (P = .31). RF was associated with less change in the vertical distance to the CMA in the unadjusted analysis (-11.9 mm ± 11.0 mm vs -6.7 mm ± 8.7 mm, respectively, P = .01) and adjusted analysis (ß = 4.3 mm, 95% confidence interval .8 to 7.9 mm, P = .02). CONCLUSION AND RELEVANCE: Utilization of the RF technique for management of the anterior neck in facelift surgery is associated with similar outcomes to the AP technique in horizontal distance to the CMA, but AP performed better in CMA change and vertical distance to the CMA.

Rotation of a Part of the Composite Flap for Simultaneous Gonion Reduction and Malar Augmentation During Rhytidectomy in Asians.

BACKGROUND: The desired facial shape that Asians aim to achieve through plastic surgery differs from that of westerners. OBJECTIVES: The author facilitates facial volume deflation by using the rotation of a part of the composite flap to the malar area resulting in volumetric augmentation during rhytidectomy; simultaneously, a volumetric reduction was implemented in the gonion. METHODS: Extended deep plane rhytidectomy with the rotation of a part of the composite flap was performed in 49 patients, whereas extended deep plane rhytidectomy without the rotation of a part of the composite flap was performed in 20 patients. For the results, the satisfaction survey of the surgery was conducted in all patients and by 2 surgeons during a follow-up visit 12 months later. To assess the surgical outcome objectively, the author used the Allergan photometric midface volume deficit scale to measure the midface volume. The midface contour and degree of projection were analyzed using lateral view photographs of the patients. The measurement of segment CM (distance between the lateral canthus and mouth corner) and segment MA (distance from segment CM to the most protruding malar area) was performed. RESULTS: The patients who underwent extended deep plane rhytidectomy with the rotation of a part of the composite flap reported higher overall satisfaction and achieved more favorable results, as evaluated by the 2 aesthetic surgeons (P < 0.05). The scores on the Allergan photometric midface volume deficit scale showed a significant increase before and after the surgery in both groups (P < 0.05), also as evaluated by the 2 aesthetic surgeons. However, the change in scores was found to be higher in the extended deep plane rhytidectomy with the rotation of a part of the composite flap group. The midface contour and degree of projection showed an increase of 20.6% on the right face and 22.7% on the left face, respectively (P < 0.001). CONCLUSION: Using the rotation of a part of the composite flap during rhytidectomy resulted in overall satisfactory outcomes for all patients. Based on these findings, it can be concluded that the use of this surgical method is beneficial and effective.

Long-Term Improvement of Crow's Feet Wrinkles in Combination With Cervicofacial and Temporal Lifting: Review of the Literature.

BACKGROUND: The lateral orbital crow's feet area is one for which rejuvenation is most frequently requested by patients. Moreover, lateral canthal wrinkles are a common source of dissatisfaction after rhytidoplasty. Botulinum toxin injection has emerged as a most popular, easy, and effective solution; nevertheless, repeated injections are required periodically for long-term effect. Other nonsurgical options have also been described to have some demonstrable advantages. Orbicularis oculi surgical manipulations have been described as well. MATERIAL AND METHODS: A systematic PubMed literature search was conducted to identify clinical cohort studies including more than 10 patients describing surgical approaches for improvement of crows' feet wrinkles in combination with face and/or temporal lifts. The search was complemented by Embase, Medline, and Cochrane searches in addition to screening of reference lists of selected studies and simple term searches about surgical treatment of crow's feet. RESULTS: Fourteen studies satisfied the inclusion criteria and were included in this review describing various muscle excision techniques including vertical strip excision, lateral partial resection, wedge resection, muscle resection in "C" pattern, and enlarged myectomy of about one-third of the whole orbital extension in addition to muscle manipulation modalities, including muscle splaying, muscle division, muscle division and splaying, muscle undermining with partial denervation, and muscle suspension. Interposition of fascia between orbicularis muscle and overlying skin was also reported. CONCLUSION: View the few studies retrieved and the wide spectrum of reported techniques, it is not possible to determine from this review the most effective modality. Nevertheless, it seems that subcutaneous undermining of the lateral canthal area combined with splaying and traction of the orbicularis oculi muscle and fixation to the temporalis fascia with or without muscle division would yield the best long-term results. This review indicates also that surgical correction of crow's feet during rhytidectomy or temporal lift could be a positive complement to improve aesthetic outcome. Unfortunately, if not underreported, it is definitely neglected. We believe that this review may be an eye-opener for surgeons.

Three-dimensional adipofascial and dermal structures involved in forehead crease formation.

Deeply etched forehead creases indicate aging. Various treatments such as filler injections, fat grafting, and facelift surgery are used to remove them. However, knowledge of the anatomical structures associated with subcutaneous tissue changes and the superficial musculoaponeurotic system is lacking, and there is no consensus about the appropriate treatment. We have investigated the subcutaneous structures involved in forehead creases; this will help to establish selection criteria for improved treatment. The forehead sections of five unfixed adult Asian cadavers were obtained. Tissues containing forehead creases were removed from the periosteum and were examined using gross observation, radiography, histology, and nano-computed tomography. All methods revealed that the dermis in the skin crease area, namely the fold visible from the body surface, was bound to the frontalis muscle by a three-dimensional fibrous structure between the fatty septa. This structure was dense near the skin folds and sparse and thin in other areas. In particular, it was tightly bound to the dermis immediately below the crease, with collagen fibers traversing toward the epidermis. In addition, there were fewer skin appendages near the crease than in the normal area, or they were absent altogether; the epidermis was thicker, and the dermal papillae were more developed. It is thought that the density and firmness of the fibrous fatty septal structures between the dermis-frontalis muscle and the specific structures of the epidermis and dermis immediately below the crease account for the characteristic plastic forehead creases.

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.

Nasal Sill Flap for Lip Lifting.

BACKGROUND: Over the years, different techniques have been developed to reduce the number of incisions and scars in subnasal lip lifting and to increase the amount of lifting. The aim of this study was to present a new technique to hide the scars at the nasal base in subnasal lip lifting procedures and to review the literature. METHODS: The file of patients who underwent subnasal lip lifting between January 2019 and January 2021 were examined. In all patients, the nasal sill flap that was designed was elevated, and the nasal sill flap that was prepared was adapted to its new location when the excision had been completed. Two different plastic surgeons evaluated the patients in the postoperative 12-month follow-ups. The scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height. RESULTS: The study included 26 patients. While 21 patients had no histories of lip lifting, five patients had had previous lip lifting history. The mean operation time was 37.11 minutes. Patients' skin types were determined as Type 3 in 18 patients and Type 4 in eight patients according to the Fitzpatrick classification. The mean follow-up period of the patients was 13.11 months. At the end of the 12-month period, the mean scar score of the patients was calculated as 11.15. The mean scar score of primary cases was 11.14, and the mean scar score of secondary cases was 11.20 (p = 0.983). There was no statistically significant difference in terms of complications among smokers (p = 0.356). The mean scar score was calculated as 12.17 in patients who had Type 3 skin and 8.88 in patients with Type 4 skin (p = 0.075). CONCLUSIONS: This technique is beneficial for patients because the scars are discrete and easier for patients to accept.

Top 50 Highly Cited Publications in Facelift Surgery: A 50-Year Bibliometric Analysis Review.

INTRODUCTION: Facelift surgery, also known as rhytidectomy, is a commonly performed procedure to address aging-related changes in the face and neck. Over the years, its techniques and methodologies have evolved. This study aimed to provide a bibliometric analysis of the top 50 most cited publications related to facelift surgery over a fifty-year period (1973-2023). METHODS: The authors obtained data from the Web of Science Core Collection on July 15, 2023. Using a predefined search strategy, the most cited articles from 1973 to 2023 on facelift surgery were identified. The publications were analyzed for their type of study, journal of publication, geographic origin, and primary outcomes. Furthermore, the authorship gender distribution was assessed. RESULTS: The majority of the publications (34 out of 50) were published in the "Plastic and Reconstructive Surgery" journal. The USA contributed to 72% of the research, followed by the UK, Mexico, Australia, and Germany. The primary outcomes varied from surgical techniques, anatomical studies, risk factors, patient-specific outcomes, and facial rejuvenation techniques, to comparative and historical progression of techniques. Notably, male authors dominated the field with 47 out of 50 papers having both a first and senior male author. CONCLUSION: Facelift surgery has seen substantial research development over the past fifty years. The USA has been at the forefront of this research, with a predominant focus on surgical techniques and anatomical studies. Male dominance in authorship indicates potential scope for increased gender diversity in this specialty. Annual updates are recommended for continued insights. LEVEL OF EVIDENCE III: 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 .

Choosing Upper Blepharoplasty, Infra-brow Lift, and Forehead Lift in Asians: An Algorithmic Approach from Personal Experience.

BACKGROUND: Eyelid surgery is a cosmetic procedure performed worldwide in the field of plastic surgery. However, achieving optimal outcomes for the upper eyelids presents a challenge, necessitating careful patient selection and appropriate surgical choices. OBJECTIVES: This article aims to provide recommendations for selecting the most suitable surgical procedure among three commonly performed treatments for aged upper eyelids. METHODS: A retrospective cohort study was conducted from October 2020 to May 2022, involving 518 patients. Pre- and postoperative photographs were analyzed to evaluate changes in the distance between the eyelids and brows. Notably, patients who habitually use the frontalis muscle to manage upper eyelid redundancy showed significant variations in the lid-brow distance after eyelid surgery. RESULTS: The study confirmed that addressing skin laxity through upper blepharoplasty or infra-brow excision reduced the stimulus for frontalis activity, resulting in true brow ptosis. However, the degree of compensatory frontalis movement differed among individuals, and changes in the lid-brow distance observed before and after the photos were influenced by various factors. As a result, obtaining clear numerical data regarding the changes in the lid-brow distance following eyelid surgery proved challenging. Nevertheless, after analyzing 518 cases, the author has classified the patients into three groups, which can contribute to more predictable and satisfying outcomes. CONCLUSION: Based on the analysis of pre- and postoperative results from 518 patients, this study recommends specific strategies to enhance patient satisfaction. The proposed treatment algorithm may assist beginner surgeons in avoiding angry or tired-looking eyes after periorbital rejuvenation. 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 .

