Endoscopic Brow Elevation and Reshaping.

One of the first signs of aging belongs to the upper third of the face. At the same time, the height and shape of the eyebrows are key points of the periorbital aesthetics. A "tired" or "sad" look implies that the complex eyebrow-upper eyelid are showing one or more of these signs. Different surgical techniques as well as nonsurgical have been described to treat this area, every one of them aiming at making the patient look rested and natural. The objective of this study is to describe a technique for endoscopic browlifting, consisting of minimal incisions, a biplanar dissection, and a different fixation technique designed for helping reshape the brow. Twenty-five patients who fulfilled the criteria for the study were analyzed for brow-position changes in height and shape. All the patients were treated by the senior authors using the technique described. This particular surgical technique has shown the advantage of being minimally invasive and effective. Careful analysis of the patient should be made to decide both the technique and the changes desired by the patient and the surgeon. The authors believe the technique described is another option for approaching and fixating the eyebrow.

Complete corset platysmaplasty: evolution of addressing the aging neck.

Various techniques have been used to address the aging changes of the neck. This article reviews this evolution and describes the complete corset platysmaplasty procedure as the choice for optimal improvements in neck rejuvenation, especially when dealing with a "difficult neck." Evaluation and treatment of the aging neck must always be individualized and when the complete corset platysmaplasty is performed for those that are candidates, our experience shows greater immediate as well as long term satisfaction with less recurrence.

Experience with percutaneous suspension of the malar fat pad for midface rejuvenation.

Repositioning of the ptotic malar fat pad represents a key element of midface rejuvenation. Traditional face-lifting techniques have been minimally effective in correcting the midface changes commonly seen in aging. Many candidates, especially younger patients, desire procedures that have rapid recovery times with reduced risk and the absence of visible incisions. Percutaneous suspension of the malar fat pad to reposition it in a more youthful position is a minimally invasive technique producing a long lasting elevation that would be a welcomed addition to midface rejuvenation.

Intravenous Anesthesia With Bispectral Index Monitoring vs Inhalational Anesthesia for Rhytidoplasty: A Randomized Clinical Trial.

IMPORTANCE: Minor adverse effects related to anesthesia are common and worrisome to patients, including perioperative vomiting, gagging on the endotracheal tube, incisional pain, and nausea. A previously published intravenous anesthesia protocol reports extremely low rates of postoperative nausea and vomiting (<1%) and decreases in postoperative pain perception compared with rates reported following administration of inhalational anesthetics. OBJECTIVE: To evaluate and compare postoperative outcomes in patients after administration of combined propofol and ketamine hydrochloride anesthesia with bispectral index monitoring (PKA-BIS protocol) vs inhalational anesthesia (IA) during lower rhytidoplasty. DESIGN, SETTING, AND PARTICIPANTS: We performed a prospective, double-blind, randomized comparison trial of the PKA-BIS protocol and IA in 30 consecutive female patients undergoing rhytidoplasty by a single surgeon at a single outpatient surgery center from October 2013 to June 2014. MAIN OUTCOMES AND MEASURES: Outcome measures included nausea, vomiting, pain, overall feeling of well-being, time to awaken, time to discharge, and cost. Patient measures were recorded using a combination of a 40-item validated postoperative quality of recovery questionnaire (QOR-40) and visual analog scales (VASs). Results were recorded immediately after surgery and on postoperative days 1 and 7. RESULTS: A statistically significant reduction in emergence time (mean [SD], 29.8 [10.6] vs 46.0 [10.2] minutes; P < .001) and time to meet discharge criteria (51.4 [19.3] vs 66.1 [12.9] minutes; P = .02) was seen in patients in the PKA-BIS group. Patient-reported (subjective) postoperative nausea (3 of 15 [20%] vs 7 of 15 patients [47%]; P = .12; χ2 = 2.40), vomiting (0 vs 2 of 15 patients [13%]; P = .14; χ2 = 2.14), and confusion on the day of surgery (3 of 15 [20%] vs 6 of 14 patients [43%]; P = .18; χ2 = 1.77) were also decreased in the PKA-BIS group, but these differences did not reach significance. Differences in global recovery scores (QOR-40 scores in the postanesthesia care unit, 158.13 [22.68] vs 155.33 [18.09]; P = .71; at day 1, 166.47 [26.39] vs 166.00 [16.00]; P = .96), postoperative overall feeling of well-being (VAS scores at day 1, 6.10 vs 6.26; at day 7, 7.49 vs 8.00), and postoperative pain perception (VAS scores at day 1, 3.40 vs 3.65; at day 7, 2.26 vs 1.81) between the PKA-BIS and IA groups, respectively, did not reach significance. The costs of anesthesia administration were similar between the PKA-BIS ($10.37/h) and IA ($8.47/h to $9.87/h) groups. CONCLUSIONS AND RELEVANCE: The PKA-BIS protocol for anesthesia appears to be a comparable alternative to traditional IA in patients undergoing elective rhytidoplasty. A larger patient sample size is needed to determine whether trends toward decreased nausea, vomiting, and postoperative confusion and differences in postoperative pain perception are significant. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02410460. LEVEL OF EVIDENCE: 1.

A retrospective comparison of open and endoscopic brow-lifts.

OBJECTIVES: To measure and compare surgical brow elevation with open and endoscopic techniques; to compare patients who did and did not undergo an eyelid procedure in the same setting as the brow-lift; and to determine whether a learning curve exists for a successful endoscopic brow-lift procedure. DESIGN: A retrospective review of patients who underwent coronal, trichophytic, and endoscopic brow-lift surgery from January 1, 1993, to December 31, 1997 (performed by K.A.L.). We analyzed preoperative and postoperative photographs obtained from 10 to 56 months after surgery while masked to the surgical technique used. Measurements included a horizontal baseline drawn through the midpoint of the right and left medial canthi, and extended laterally across the face; the distance from the baseline to the superior border of the medial eyebrow on the right and left sides; and the distance from the baseline to the highest point of the brow on the right and left sides. A second, nonbiased observer analyzed a random sampling of patient photographs to determine the degree of interobserver variation. SETTING: Private facial plastic and reconstructive surgery practice. All procedures were performed in an ambulatory surgery setting. PARTICIPANTS: We identified 125 patients (average age, 54 years) with greater than 10 months of postoperative photographic documentation. We excluded 41 patients owing to several inconsistencies between their preoperative and postoperative photographs and included 84. These patients were divided into 3 groups: those undergoing coronal, trichophytic, and endoscopic procedures. Of the patients undergoing concomitant eyelid procedures, 12 underwent upper lid blepharoplasties; 15, lower lid blepharoplasties; 16, bilateral upper and lower lid blepharoplasties; 6, periorbital laser resurfacing or chemical peel; 1, canthoplasty; and 1, ptosis repair. The endoscopic brow-lift procedure was not performed in this facial plastic surgery practice until 1995. To determine whether better results were obtained in the later half of the study, when the surgeon had more experience, this group was divided between the 14 patients who underwent the procedure from January 1, 1995, to June 30, 1996, and the 20 who did from July 1, 1996, to December 31,1997. MAIN OUTCOME MEASURE: Comparison of preoperative photographs with postoperative 10- to 32-month follow-up photographs and with final 35- to 56-month follow-up photographs. RESULTS: We found no statistically significant difference in: the distance of the medial brow (P =.89) or highest elevated point of the brow (P =.93) between the coronal, trichophytic, and endoscopic groups; the distance that the medial brow (P =.15) or the highest point of the brow (P =.11) was raised for those patients undergoing concomitant eyelid procedures; and the distance that the medial brow (P =.80) or highest point of the brow (P =.79) was raised between the 2 endoscopic brow-lift groups. Interobserver variation in brow measurements was 0.1 cm or less in more than 90% of cases. CONCLUSIONS: Both open and endoscopic brow-lift techniques described herein elevate the entire brow successfully. We found no statistical difference in patients undergoing concomitant eyelid procedures, and there was no identification of a "learning curve" for a successful endoscopic brow-lift with the surgical technique described.

Lower lid blepharoplasty: panel discussion, controversies, and techniques.

UNLABELLED: What is the most frequent displeasing effect you see when performing lower eyelid blepharoplasty? What surgical approach do you most frequently use when performing lower eyelid blepharoplasty? How much skin removal of the lower eyelids? When performing lower lid blepharoplasty, what is your preferred method of managing pseudoherniated fat? If you perform midface lifting during blepharoplasty, what approach do you use? ANALYSIS: Over the past 5 years, how has your technique or approach evolved or what is the most important thing you have learned in doing blepharoplasty?

Periocular rejuvenation: lower eyelid blepharoplasty with fat repositioning and the suborbicularis oculi fat.

Treatment of the aging lower eyelid is determined by the anatomic variables noted for each surgical candidate. Although surgeons have traditionally considered dermatochalasis, fat pseudoherniation, and eyelid position as the main treatment objectives in lower blepharoplasty, the vector of the infraorbital rim and the anterior plane of the cornea, tear trough, and aging in the midface also merit critical consideration. In this article, indications and technical aspects, the transconjunctival and external approaches, fat excision versus fat repositioning, and suborbicularis oculi fat lifting and fat transplantation are discussed and the authors' preference for the various methods of lower blepharoplasty is presented. Common adjunct procedures used to supplement lower blepharoplasty techniques and the role of injectable fillers in periocular rejuvenation are also mentioned.

Transblepharoplasty: subperiosteal approach to rejuvenation of the aging midface.

Multiple approaches are available to rejuvenate the aging midface. Our preferred technique is a graduated transblepharoplasty approach beginning with lower blepharoplasty with or without orbital fat repositioning and progressing to a subperiosteal midface lift, guided by the extent of aging changes present in the midface. In this article we discuss the rationale for this method and describe the preoperative analysis, relevant anatomy, surgical technique, postoperative considerations, and complications associated with each technique. Case examples are provided to illustrate major concepts.