The Extended Superficial Musculoaponeurotic System Deep Plane Facelift.

Over the past four decades, the senior author has evolved and perfected his preferred method for face and neck lifting, the extended superficial musculoaponeurotic system deep plane rhytidectomy, and submentoplasty. With this procedure, the superficial musculoaponeurotic system layer is addressed both in the face and neck, repositioning the tissues in a superior and posterior vector and creating a sling in the cervicomental area. Outcomes have proven to be both successful and long lasting. In this article, a detailed update and discussion of the specific techniques utilized are provided.

Rejuvenating the Aging Upper Lip: The Longevity of the Subnasal Lip Lift Procedure.

Objective: This study sought to retrospectively analyze the longevity of the subnasal lip lift procedure on the aging upper lip by determining if the amount of skin resected was maintained. Methods: Patients who underwent subnasal upper lip lift procedure of 5-mm resection with the senior author (S.W.P.) from 2006 to 2020 were identified for a total of 52 patients who met inclusion criteria. Pre- and postoperative measurements of nasal base to upper lip vermillion border and vermillion height were taken. Longevity of results were measured through percentage retention of 5-mm lift and percentage improvements of lip show. Results: The percentage retention of the 5-mm lift and percentage improvement of lip measurements were maintained over time with a slow decline. The average percentage improvement of lip show was 48.2%. Patients <5 years out from surgery had 50.1% improvement compared with 40.3% for those ≥5 years out (p = 0.569). Conclusions: The subnasal lip lift procedure shortens the vertical height of the elongated upper lip and gives increased vermillion show with predictable results.

Preoperative Imaging and Online Photo Galleries: The #Key to Surgical Commitment.

Importance Preoperative imaging provides an advantageous balance by helping patients to effectively communicate their aesthetic desires while allowing surgeons to establish realistic expectations of surgical outcomes. Objective To determine the role of preoperative imaging and the importance of online-based photo galleries in influencing a patient's decision to pursue cosmetic facial plastic surgery. Design, Setting, and Participants A retrospective study was conducted on 100 patients who underwent preoperative imaging prior to undergoing aesthetic facial plastic surgery from July 2019 to May 2020. An in-office physician-led clinical consultation followed by a preoperative imaging session was performed on each patient prior to surgical intervention. A 6-question survey was provided once to all patients between their 3- and 12-month postoperative time periods. Main Outcomes and Measures The importance of preoperative imaging and the influence of physician website and social media photo galleries regarding surgical decision-making was evaluated. Results A total of 100 participants (female [90; 90%]) and mean age 52.6 (range, 18-77) years were included. Nearly 60% of patients underwent facial rejuvenation procedures. All reported that preoperative in-office physician consultation in combination with the use of preoperative imaging were helpful in facilitating a commitment to surgical intervention. Sixty-nine (69%) patients endorsed the use of both the frontal and lateral imaging views, while 30 (30%) deemed a single angle to be superior. Seventy (70%) participants utilized online-based "before & after" photo galleries in the form of physician websites and/or social media platforms to assist in their decision to undergo surgical intervention. Conclusions and Relevance The combination of in-office physician consultation, preoperative imaging, and availability of website and/or social media photo galleries plays a key role in a patient's decision to pursue cosmetic surgery. Thus, implementation of all facets should become an integral part of any facial plastic surgeon's aesthetic practice.

Incorporating Midline Platysmaplasty with Lateral Superficial Muscular Aponeurotic System Facelifting.

Management of the platysma is key to achieving an ideal neck contour during rhytidectomy. This article reviews platysmal anatomy, indications for platysmaplasty, preoperative patient assessment, surgical technique for midline platysmaplasty, postoperative management, long-term outcomes, and the senior author's experience and philosophy on midline platysmaplasty in the setting of lateral superficial muscular aponeurotic system facelifting.

Anatomy of the Facial Profile.

The facial profile is an essential part of facial analysis and significantly impacts surgical decision making. Knowledge of the underlying anatomy, which creates the facial profile, and the anatomic sources of the common abnormalities in the profile can help to ensure adequate surgical correction of the abnormality.

The Use of Spreader Grafts or Spreader Flaps-or Not-in Hump Reduction Rhinoplasty.

Hump reduction is one of the most common reasons patients seek cosmetic rhinoplasty. Spreader grafts or spreader flaps have become a key maneuver in supporting and reconstructing the nasal midvault after reductive profileplasty to prevent long-term functional and cosmetic sequelae. This article reviews the pertinent anatomy, describes indications for spreader graft or spreader flap placement, discusses surgical techniques and approaches for spreader graft placement, and describes complications of spreader graft use after hump reduction.

