External Approach to Buccal Fat Excision in Facelift: Anatomy and Technique.

BACKGROUND: Masculinization of the face is a common finding in facelift patients. It is attributed to deflation and decent of the midface-jowls coupled with skin laxity. Fullness is evident lateral to the jowl in a small percentage due to prominent buccal fat pad (BFP). OBJECTIVES: The authors sought to examine the anatomy of the BFP, triangulate the prominent BFP with surgical landmarks, and describe an external approach to excise the BFP during facelift surgery. METHODS: Eighteen cadaveric dissections were performed. Facelift flap was elevated and the prominent buccal extension of the BFP protruding through the superficial-musculo-aponeurotic-system was identified. Measurements were taken from the BFP to surgical landmarks: zygomatic arch, tragus, and gonial angle. The locations of the facial nerve, parotid duct, and vascular pedicle relative to the BFP were calculated. RESULTS: BFP was 4.1 cm inferior to the zygomatic arch, 7.5 cm anterior the tragus, and 4.5 cm medial the gonial angle. The middle facial artery supplied the BFP on the inferior-lateral quadrant in 61% and inferior-medial quadrant in 39% of specimens . In all specimens, the parotid duct traversed the BFP superiorly, and the buccal branches of the facial nerve traversed the capsule superficially. CONCLUSIONS: The buccal extension of the BFP can pseudoherniate in the aging face. Excision may improve lower facial contour. Measurements from facial landmarks may help surgeons identify the buccal extension of the BFP intraoperatively. The surgeon must be careful of the vascular pedicle, parotid duct, and the facial nerve. The external approach safely excises buccal fat during facelift dissection while avoiding intraoral incisions and unnecessary contamination.

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding.

BACKGROUND: Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery. OBJECTIVES: The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage. METHODS: This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded. RESULTS: The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications. CONCLUSIONS: TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

Anterior Approach to the Neck: Long-Term Follow-Up.

BACKGROUND: The anterior or submental necklift has been well described. Long-term results have been demonstrated in patients with minimal, mild, and moderate skin excess. It relies on the skin's unique ability to contract once separated from its attachments and further enhances the surgical result with treatment of the intermediate layer- subplatysmal fat, anterior digastric, submandibular gland, and platysma. Treatment of this layer differentiates this operation from liposuction and offers benefits beyond liposuction alone. OBJECTIVES: The authors sought to assess the long-term success of the anterior necklift for neck rejuvenation and determine its utility in patients with severe cervicomental angles. METHODS: This was a single-surgeon, retrospective review of patients who underwent an isolated anterior necklift with no additional procedures between 1998 and 2017. Pre- and postprocedure photographs were scrambled and examined by independent evaluators grading the change in cervicomental angle based on the Knize scale. The reduction in apparent age was calculated utilizing the validated apparent age assessment scale. RESULTS: Twenty-seven patients were evaluated (42% mild and 58% moderate to severe necks preoperatively). The average follow-up was 24.7 months. There was an average 3.6-year age reduction and 1.0-grade improvement in all patients. In moderate to severe necks, there was a 3.9-year age reduction and 1.4-grade improvement in the cervicomental angle following surgery. CONCLUSIONS: This study demonstrates the effectiveness of the operation in improving the cervicomental angle and reducing the overall apparent age of patients, even more so in severe cases. The operation is an option for patients who desire neck improvement but are unwilling to undergo a facelift.

Association between Agent Orange exposure and nonmelanotic invasive skin cancer: a pilot study.

BACKGROUND: Agent Orange, or 2,3,7,8-tetrachlorodibenzodioxin, has been shown to cause indirect DNA damage, producing malignancies. However, its connection to nonmelanotic invasive skin cancer is unclear. This study investigated whether 2,3,7,8-tetrachlorodibenzodioxin exposure increases the incidence of this cancer. METHODS: The authors retrospectively reviewed the medical records of 100 consecutive male patients with Fitzpatrick skin types I through IV who enrolled in the Agent Orange registry at the Veterans Affairs Hospital of Washington, D.C., between August of 2009 and January of 2010. RESULTS: The study population's mean age was 65.7 years (range, 56 to 80 years). 2,3,7,8-Tetrachlorodibenzodioxin exposure included living or working in contaminated areas (56 percent), actively spraying it (30 percent), or traveling in contaminated areas (14 percent). Fifty-one percent of patients had nonmelanotic invasive skin cancer; 43 percent had chloracne; and 26 percent had other malignancies, such as prostate (14 percent), colon (3 percent), or bladder cancer (2 percent). The nonmelanotic invasive skin cancer incidence rate in the study population (51 percent) was significantly higher than the national age-matched incidence rate (23.8 percent; p < 0.001). High Fitzpatrick skin type score (p = 0.010) and dark eye color (p = 0.036) were associated with a decreased incidence of the cancer. Exposure by means of active spraying (73 percent versus 67 percent; p = 0.003) and presence of chloracne (81 percent versus 28 percent; p < 0.001) were associated with increased nonmelanotic invasive skin cancer incidence rates. CONCLUSIONS: 2,3,7,8-Tetrachlorodibenzodioxin exposure appears to be associated with the development of nonmelanotic invasive skin cancer. Further studies are warranted to determine the relative risk within this patient population and to determine appropriate management strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.