Trials, Tribulations, and Techniques for Transitioning to an Extended Deep Plane Facelift for All Patients: Insight from a Very Experienced Surgeon's Perspective.

The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. After many years of superficial muscular aponeurotic system lift techniques, the senior author transitioned to an extended deep plane facelift for all patients. The primary catalyst for this shift in practice was the pursuit of superior rejuvenation of the midface. Consistent uniform elevation of the deep plane with complete ligament release and management of the soft tissue flap were the most significant challenges in the early adoption period. Navigating the transition was facilitated by consultation with experienced colleagues and frequent cadaver dissections. This manuscript details the authors' current technique. Complications and recovery from this technique are similar to those reported with historical techniques and are minimized with proper preparation, precision, and perioperative management. In our experience the results from this procedure are extremely reproducible, durable, and natural, and patients are overwhelmingly extremely satisfied.

Grafts in Endonasal Rhinoplasty.

Rhinoplasty is arguably one of the most challenging but rewarding procedures for the facial plastic surgeon. To adequately improve facial aesthetic parameters and preserve nasal function, the appropriate utilization of grafts is of utmost importance. While there is no best method, I found that in my hands, the endonasal approach allowed me to achieve greater control over my results by limiting dissection, utilizing less cartilage, and minimizing variables. In this manuscript, I outline the surgical pearls I have developed throughout my career that have helped me execute these grafts efficiently and effectively.

A Comprehensive Approach to Midface Rejuvenation: Our Philosophy, Algorithm, and Surgical Technique.

With a greater understanding of the aging process and relevant anatomy, the facial plastic surgeon has an expansive armamentarium of options for midface rejuvenation. Upon reflection, our practice has evolved over the years and only recently found a select number of interventions that have consistently produced excellent results. In this article, we discuss the steps needed to establish an effective patient relationship, present an algorithm on how to approach midface rejuvenation, describe our surgical technique, and review the attributes and liabilities of each procedure.

Does Increasing the Dose of Abobotulinumtoxina Impact the Duration of Effectiveness for the Treatment of Moderate to Severe Glabellar Lines?

OBJECTIVE: To evaluate the duration of effect of a single dose of 120 units of abobotulinumtoxinA for the treatment of moderate to severe glabellar lines. DESIGN: Investigator-initiated, prospective, multi-center, open-label study. MATERIAL AND METHODS: This open-label trial of thirty subjects with moderate to severe glabellar lines at maximum frown was per- formed at 2 private plastic surgery clinics. 120 units of abobotulinumtoxinA was injected in 5 equal aliquots (24 units each) into each of 5 injection sites in the glabellar complex. Investigator and subject assessments of wrinkle severity at maximum frown and repose using 4-point scales and adverse events were conducted. Follow-up was monthly for up to 11 months. RESULTS: The median duration of response for all subjects, as assessed by the investigator, was 150 days (95% CI: 120, 180). The median duration of response was 165 days (95% CI: 90, 180) for subjects with Grade 2 (Moderate) wrinkles at baseline and 75 days (95% CI: 30, 120) for subjects with Grade 3 (Severe) wrinkles at baseline. Overall, 76.7% of subjects had a duration of ≥ 120 days. At the end of study (day 300) 9/16 (53%) of subjects who were Grade 3 at baseline still rated themselves as not returning to Grade 3, demonstrating ongoing improvement. Adverse events were mild and transient. There were no events of lid or brow ptosis. CONCLUSIONS: The 120 units of abobotulinumtoxinA were significantly effective in reducing glabellar lines in subjects with Grade 2 (Moderate) wrinkles at baseline for a longer duration than the reported 85 days in the FDA Phase III randomized, placebo-controlled clinical studies using a standard 50 unit dose. Subject satisfaction was high. There was no increase in the incidence of adverse events with this higher dose. J Drugs Dermatol. 2016;15(12):1544-1549.

