Our 40 Years' Experience on Face and Neck Lift Procedures with High-SMAS Flap Techniques: How to Manage Secondary and Tertiary Surgeries.

BACKGROUND: Facial aging drives a growing demand for esthetic procedures, with nonsurgical options often falling short in longevity compared to surgery. Despite primary face and neck lift techniques receiving substantial attention, revision procedures have been relatively overlooked in terms of their unique surgical management, complication incidence, and preventive strategies. METHODS: The authors present a 40-year experience with revision face and neck lifts, comprising 283 cases. The primary focus was on the high-SMAS flap technique in revision surgeries, with data collected on complications compared to primary procedures and existing literature. Secondary analysis investigated the time-lapse between primary and revision surgeries in the author's series (secondary and tertiary rhytidectomy) compared to the literature findings. RESULTS: Out of 283 cases, 232 were secondary and 51 were tertiary procedures. Overall complication rates in secondary cases mirrored those of primary procedures, with no statistically significant difference observed (p > 0.05). The mean interval between procedures was 9.0 years (range: 3.4-28.8 years), with a significant statistical difference (p < 0.05) observed between the first and second procedures (10.7 years, range: 3.8-18.8 years) and the second and third procedures (7.8 years, range: 3.5-10.8 years). CONCLUSION: Results indicate that high-SMAS flaps yield consistent and satisfying outcomes, even in secondary and tertiary cases. Complication rates are comparable to primary surgeries, underscoring the importance of meticulous attention to detail in managing the complexities associated with previous surgeries and the aging process. 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 .

Evaluating the Effectiveness of the High-SMAS Facelift Technique: Objective Clinical Outcomes at 1-year.

BACKGROUND: The primary goal of the facelift is to rejuvenate the face without changing its natural features. This involves working on the deeper layers to preserve the surface look while adjusting the fat pads beneath. Thus, we often use a modified High-SMAS facelift method, following this deep-layer approach. The study evaluates whether the high-SMAS facelift, focusing on optimal repositioning, can effectively reduce aging signs in the mid to lower face and neck. METHODS: Conducted from 2018 to 2022, this retrospective cohort study included demographic data, relevant comorbidities, and operative details of patients undergoing lateral extended high-SMAS facial lifting, excluding revision cases. Complications were recorded, and a minimum one-year follow-up was ensured. The technique's effectiveness was assessed using pre- and one-year post-surgery images analyzed by three masked examiners with a validated scoring method by La Padula et al. RESULTS: The study included 325 patients, with no major complications reported. Significant improvements were noted in post-operative High-SMAS visual scores compared to pre-operative scores (p < 0.0001), particularly in cheek fullness, jawline, and cervical angle definition. CONCLUSIONS: The High-SMAS facelift technique, evaluated using the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale, demonstrated significant cosmetic enhancements. This technique, focusing on optimal flap draping vectors, effectively restores a youthful appearance by improving facial contours. 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 .

Complete Hemifacial Paralysis Post-facelift: Making Sense of a Plastic Surgeon's Worst Nightmare.

BACKGROUND: Postrhytidectomy hemifacial paralysis is a frightening clinical condition affecting the proximal facial nerve and most often associated with Bell's palsy. Associated symptoms are common and include auditory, salivary, vestibular, and gustatory complaints. OBJECTIVES: The aim of the study was to provide increased awareness of postrhytidectomy hemifacial paralysis secondary to Bell's palsy in the plastic surgery community. METHODS: Following a roundtable discussion with the senior author's (J.C.G.) plastic surgery colleagues located all over the world, 8 surgeons reported having had firsthand experience with hemifacial paralysis in patients following facelift. Descriptions of their cases, including preoperative, intraoperative, and postoperative courses were collected and reported. RESULTS: A total of 10 cases of postrhytidectomy hemifacial paralysis were analyzed based on results of a clinical questionnaire. Eight of the 10 cases involved all facial nerve branches, with 2 cases sparing the marginal mandibular branch. The vast majority of cases were referred to a neurologist and steroids initiated. Two patients were returned to the operating room for exploration. Associated symptoms reported included pain in the ear, hearing loss, ocular symptoms such as tearing or dryness, vestibular symptoms such as vertigo, changes in taste, and in 1 patient an electric-shock type sensation to the face. CONCLUSIONS: Hemifacial paralysis associated with Bell's palsy following rhytidectomy is a rare but known clinical entity that should be included in the preoperative informed consent process before facelift. Current management trends are neurology referral and steroid initiation.

A Single Center's Clinical Experience With Ergonomix Breast Implants.