Complications in Reductive Profileplasty.

The ability of a surgeon to create an aesthetically pleasing and functionally competent nasal dorsum weighs heavily on following the foundations of rhinoplasty, beginning with the examination and analysis. These same fundamental principles should be used and applied in secondary rhinoplasty. The most common chief complaints of those patients seeking primary rhinoplasty relates to the presence of a hump or dorsal convexity, and similarly complications surrounding the dorsum are the most common indications for secondary rhinoplasty. The surgeon must be able to appropriately evaluate and correct deformities in patients who have already undergone rhinoplasty with dorsal profileplasty. Patients can present with a wide range of postoperative deformities within the bony pyramid or middle vault, including, but not limited to, contour irregularities and internal nasal valve compromise, respectively. The authors will outline the evolving methods by which these techniques can be executed to correct deformities and give a balanced functional and aesthetically pleasing profile.

The Graduated Approach to Surgical Neck Contouring.

Achieving a more youthful neckline is one of the most common reasons why patients seek facial plastic surgery. A variety of treatment options are available to contour the neck, ranging from injectable medications to minimally invasive energy devices to surgery. A spectrum of surgical procedures can be offered to contour the neck, including liposuction, submentoplasty, necklift, and facelift, all with or without implants. The ideal neck aesthetic, pertinent anatomy, patient evaluation process, indications, and techniques for the aforementioned procedures are discussed in this article. A graduated approach to neck contouring based on the senior author's long-term experience is provided.

The Past, Present and Future of Facial Plastic and Reconstructive Surgery: Facelift.

Facelift or rhytidectomy has been performed in some form for over 100 years. This article seeks to explore the evolution of this surgical procedure, focusing on the advances of the most recent 40 years. From minimal intervention to aggressive techniques and back to the minimally invasive again, the authors follow the journey of surgical intervention for facial rejuvenation and discuss some thoughts for the future.

Advances in Face-lift Techniques, 2013-2018: A Systematic Review.

IMPORTANCE: Rhytidectomy, or face-lift surgery, is the mainstay of facial rejuvenation and is constantly evolving. There is continuous research to improve outcomes and minimize complications of this surgery. OBJECTIVE: To synthesize the updated techniques in rhytidectomy published during the past 5 years, including surgical technique, advances in anesthetic technique, minimally invasive techniques, and adjunctive procedures performed at the time of rhytidectomy. EVIDENCE REVIEW: On February 8, 2018, a literature search was performed of the PubMed and Cochrane databases using the search terms, face-lift or rhytidectomy and techniques. Articles published from February 8, 2013, to February 8, 2018, that related to techniques of facial rejuvenation in the lower one-third of the face by lifting and supporting tissue with 5 or more patients were included. Systematic reviews and primary literature were considered; narrative reviews, validation studies, and anatomic studies were eliminated. The initial search resulted in 604 articles after duplicates were removed. This was reduced to 84 articles after dual independent review screening. FINDINGS: Of the 84 articles included, 51 (61%) regarding techniques of face-lifting in the past 5 years pertained to soft-tissue techniques; 14 (17%) pertained to implants or adjunctive medications, such as tissue sealants; and 12 (14%) related to adjunctive techniques performed in addition to face-lifting, such as fat grafting, resurfacing, and liposuction. All studies found the techniques reported therein to be effective, with similar or fewer complications compared with the literature. However, according to the Oxford Centre for Evidence-Based Medicine criteria, the level of evidence of the studies was generally poor, because 45 of the studies (54%) were case series (level 4 of evidence). CONCLUSIONS AND RELEVANCE: Several new techniques have been explored for rhytidectomy or face-lift in the past 5 years, including soft-tissue techniques, introduction of implants or topical medications such as tissue sealants, and concomitant adjunctive techniques to enhance results. The overall quality of the evidence is poor, with most articles using case series with nonvalidated measures to evaluate outcomes. There is considerable room for improvement in the literature if additional studies using cohort designs and validated outcomes are performed to validate the quality of the techniques introduced during the past 5 years.

Postoperative Care in Facial Implants.

Facial augmentation is a growing field, secondary to the appreciation of the changes seen in the facial skeleton with aging and the growing acceptance/popularity of facial fat grafting and facial fillers. In addition, it plays a significant role in patients with congenital facial deficiencies as well as those interested in facial feminization/masculinization surgery. Several facial implants are discussed in this article including classic facial implants such as malar, submalar, chin, and prejowl implants as well as newer facial implants such as mandible, temporal, forehead, and skull implants. Special care is given to the postoperative care of these implants. Custom-made implants with three-dimensional computed tomography reconstruction are also discussed.

The Superficial Musculoaponeurotic System and Other Considerations in Rejuvenation of the Lower Face and Neck.

This article addresses several facelift challenges involving anatomic conditions, including platysma banding, endomorphic facial habitus, and midface hypoplasia. In addition, patient counseling and conveying realistic expectations about limitations of facelift alone, with and without adjunctive procedures, are presented. In addition, a few technical modifications of the facelift procedure contributing to more uniform success and longevity are discussed.

Managing the Lower Eyelid Complex in the Thick-Skinned Patient.

Thick skin presents a unique set of challenges within the realm of facial plastic surgery, and addressing the lower lid complex is no exception. There are several procedures for addressing the lower lids, the first and foremost being lower lid blepharoplasty. However, the remaining procedures combined with surgical techniques have exclusive implications in thick skin. Understanding the anatomy and various techniques that can be applied to thick skin can help achieve aesthetically more pleasing results in comparison to those of thin skin. As will be discussed in this article, patients with skin color of Fitzpatrick's grade III or higher have several characteristics associated with their skin, including thicker dermis as well as different patterns of aging, which have implications for addressing the lower lid complex. The senior author has extensive experience performing lower lid procedures and seeks to impart how best to understand and adapt for these differences to allow for the best aesthetic result.

Measurement of Change in Lower Eyelid Position in Patients Undergoing Transcutaneous Skin-Muscle Flap Lower Eyelid Blepharoplasty.

IMPORTANCE: Transcutaneous lower eyelid blepharoplasty is a commonly performed procedure with a postoperative risk of eyelid malposition. OBJECTIVE: To quantify the change in lower eyelid position after transcutaneous lower eyelid blepharoplasty. DESIGN, SETTING, AND PARTICIPANTS: This retrospective medical record review describes patients who underwent transcutaneous blepharoplasty at a private facial plastic surgery practice. Patients with less than 3 months of follow-up, a history of periocular trauma, and concurrent midface lift were excluded. INTERVENTIONS: Bilateral skin-muscle flap lower eyelid blepharoplasties with possible tarsorrhaphy, canthopexy, or canthoplasty as indicated. MAIN OUTCOMES AND MEASURES: Lower eyelid position determined by measurement of preoperative and postoperative pupil to eyelid and lateral limbus to eyelid distances. RESULTS: Data from 100 consecutive patients (mean age, 56.7 years; 92 female [92.0%]) undergoing bilateral skin-muscle flap lower eyelid blepharoplasty were analyzed. The mean increase in distance was 0.33 mm (95% CI, 0.24-0.42 mm) from the pupil to the lower eyelid margin and 0.32 mm (95% CI, 0.23-0.41 mm) from the lateral limbus to the lower eyelid margin at final follow-up. For both measurements, patients undergoing concurrent canthopexy had a significantly greater change in eyelid position (P < .001). Men had a greater change in the distance of pupil to lower eyelid compared with women (0.76 mm; 95% CI, 0.44-1.08 mm, vs 0.30 mm; 95% CI, 0.20-0.39 mm, respectively; P = .008) at final follow-up. Two patients required revision procedures secondary to eyelid malposition, and 25 patients had new onset of dry eye symptoms. CONCLUSIONS AND RELEVANCE: Transcutaneous skin-muscle lower eyelid blepharoplasty with selective performance of canthoplasty or canthopexy causes a small, predictable eyelid position change in this population with a low rate of revision procedures. LEVEL OF EVIDENCE: 3.

Surgical treatment of the brow and upper eyelid.

Surgical management of the aging upper face has taken on a critical role in total facial rejuvenation, with a variety of techniques available. The hallmarks of the aging upper third of the face and periorbital region most commonly manifest as rhytids, brow descent, prolapse of periorbital fat, dermatochalasis, and volume loss and hollowing. The surrounding structures should be assessed individually and their relationships carefully analyzed to guide selection of the appropriate treatment. In this article, the authors explore the various approaches and techniques available for rejuvenation of the upper face, including the upper periorbital region.