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 .

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process. METHODS: Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021. RESULTS: Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001). CONCLUSIONS: A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time. LEVEL OF EVIDENCE III: 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 .

Advanced Facial Rejuvenation: Synergistic Effects of Lower Blepharoplasty and Ultrasound Guided Mid-Face Lift Using Polydioxanone (PDO) Threads.

BACKGROUND: Traditional facial aging surgeries have risks and extended recovery times, leading to a demand for minimally invasive alternatives. PDO (polydioxanone) threads, which are absorbable sutures that stimulate collagen production and tissue contraction, offer improved aesthetic outcomes. This paper evaluates the combined use of PDO thread mid-cheek lift and lower blepharoplasty for facial rejuvenation. METHODS: This retrospective study compared outcomes in patients undergoing lower blepharoplasty combined with a mid-face lift using PDO threads versus those undergoing only lower blepharoplasty. Focused on individuals with baggy lower eyelids and pronounced nasolabial folds, outcome measures included the Modified Fitzpatrick wrinkle scale, Allergan® midface volume deficit scale, Width of inter zygomatic distance, Patient and Observer Scar Assessment Scale, and patient satisfaction questionnaires, assessed at baseline, 3 months, and 1 year postoperatively. RESULTS: The combined procedure demonstrated superior aesthetic outcomes and higher patient satisfaction compared to lower blepharoplasty alone. Improvements were more significant in wrinkle reduction, midface volume, and inter-zygomatic distance in the combined procedure group. Although the combined procedure had a longer mean operation time, scar assessment scores were similar between both groups, with no complications reported. CONCLUSION: The combination of lower blepharoplasty and mid-face lift using PDO threads is a comprehensive and effective approach for facial rejuvenation. It significantly enhances wrinkle reduction, mid-face lifting, and patient satisfaction. Ultrasound-guided thread lifting, a method of assessing and performing mid-face lifting, proves to be safe and efficient. This approach holds promise as a future option in cosmetic anti-aging surgery, presenting a minimally invasive alternative with natural-looking results and reduced downtime. 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 https://link.springer.com/journal/00266 .

Evaluation and Classification of Supraorbital Nerve Emerging Patterns.

BACKGROUND: Numerous significant variations in the supraorbital nerve (SON) pass through the notches and foramina. During endoscopic forehead lifting, the passage and the location of the nerve against the frontal bone render it susceptible to injury, resulting in diminished or absent sensation in the corresponding location. We attempted to obtain accurate knowledge of the SON emergence routes. METHODS: Data of patients who underwent an endoscopic forehead lift in a plastic surgery clinic between November 2015 and August 2021 were retrospectively analyzed. Deep and superficial branch pathways of SONs were identified and compared according to side and gender. We also classified the nerve patterns into six types. RESULTS: Altogether, 942 patients (1884 SON cases) were evaluated. Out of the patients, 86 patients were male, and 856 were female. The overall mean age was 48.6 (± 13.1) years. In the deep branches, 49% came from the notch, and 51% came from the foramen. In the superficial branches, 67% came from the notch, and 33% of superficial branches came from the foramen. Unlike the deep branch, superficial branches from the notch were significant. Deep and superficial branches of male patients were much more notched than those of female patients. Branches emerged together in 56% and separately in 44% of the cases. CONCLUSION: The absolute number of SON notches was higher than that of SON foramina. This study with the largest number of SON cases will help surgeons understand the variation and course of SON. LEVEL OF EVIDENCE IV: This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

The 3-Level Approach to Facelift Planning: A Simple Paradigm for Surgical Rejuvenation of the Face.

Our role as aesthetic surgeons demands individualized surgical planning that maximizes patient input and understanding. The value of such shared decision-making (SDM) in aesthetic surgery is becoming increasingly appreciated. This is particularly true for potential patients seeking surgical rejuvenation of the face, where the volume of "educational" information available on the internet, and through various social medial channels, may be overwhelming and even misleading. Presented is a "3-Level approach to facelift planning" named for the facial subregions targeted. This novel paradigm maximizes SDM with its simplicity and reproducibility, serves as an invaluable educational tool for patients, novice and seasoned surgeons alike, and facilitates communication between senior surgeons through its descriptive standardization. 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 .