BACKGROUND: This retrospective study reports on the early experience of a private surgical center with Motiva Ergonomix SilkSurface breast implants. OBJECTIVES: The aim of this study was to examine the incidence of complications and satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with Ergonomix SilkSurface breast implants. METHODS: A total of 356 consecutive patients received Ergonomix SilkSurface breast implants between April 2014 and October 2018 by 3 different surgeons and were followed-up for a minimum of 12 months. Complications were assessed by measuring the rate of rupture, capsular contracture, malposition, late seroma, double capsule, reoperation, symmastia, ptosis, extrusion, and infection. Satisfaction with aesthetic results was assessed on a Likert scale by both surgeon and patient. RESULTS: Only 6 major complications were observed in these 356 patients (712 implants): 1 unilateral implant ptosis ("bottoming out") at 12 months (0.14%) and 2 capsular contractures (0.28%), 1 at 14 months and 1 at 2 years. At all time points, 98% of the patients were "extremely satisfied or very satisfied" with the aesthetic results, and the surgeons categorized the outcomes as "very important or important improvement" in 96% of the cases. CONCLUSIONS: Motiva Ergonomix SilkSurface devices provided high patient satisfaction up to more than 5 years postoperatively with very few complications. These data are consistent with other reports in the literature. The observed favorable outcomes might be attributed, at least in part, to the bioengineered "cell-friendly" surface of these implants.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL.

BACKGROUND: Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL. OBJECTIVES: The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance. METHODS: A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement. RESULTS: The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria. CONCLUSIONS: BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

Facial Aging Surgery: Healing Time, Duration Over the Years, and the Right Time to Perform a Facelift.

BACKGROUND: The "time variable" assumes paramount importance, especially regarding facial rejuvenation procedures. Questions regarding the length of recovery time before returning to work, how long the results will last, and the ideal time (age) to undergo this particular type of surgery are the most commonly asked by patients during the initial consultation. OBJECTIVES: The authors endeavored to determine the healing time, optimal age to perform the surgery, and duration of the results after cosmetic face surgery. METHODS: A 35-year observational study of 9313 patients who underwent facial surgeries was analyzed. The principal facial rejuvenation interventions were divided into 2 subgroups: (1) eyelid and periorbital surgery, including eyebrow lift, blepharoplasty, and its variants and midface lift; and (2) face and neck lift. Significant follow-ups were conducted after 5, 10, and 20 years. To evaluate the course of convalescence, the degree of satisfaction with the intervention, and the stability of the results, a questionnaire survey was administered to a sample of 200 patients who underwent face and neck lifts. RESULTS: The answers given indicated that surgery performed according to rigorous standards allowed for a relatively rapid recovery, and the positive results were stable up to 10 years after surgery. The level of patient satisfaction also remained high even after 20 years. CONCLUSIONS: The "right time" for a facelift, taking into account age, recovery time, and the longevity of the results, is an important consideration for both the patient and the cosmetic surgeon.

"Dynamic Canthopexy" Drill Hole Canthal Repositioning.

BACKGROUND: Canthopexies can be performed to modify the eye slant, both when the lateral canthus is lower than the medial one (congenital defect) or in case the patient asks for an almond-shaped eye (cosmetic indication). OBJECTIVES: This peculiar type of canthopexy can be defined as "dynamic canthopexy," meaning that the lateral canthus is released from its original insertion and raised to a higher position. The goal of this study is to demonstrate the differences and the efficacy of the dynamic cantoplasty. METHODS: The authors reviewed 30 patients treated with a "dynamic canthopexy" between January 2005 and March 2015. Eighteen patients were affected by true downslanting palpebral fissure, and 12 patients had a normal eye shape but were wishing for a more "Asian" look. Dynamic canthopexy involves a total modification of the canthal suspension system and its careful reconstruction at a higher level inside the orbital rim. To obtain a permanent result, canthal ligament and tendon had to be anchored to drill holes in the orbital rim bone with nonabsorbable sutures. Symmetry was very carefully assessed. The average surgical time was 1 hour. RESULTS: This surgery proved extremely effective in all cases. Patients must be warned, though, that an initial hypercorrection is necessary to achieve the desired canthal position. About 6 months after surgery the result of this operation can be considered permanent. Severe complications are rare. CONCLUSIONS: Dynamic canthopexy can provide stable correction of anti-Mongolian slant. It can also be effectively employed to obtain permanent slant eyes when required by purely cosmetic patients. If precisely carried out, this technique can yield very rewarding outcomes.

Expert Consensus on the Use of a New Bioengineered, Cell-Friendly, Smooth Surface Breast Implant.

BACKGROUND: Although general guidelines are available for established silicone gel breast implants, the unique characteristics of the latest Motiva implants warrant specific guidelines. OBJECTIVES: This study aimed to generate consensus recommendations and summarize expert-based advice to better understand current surgical practices and to establish guidelines for surgeons transitioning from other implant devices to the Motiva implants. METHODS: A survey was compiled by 12 plastic surgeon experts in aesthetic and reconstructive breast surgery and 1 biotechnology scientist, and distributed to 36 plastic surgeons to establish a consensus on the use of these devices. Surgical techniques, complication rates, and implant selection were among the topics discussed. RESULTS: The experts agreed on 3 core principles regarding the use of Motiva Round and Ergonomix implants. Firstly, the dissected pocket needs to be close fitting and steps must be taken to prevent expansion of the pocket. Secondly, implant selection must be individualized. Finally, surgical planning and technique must be carefully considered. When questioned about problems they had ecountered, 84.6% of the experts agreed that they experienced fewer overall complications and 76.9% confirmed reduced capsular contracture rates with these devices. Overall, 84.6% of the experts favored selecting Motiva Ergonomix implants over Round implants to achieve a more natural look. In addition, 92.3% of the experts agreed that Motiva implants, due to their innovative technology, reduce the risk of anaplastic large-cell lymphoma. CONCLUSIONS: This international consensus of leading practitioners will assist plastic surgeons with patient selection, preoperative planning, and surgical technique. These recommendations are designed to optimize surgical outcomes, resulting in lower overall complication rates, more natural-looking breasts, and highly satisfied patients.

