Lower Lid Blepharoplasty in Men.

Periorbital changes in men occur similarly to in women and may result in a need for correction through blepharoplasty. Lower lid techniques vary, but the authors prefer a transconjunctival approach that may extend into a retroseptal approach in men. Using this approach, excess fat can be excised and even redraped with orbitomalar retaining ligament release. Optimal outcomes are achieved when the surgical technique is targeted to correct the palpebromalar and nasojugal grooves, which are often the main concern for patients presenting to the office. Lower lid stabilization, support/tightening procedures are critical to prevent lower lid malposition and to ensure complete restoration of a youthful lower lid contour.

Discussion-Cervico-Mental Angle Suspensory Ligament: The Keystone to Understand the Cervico-Mental Angle and the Aging Process of the Neck.

This is a commentary and discussion in response to a cadaveric study entitled, "Cervico-mental angle suspensory ligament: The keystone to understand the cervico-mental angle and the aging process of the neck." While highlighting the cervico-mental angle suspensory ligament has the potential to give rise to new surgical technique in neck rejuvenation surgery, the authors caution readers of the study's major limitation. Without well-documented results aligning with aesthetic ideals or reports of the safety and longevity of the procedure, it seems too early to consider this ligament the keystone to understand the aging neck. An actual surgical technique must be described and further clinical studies need to be performed before this ligament can be included in the armamentarium of neck rejuvenation surgery. As the goal of surgery should be a natural result that restores aesthetic ideals of the youthful neck, regardless of the significance that this ligament will carry, its application should be tailored to the patient to avoid overly aggressive treatment. 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 .

Finesse in forehead and brow rejuvenation: modern concepts, including endoscopic methods.

BACKGROUND: The brow and forehead are essential elements of the facial aesthetic architecture. Although frequently overlooked in youth, signs of facial aging are often most noticeable in the upper third of the face. Ptosis and loss of contour in the brows, along with temporal volume loss, sagging of periorbital tissue, and rhytides in the forehead, are common presenting complaints for aesthetic surgery. Although use of nonsurgical procedures (e.g., neuromodulators) has become very common practice, knowledge of surgical anatomy and interventions for brow and forehead rejuvenation are critical for a plastic surgeon. The earliest descriptions of brow-lift procedures are nearly a century old. Techniques have evolved significantly, to the point that patients may now return to work within 1 week of surgery, with minimal or no stigmata from an operation. METHODS: The literature and a series of cases from the senior surgeon (P.K.S.) were reviewed. RESULTS: A minimally invasive approach with an endoscope for dissection and repositioning of the brow was used in all patients. The authors have found that permanent suture fixation with cortical tunnels can produce an excellent, long-lasting aesthetic result for not only the forehead and brow but also the lateral periorbital and temporal regions. CONCLUSIONS: Although each operation is tailored to the patient's individual anatomy, the authors' approach to the endoscopic procedure is described in this article, along with a review of anatomical and surgical considerations. Finally, several patients provide demonstrative results from the senior surgeon's series of 546 patients.

Evidence-based medicine: Blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Identify the essential preoperative considerations for patients undergoing blepharoplasty. (2) Describe upper and lower eyelid anatomy and the relevance to blepharoplasty techniques. (3) Discuss a standard approach to upper and lower lid blepharoplasty, beginning with preoperative assessment, planning, and marking. 4. Describe the major considerations in periorbital rejuvenation and the critical steps taken during blepharoplasty to create aesthetic improvements. SUMMARY: Blepharoplasty is one of the most common aesthetic procedures performed in the United States. Significant improvements in facial aesthetics can be made with a relatively short operation that can be performed under intravenous sedation or entirely with local anesthesia. Upper blepharoplasty focuses primarily on removal of excess skin and aesthetic placement of the supratarsal crease, along with filling and contouring of a deep upper orbital sulcus with injections when necessary. Lower blepharoplasty addresses the orbitomalar sulcus (lid-cheek junction and tear-trough abnormalities) and pseudoherniation of periorbital fat, and is based on selective removal and repositioning of fat. Upper blepharoplasty generally does not require fat removal. In addition, lower blepharoplasty involves releasing deep structures, whereas upper blepharoplasty is generally more superficial. In general, the upper lid should be approached transcutaneously, whereas lower blepharoplasty can be safely performed through a transconjunctival or a transcutaneous incision. Complications of upper blepharoplasty are uncommon with more current techniques, but lower lid blepharoplasty has potentially disastrous complications. Blepharoplasty can significantly enhance periorbital and midface aesthetics by improving the tired appearance of even young patients, and is an important tool for facial rejuvenation.

Extended lower lid blepharoplasty for eyelid and midface rejuvenation.

UNLABELLED: Many techniques have been described for lower eyelid surgery, and the evolution of these procedures has seen significant advances, from simple skin excision to fat preservation and repositioning. Lower lid blepharoplasty can address lid-cheek junction and tear-trough deformities, which cause significant aesthetic concerns for patients, giving the appearance of fatigue and sadness. However, there is potential for serious functional and aesthetic complications, including dry eyes, scleral show, and ectropion. In addition, many surgeons perceive a steep learning curve and difficulty of reliably obtaining excellent cosmetic results. However, the authors have found that an extended lower blepharoplasty can significantly improve eyelid and midface contour, creating substantial aesthetic improvements without visible scars or an operated appearance. In this article, the authors review the relevant pathoanatomical causes of periorbital contour deformities and the evolution and history of lower eyelid surgery, and present the results of their extended blepharoplasty technique in over 300 patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

An anatomical evaluation and surgical approach to the perioral mound in facial rejuvenation.

BACKGROUND: Premature aging of the perioral soft tissues of the face is a common complaint of patients seeking facial rejuvenation, although its cause is unclear. The subcutaneous fat compartments of the face may be differentially affected by facial aging. Despite efforts to study and rejuvenate the aging periorbit, midface, and jowls, the effects of aging on the perioral mound have been less studied. METHODS: To better understand the cause of age-associated changes in the perioral area, a cadaver dissection study was performed. Eight fresh and fixed cadavers with evidence of perioral fullness were used in anatomical dissection. Anatomical observations and histologic examination were used to describe the age-related changes in this area. After describing the defect, the authors present a surgical approach to rejuvenation of this region, tailored to the findings in this anatomical study. RESULTS: Histologic sections demonstrated a lipomatous area without defined ligamentous attachments or encapsulations. Chambers of adipocytes in the hypodermis were separated by thin fibroseptations: a scaffold in the structural support of this region. Superficial lipodystrophy defines thisfacial region in the cadaver specimens. The end result is a fatty, ptotic perioral mound of tissue that is not well addressed by conventional rhytidectomy. CONCLUSIONS: The area of the perioral mound may represent a small, independent fat compartment or a differentially affected extension of the nasolabial compartment described by Pessa. This cadaver study has increased the authors' understanding of the perioral region and allowed them to improve results in its rejuvenation. The senior author's preferred approach is liposculpture with fine-cannula liposuction.

The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation.

BACKGROUND: Forehead rejuvenation procedures can lead to excessive elevation of the medial brow, resulting in the "surprised look." Differential treatment of the medial and lateral brow allows more precise positioning. The purpose of this study was to determine whether retaining structures exist in the forehead that would permit this differential elevation. METHODS: Anatomical dissections were performed in the foreheads of 12 cadavers. Multiplanar dissections at the subperiosteal, subgaleal, and subcutaneous levels were performed on eight hemiforeheads. Clinical correlation for these findings was obtained during endoscopic and open brow-lift surgery. RESULTS: Four retaining structures of the brow were identified: three medial and one lateral. The superomedial attachment begins 13 mm from the midline and 10.8 mm above the supraorbital rim. The superolateral attachment begins 23 mm from the midline and 10.3 mm above the supraorbital rim. The inferomedial attachment begins 12.6 mm from the midline at the level of the supraorbital rim, just medial to the supraorbital nerve. These three structures were found to control the position of the medial brow. Laterally, brow position was controlled by a broad ligamentous attachment extending across the lateral aspect of the supraorbital rim. CONCLUSIONS: Medial retaining structures have been found to extend from the cranium into the forehead musculature. Release of the lateral broad ligamentous attachment was performed, followed by selective preservation of medial retaining structures. With this approach, we were able to gain control of the position of the medial brow and prevent overelevation and lateral spreading.

Contouring the aging neck with submandibular gland suspension.

Submandibular gland suspension, a procedure designed to complement surgical rejuvenation of the aging neck, uses largely blunt dissection and suspension to the mandibular periosteum to elevate the gland, improving neck contour without excision of submandibular gland tissue. Although there is an increase in operative time, the risk of intraoperative and postoperative bleeding problems is very low, and the authors report high patient satisfaction.

Submandibular gland I: an anatomic evaluation and surgical approach to submandibular gland resection for facial rejuvenation.

Submandibular gland resection for aesthetic reasons has been hotly debated. Detractors maintain that the procedure is dangerous because it puts too many important structures at risk, notably motor nerves. The present study was undertaken to elucidate the neurovascular and soft-tissue anatomy of the digastric triangle via cadaver dissections so that a surgical approach to achieve safe aesthetic submandibular resection could be performed. Fifteen digastric triangles dissections were performed in fixed and fresh cadaver specimens. The dissection focus was to understand the submandibular neurovascular relationships, capsule as well as fascial layers, and measurements to known structures. The marginal mandibular nerve is located external to the submandibular capsule, approximately 3.7 cm cephalad to the inferior margin of the gland. The hypoglossal nerve is posterior to the digastric sling in a position that is protected deep within the visceral layer of the neck. The lingual nerve is located underneath the mandibular border, crossing anterior to the submandibular duct. The vascular supply is variant, but with an average of one and a half vessels entering medially to the superficial lobe of the gland, one intermediate vessel entering medially to supply the superficial and deep lobes, and one deep perforator that runs from the central portion of the deep lobe to the superficial lobe. Appreciation of this anatomy is critical in the submental approach for partial resection. Although it can be technically challenging, the anatomy is straightforward and partial submandibular gland resection can be executed via a consistent, safe approach to optimize facial rejuvenation in certain patients.

A morphometric study of the external ear: age- and sex-related differences.

The human ear is a defining feature of the face. Its subtle structures convey signs of age and sex that are unmistakable yet not easily defined. With analysis of normative cross-sectional data, this study explored anatomic and aesthetic differences in the ear between men and women, as well as changes in ear morphology with age. A total of 123 volunteers were randomly selected for this study. The cohort consisted of 89 women ages 19 to 65 years (median age, 42 years) and 34 men ages 18 to 61 years (median age, 35 years). The average total ear height across the entire cohort for both left and right ears was 6.30 cm, average lobular height was 1.88 cm, and average lobular width was 1.96 cm. As expected based on head size, significant sex-related differences were noted in the distance from the lateral palpebral commissure to both the helical root and insertion of the lobule. Measured distances in both vectors were approximately 4.6 percent longer in men than in women. Similarly, the height of the pinna was significantly larger in men than in women by approximately 6.5 percent. The average height and width of the lobule, however, were nearly identical in men and women. Analysis of age-related data showed a significant difference in the total ear height between the subpopulations; however, this difference was not significant after the lobular height was subtracted from total ear height, suggesting that the lobule was the only ear structure that changed significantly with age. In addition, lobular width decreased significantly with age. This study establishes normative data for ear morphology and clearly demonstrates the changes in earlobe morphology that occur with advancing age.