Endoscopic midfacial rejuvenation.

Early facial rejuvenation focused largely on the upper and lower thirds of the face. More recently, improvements in understanding of midfacial aging and anatomy have paralleled the development of endoscopic and minimally invasive surgical techniques. The midface is now understood to include both the lower lid subunit and the cheek down to the nasolabial fold. Many surgical techniques for midface rejuvenation have been used, including skin tightening with direct excision, skin-muscle flaps, isolated fat pad transposition, and subperiosteal lifting. The methods of endoscopic subperiosteal midface lifting and endoscopic malar fat pad lifting are discussed.

Volume rejuvenation of the facial upper third.

The next three articles in this issue take a unique approach to discussing volumetric restoration. Robert Glasgold has provided an assessment for each facial region and five different renowned authors (TK, SPS, RF, SML, and EFW) have been asked to speak on a particular volumetric product, of which they are considered an expert, as it applies to the different regions of the face. The articles are broken into the following: (1) upper third which corresponds to the upper eyelid, brow, temple, and forehead; (2) middle third which will cover lower eyelid, cheek, and perioral area; and (3) lower third which discusses the marionette, prejowl, and jawline. Our hope is that by placing differing opinions of experienced authors, organized by facial region together, the reader will have the opportunity to more readily compare the options. The contributing authors and their product area are as follows: Theda Kontis, MD-hyaluronic acid; Steve Smith, MD-calcium hydroxyl appetite; Rebecca Fitzgerald, MD-poly-L lactic acid; Sam Lam, MD-polymethyl methacrylate; and Edwin Williams, MD-Autologous Fat Transfer. If the author included general comments on the product, they are included in the article on the upper face only and are not repeated. Please note that other individuals may also have significantly assisted in the production of these articles, but those listed above are the senior authors.

Volume management of the middle third-lower orbit/midface.

This is the second of the three articles discussing volumetric rejuvenation of the face. The previous article, Volume Rejuvenation of the Facial Upper Third, focused on the upper one-third of the face while this article focuses on the middle one-third, primarily the lower eyelid, cheek, and perioral area. Again, the authors (RG, TK, SPS, RF, SL, and EFW) from the upper face article have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Volume rejuvenation of the lower third, perioral, and jawline.

This is the third and final article discussing volumetric rejuvenation of the face. The previous two articles, Rejuvenation of the Upper Third and Management of the Middle Third, focused on the upper two-thirds of the face while this article focuses on the lower face, including the marionette area, jawline, and neck. Again, the authors of the previous two articles have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Quantitative assessment of the longevity of poly-L-lactic acid as a volumizing filler using 3-dimensional photography.

OBJECTIVE: To demonstrate the efficacy and longevity of injectable poly-L-lactic acid as a volumizing injectable in the midface region quantitatively using 3-dimensional (3-D) imaging. DESIGN, SETTING, AND PARTICIPANTS: Prospective study assessing changes in midfacial volume in 15 women aged between 40 and 60 years using a 3-D imaging system at 12, 24, 36, and 48 weeks after 3 treatments with poly-L-lactic acid. Three-dimensional imaging was acquired using the 3-D camera and software. INTERVENTION: Patients were treated with poly-L-lactic acid. The first 2 treatments were 6 weeks apart. The third treatment was performed 12 weeks after the second treatment. MAIN OUTCOMES AND MEASURES: Changes in midfacial volume following 3 treatments of poly-L-lactic acid were measured quantitatively using the 3-D imaging system. A paired t test was used to analyze the difference between pretreatment and posttreatment values at each study time point. RESULTS: Of the 15 patients, 1 only received 2 treatments and was therefore excluded from the statistical analysis. There was a statistically significant increase in mean midfacial volume at all study time points, 12 weeks (mean [range], 7.2 [1.6-20.7] mL; P < .001), 24 weeks (mean [range], 7.2 [1.9-19.4] mL; P < .001), 36 weeks (mean [range], 4.6 [1.1-9.2] mL; P = .002), and 48 weeks (mean [range], 4.1 [0.8-6.4] mL; P < .001), compared with pretreatment volume. There was no significant change in volume between each of the follow-up time points. CONCLUSIONS AND RELEVANCE: Our prospective investigation quantitatively demonstrates the efficacy of poly-L-lactic acid as a long-acting volumizing agent, with an increase in midfacial volume from baseline sustained at least 1 year after treatment. LEVEL OF EVIDENCE: 2. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01307865.