Effectiveness, Longevity, and Complications of Facelift by Barbed Suture Insertion.

BACKGROUND: Minimally invasive facelift techniques involving barbed suture insertion have become popular among patients who wish to correct facial tissue ptosis. OBJECTIVES: The authors sought to determine the effectiveness, longevity, complications, and postoperative sequelae associated with facelift by means of barbed polydioxanone (PDO) threads. METHODS: A total of 160 consecutive patients who underwent facelift with barbed threads were evaluated retrospectively. For malar augmentation and correction of nasolabial grooves, 2 or 3 PDO threads (23 gauge) were placed per side; for treatment of mandibular lines, 2 to 4 PDO threads (21 gauge) were inserted per side. RESULTS: Immediately after suture placement and for 1 month postoperatively, patients experienced improvement in facial tissue ptosis. This aesthetic result declined noticeably by 6 months and was absent by 1 year. The overall complication rate in the early postoperative period was 34% (55 of 160 patients). Eighteen patients (11.2%) had superficial displacement of the barbed sutures, 15 (9.4%) experienced transient erythema, 10 (6.2%) had infection, 10 (6.2%) experienced skin dimpling, and 2 (1.2%) had temporary facial stiffness. CONCLUSIONS: Placement of barbed threads yields instantaneous improvement in facial ptosis that is no longer apparent by 1 year. Given this transient benefit and the complication rate of 34%, we recommend limiting this procedure to patients with contraindications for more invasive facial surgery.

Facelift 2015.

Among the current topics, one that is more commonly discussed is that of the mini-invasive or "soft" techniques that seem to attract doctors and patients more than real surgery. We instead propose a relatively aggressive technique that can really rejuvenate the faces and necks of our patients. Are we not in step with the times? The problem is, unfortunately, that until now there is nothing that, without anesthesia, swelling, bruising, and so forth, can magically bring about the result of a well-done facelift. There are no "thread lifts" or fillings or endopeels or weird devices using radiofrequency, ultrasound, or shock waves-the list could go on forever-that can compare with a properly performed facelift. But how should a good facelift be done? For many years, we have been using the protocol described in this article, and the request for facelifts has not dropped, despite never having used advertising in our practice. We want to give our patients natural and long-lasting results, and for this purpose we must use an effective and individualized technique, even if it implies a relatively long down time. In this article, we describe the technical choices that we have made based on a long clinical experience and on detailed anatomical studies. Most difficulties that are encountered with this type of surgery concern finding the proper dissection plane and the proper amount of traction to be applied to the different tissue layers. It is indeed not at all easy, especially for a beginner, to be sure that one has reached the proper depth of dissection, which will allow the elevation of the superficial musculo-aponeurotic system (SMAS) in a risk-free manner even in the area which is medial to the anterior border of the parotid gland where the facial nerve is no longer protected by the gland itself. We will nevertheless try to provide precise indications concerning every important detail needed to perform the operation safely.

Chin Microgenia: A Clinical Comparative Study.

BACKGROUND: The aesthetic relevance of the chin and its relatively simple correction through different approaches make genioplasty one of the most performed aesthetic procedures of the face. Sliding genioplasty is extremely rewarding, particularly when performed as an adjunction to rhinoplasty, rhytidectomy, or jaw surgery. In the scientific literature, many different surgical techniques are described, but the biological implications and the economical impact can shape the surgeon's decision on which can be the best treatment: surgical correction with osteotomy, chin implants, or with fillers. OBJECTIVE: The authors propose a decision making protocol for correcting chin microgenia based on a revision of 345 treated cases. METHODS: A retrospective review of 345 cases of chin microgenia was undertaken to understand the proper preoperative assessment and therapeutic planning. A total of 135 patients were treated with surgical sliding genioplasty (group A): 60 patients (group B) have been grafted with alloplastic implants and the remaining 150 patients (group C) with hyaluronic acid. We recorded clinical indications, complications, and long-term aesthetic results at 3-year follow-up. RESULTS: The analysis of the results based on the entity of the chin's sagittal defect, the chin soft-tissue thickness, the patient's age, and self-judgment allows for simplified treatment planning for sagittal chin deformities showing a greater predictability and a more stable long-term aesthetic result regarding sliding genioplasty compared to alloplastic implant placement and fillers. CONCLUSIONS: Our proposal for a simple and versatile protocol of chin microgenia aims to simplify the therapeutic indications for a predictable and a stable long-term aesthetic result. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .