Skin Perfusion After Hemostatic Net: An Anatomic and Radiologic Study in a Cadaver Model.

BACKGROUND: The hemostatic net is a recent technique initially developed to reduce the occurrence of postoperative hematomas following facelift procedures. Its applications have expanded to include skin redraping, deep plane fixation, and other areas beyond the face. However, no experimental study has investigated its effect on skin blood supply. OBJECTIVES: The aim of this study was to analyze facial skin vascularization after applying a hemostatic net to fresh cadavers. METHODS: Fourteen hemifaces from fresh adult cadavers were examined. The study model involved a deep plane facelift procedure with the use of a hemostatic net. The first step, involving 4 hemifaces, included dissections and two-/three-dimensional angiographies by digital microangiography and computed tomography scan, respectively. The purpose was to evaluate the influence of the hemostatic net on vascular perfusion. The second step involved a sequential dye perfusion study performed on 10 other hemifaces that underwent facelift procedures with the hemostatic net to determine its impact on skin perfusion. RESULTS: The anatomic and radiologic techniques enabled visualization of skin, and showed the arterial system reaching the subdermal vascular plexus and branching between the vascular territories, without interference from the net. The sequential dye perfusion study showed staining after injection in each facelift flap, with comparable coloration distributions before and after the application of the net. CONCLUSIONS: The hemostatic net did not affect the skin blood supply, correlating with no clinical increases in ischemia and necrosis rates in the facelift flap. This study provides additional evidence supporting the safety of the hemostatic net in clinical practice.

The Short Neck: Challenges and Techniques.

Establishing a pleasant cervical contour in short-neck patients is of one the most difficult challenges for a facial plastic surgeon. Subplatysmal volume reduction, platysma tightening, and skin distribution adequately coupled with the middle third facelift are the pillars of the surgical approach. Additionally, treating the small chin, which is frequently observed in these patients, improves the overall result. In this paper, an objective method to define short-neck patients is offered. The applied surgical anatomy of the neck is revised. Innovative strategies to treat the supra and infrahyoid subplatysmal structures are presented, including the sternohyoid muscles plicature and the use of the interplatysmal/subplatysmal fat flap. A novel chin augmentation technique, using a subperiosteal en bloc fat graft is also introduced. A modified deep plane approach is described, including a continuous suture of the middle third fasciocutaneous flap. A combined lateral platysma tensioning with the sternocleidomastoid rejuvenation is demonstrated. Lastly, the hemostatic net is revisited as a critical approach to resolve the defying skin accommodation.

Management of the Submandibular Gland in Neck Lifts: Indications, Techniques, Pearls, and Pitfalls.

Neck contour deformities are common among patients who present for facial rejuvenation. A thorough physical examination and photographic analysis, including an upward view of the flexed neck, enable the surgeon to determine which structures should be treated. Common causes of neck concerns include hypertrophy of the subplatysmal fat, the anterior belly of the digastric muscle, and/or the submandibular salivary glands. Partial removal of the submandibular salivary glands requires advanced knowledge of subplatysmal anatomy and surgical expertise but can be performed safely and reliably to yield favorable results of neck rejuvenation.

Subplatysmal Necklift: A Retrospective Analysis of 504 Patients.

BACKGROUND: Improvement of neck contour is a primary goal of patients who seek rejuvenation of the face and neck. Subplatysmal structures, including fat, the digastric muscle, and the submandibular salivary glands (SMSGs), may contribute to the appearance of a disproportionately large neck. OBJECTIVES: The authors sought to evaluate the safety, effectiveness, and predictability of necklift combined with reshaping and repositioning of the subplatysmal structures. METHODS: The records of 504 patients were reviewed retrospectively. Surgical maneuvers for subplatysmal necklift were described comprehensively and supplemented with videos. The subplatysmal anatomy was detailed by means of 2 cadaver dissections. RESULTS: A total of 430 patients (85.3%) underwent subplatysmal necklift. The most commonly treated structures were fat (423 patients [83.9%]), the SMSGs (307 patients [60.9%]), and the digastric muscle (91 patients [18.1%]). The most common complications were weakness of the lower lip depressor (29 patients [5.7%]), followed by sialoma of the parotid gland (10 patients [2%]). No patients experienced subplatysmal hematoma. CONCLUSIONS: Subplatysmal necklift is a safe, effective, and reliable option for patients who desire improved cervical contour. LEVEL OF EVIDENCE: 4 Therapeutic.

Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients.

BACKGROUND: Hematoma is the most common postoperative complication of rhytidoplasty, resulting in higher morbidity and longer recovery. Quilting suture for closure of the undermined area in abdominoplasty avoids the occurrence of seroma. Based on this principle and with the objective of reducing the number of patients with hematomas in rhytidoplasty, a similar surgical tactic was developed in which a hemostatic net is created with a running transfixing suture of 5-0 nylon encompassing the skin and the superficial musculoaponeurotic system-platysma. METHODS: The study enrolled 525 consecutive patients who underwent rhytidoplasty between July 2009 and February 2013. The first 120 patients (group A) were evaluated retrospectively and considered control subjects. The remaining 405 patients (group B) had application of the described tactic, with data collected prospectively. The occurrence of hematoma, ischemia, and necrosis was observed during the first 72 h after surgery. RESULTS: Control group A included 17 patients with hematoma (14.2 %) during the first 72 h, whereas no patient in group B experienced such a complication (p < 0.001). The surgical tactic did not significantly increase the occurrence of ischemia. This complication was experienced by 11 patients in group A (9.2 %) and 26 patients in group B (6.4 %) (p = 0.408). The tactic also did not change the incidence of necrosis, which was present in three group A patients (2.5 %) and six group B patients (1.5 %) (p = 0.723). CONCLUSION: The hemostatic net is an efficient and safe method for preventing early hematomas in rhytidoplasties. 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 .

Innovative tactic in submandibular salivary gland partial resection.

SUMMARY: Adequate neck contour is one of the goals in facial rejuvenation. In some patients, treating the submandibular salivary gland (SMSG) ensures a satisfying result. Hematoma, sialoma, and paralysis of the depressors of the lower lip may occur when the deep neck is approached. The objective of this work is to present a new tactic to prevent the aforementioned complications. Two hundred forty consecutive neck lift patients with partial resection of the SMSG were studied. The tactic consisted of placing sutures to facilitate the retraction of the platysma muscle and the accompanying marginal mandibular and cervical branches of the facial nerve during the resection of the SMSG. It also included stitches that bring the platysma muscle in contact with the remaining SMSG, sealing the dissected area. The first 25 (control) subjects did not undergo the tactic; the remaining 215 (study group) did. The occurrence of paralysis of the depressors of the lower lip and of hematoma and sialoma originating from the SMSG resection was observed. When comparing the control group with the study group, the rates of hematoma (8% vs 0%) and sialoma (24% vs 0%) were significantly higher in the former. Paralysis of the depressors of the lower lip also had a higher rate in the control group (4% vs 0.9%) although this difference was not statistically significant. The surgical tactic described is efficient in preventing the occurrence of hematoma, sialoma, and paralysis of the depressors of the lower lip in neck lift with partial resection of the SMSG.