Key principles in running a successful business in facial plastics.

The ultimate goal for most facial plastic surgeons is to develop a successful practice. For those currently owning a practice and those planning on developing a practice, the skills and training necessary to establish and manage a facial plastic practice are not taught in medical school, residency, or most fellowships. The goal of this article is to underline the key principles of running a successful business. This article does not replace an MBA, but it allows you to be aware of potential challenges that all businesses encounter.

Midface injectable fillers: have they replaced midface surgery?

This article examines the increasing role of injectable fillers to treat midface aging and our approach to decision making regarding the use of fillers versus surgery. We discuss the volume changes of the aging midface and advocate taking an anatomic approach to correct these changes. We discuss our approach to patient selection and injection technique. Finally, we review potential complications from injectable fillers and discuss the management of complications.

Complications associated with injectable soft-tissue fillers: a 5-year retrospective review.

IMPORTANCE: Even when administered by experienced hands, injectable soft-tissue fillers can cause various unintended reactions, ranging from minor and self-limited responses to severe complications requiring prompt treatment and close follow-up. OBJECTIVES: To review the complications associated with injectable soft-tissue filler treatments administered in the Williams Rejuva Center during a 5-year period and to discuss their management. DESIGN AND SETTING: Retrospective medical record review in a private practice setting. PARTICIPANTS: Patients receiving injectable soft-tissue fillers and having a treatment-related complication. INTERVENTIONS: Injectable soft-tissue filler treatments. MAIN OUTCOME MEASURES: A retrospective medical record review was conducted of patients undergoing treatment with injectable soft-tissue fillers between January 1, 2007, and December 31, 2011, and identified as having a treatment-related complication. RESULTS: A total of 2089 injectable soft-tissue filler treatments were performed during the study period, including 1047 with hyaluronic acid, 811 with poly-L-lactic acid, and 231 with calcium hydroxylapatite. Fourteen complications were identified. The most common complication was nodule or granuloma formation. Treatment with calcium hydroxylapatite had the highest complication rate. CONCLUSIONS AND RELEVANCE: Complications are rare following treatment with injectable soft-tissue fillers. Nevertheless, it is important to be aware of the spectrum of potential adverse sequelae and to be comfortable with their proper management. LEVEL OF EVIDENCE: 4.

Understanding midfacial rejuvenation in the 21st century.

Facial rejuvenation has largely focused on surgical procedures of the lower and upper one thirds of the face. Over the past 15 years, research focus on the midface has given aesthetic facial surgeons more tools to improve the signs of aging. The term midface has been used with various definitions, but includes the lower eyelid subunit beginning at the inferior border of the tarsal plate and cheek, down to the nasolabial fold. Many surgical approaches to the midface have been described including skin tightening with direct excision, skin-muscle flaps, fat repositioning, and, our preferred method of endoscopic browlift approach, subperiosteal lifting. We will describe the anatomy and aging of the midface, review surgical and adjunctive techniques, describe our method of the subperiosteal midface-lift including its limitations and risks, and discuss current challenges.

Alar-columellar disharmony using the tongue-in-groove maneuver in primary endonasal rhinoplasty.

The correction of alar columellar disharmony can be very challenging and is often neglected during rhinoplasty. Failure to address alar columellar disharmony may adversely affect an otherwise satisfactory outcome. The tongue-in-groove suture technique has been described in the literature using an open approach as an effective surgical maneuver to assist in correcting this deformity. The endonasal approach in rhinoplasty has the advantage over the external approach of preserving greater nasal tip support. Herein, I highlight the tongue-in-groove suture technique using the endonasal approach in primary rhinoplasty as an effective long-term tool for correcting alar-columellar disharmony caused by the hanging columella in conjunction with other variant anatomy.

Long-term results of autologous periorbital lipotransfer.

OBJECTIVE: To evaluate the long-term aesthetic results in patients treated with autologous periorbital lipotransfer. METHODS: A retrospective review of 114 consecutive patients during 4 years who underwent autologous periorbital lipotransfer. Of these patients, 99 were identified who had complete photographic and medical records and were therefore included in the study. Patients were placed into 5 groups based on their total length of postoperative follow-up. Periorbital volume augmentation was assessed by 3 independent masked evaluators using a standard aesthetic scale from 0 to 2 (with 0 indicating no improvement; 1, mild improvement; and 2, marked improvement). Interobserver correlation was determined by κ correlation, and Mann-Whitney tests were used to assess for statistical significance comparing the same patients in each group. RESULTS: Scores from the 3 independent evaluators correlated well (κ = 0.316); aesthetic improvement was seen in almost all patients (86.4%), who had demonstrated improvement for the first 3 years of follow-up. The degree of improvement decreased each year, and only mild improvement was retained in most patients (68.2%) by the 3-year follow-up point (P = .049). CONCLUSIONS: Results from most patients who underwent autologous periorbital lipotransfer demonstrated improvement that lasted as long as 3 years. Autologous periorbital lipotransfer remains a valid and effective technique for periorbital rejuvenation and demonstrates long-term potential effectiveness.

Lipotransfer in the upper third of the face.

PURPOSE OF REVIEW: The purpose of this article is to review the latest developments and techniques in lipotransfer to the upper third of the face. RECENT FINDINGS: Volume loss is becoming increasingly recognized as a significant contributor to upper facial aging. Lipotransfer has been used more extensively because fat exhibits many qualities of an ideal filler, able to restore volume to deflated tissues. Whereas certain nuances and differences in techniques exist, all authors agree that transfer of conservative volumes of fat in key regions of the upper face restores a natural youthful look. SUMMARY: Volume loss in the upper third of the face contributes significantly to aging. The use of lipotransfer in this area is an important adjunct to traditional surgical techniques. It can also be used as a primary rejuvenation procedure in select patients. More studies are needed to elucidate the optimal method of fat harvest, processing, and injection as well as longevity of transplanted grafts.

Midface lifting: current standards.

The most significant factor contributing to the overall change in the appearance of an individual's facial features over time is age. This process of gradual structural weakening of the face begins during the third decade and continues to worsen during the remainder of an individual's lifetime. Here, we discuss how the approach to midface rejuvenation has evolved over time owing to our increased understanding of the aging process. In addition, we discuss specific techniques that we use that have helped us achieve more natural and lasting results.

Office managers' forum.

This article is a summary of the key elements presented during the conference held as part of the Practice Management and Development course sponsored by the Multi-Specialty Foundation in Las Vegas, Nevada in 2009. This article represents an amalgam of perspectives from practices across the United States. The Office Managers' Forum brought together the office managers and surgeons from practices across the United States as panelists. The panelists answered a multitude of practice management questions that included wide-ranging topics such as accounting and financing, staff well being, working with a spouse, hiring and firing, staff meetings, accreditation, motivation, and problems and perks specifically associated with a facial plastic surgery practice.

Lipotransfer in the upper third of the face.

Autologous lipotransfer provides an effective means of volume restoration for facial rejuvenation. The upper one-third of the face falls victim to age-related volume depletion and can be a target for fat transfer. This article describes the senior author's technique of fat transfer in some of the specific anatomic subunits of the upper face.