Long-Term Improvement of Crow's Feet Wrinkles in Combination With Cervicofacial and Temporal Lifting: Review of the Literature.

BACKGROUND: The lateral orbital crow's feet area is one for which rejuvenation is most frequently requested by patients. Moreover, lateral canthal wrinkles are a common source of dissatisfaction after rhytidoplasty. Botulinum toxin injection has emerged as a most popular, easy, and effective solution; nevertheless, repeated injections are required periodically for long-term effect. Other nonsurgical options have also been described to have some demonstrable advantages. Orbicularis oculi surgical manipulations have been described as well. MATERIAL AND METHODS: A systematic PubMed literature search was conducted to identify clinical cohort studies including more than 10 patients describing surgical approaches for improvement of crows' feet wrinkles in combination with face and/or temporal lifts. The search was complemented by Embase, Medline, and Cochrane searches in addition to screening of reference lists of selected studies and simple term searches about surgical treatment of crow's feet. RESULTS: Fourteen studies satisfied the inclusion criteria and were included in this review describing various muscle excision techniques including vertical strip excision, lateral partial resection, wedge resection, muscle resection in "C" pattern, and enlarged myectomy of about one-third of the whole orbital extension in addition to muscle manipulation modalities, including muscle splaying, muscle division, muscle division and splaying, muscle undermining with partial denervation, and muscle suspension. Interposition of fascia between orbicularis muscle and overlying skin was also reported. CONCLUSION: View the few studies retrieved and the wide spectrum of reported techniques, it is not possible to determine from this review the most effective modality. Nevertheless, it seems that subcutaneous undermining of the lateral canthal area combined with splaying and traction of the orbicularis oculi muscle and fixation to the temporalis fascia with or without muscle division would yield the best long-term results. This review indicates also that surgical correction of crow's feet during rhytidectomy or temporal lift could be a positive complement to improve aesthetic outcome. Unfortunately, if not underreported, it is definitely neglected. We believe that this review may be an eye-opener for surgeons.

Determination of Appropriate Umbilicus Position during Abdominoplasty in Male Patients.

Background: Abdominoplasty techniques are well documented. The ideal position of the umbilicus has, however, received limited attention. Unfortunately, umbilicus position is not universally agreed upon in male cosmetic abdominoplasty. This study was conducted to determine the ideal umbilicus anthropometric measurements in young men, and the relationships between umbilical position and anterior trunk and torso reference points that may be applicable to intraoperative positioning. It is aimed also at investigating whether umbilicus position would be more accurately determined by considering nipple position instead of the abdominal crease, as recently proposed. Methods: Several anthropometric measurements of various anterior abdominal and thoracic landmarks were conducted on 60 young and middle-aged male volunteers and 30 cadavers at São Paulo city. All statistical analysis was completed using Stata software. Results: Of all the measured reference points, a much stronger correlation (0.513) was demonstrated between umbilicus-anterior axillary fold (U-AX) and inter-nipple (N-N) distances with a constant golden number ratio relationship (N-N = U-AX × 0.618) compared with the weak correlation of 0.034 between umbilicus-xiphisternum and umbilicus-abdominal crease. In 75% of volunteers, the calculated U-AX was within ±3 cm of actual measurement, and in 33.33% within ±1 cm. Conclusions: U-AX = 1.618 × N-N equation is more predictive of adequate umbilicus repositioning during abdominoplasty in male patients. Chest and abdomen of men are a single aesthetic unit. Proper positioning of the nipples and umbilicus, as well as harmonious abdominal and torso proportions are critical for an optimal final aesthetic outcome.

Surgical Management of Platysma Bands: A Narrative Review of Evolving Concepts and Changing Techniques for Neck Rejuvenation.

INTRODUCTION: Platysmal bands are an unappealing feature of the aging face. Incomplete understanding of anatomy and physiology of platysmal bands has led to a long period of flawed or incomplete treatment. This review aims to elucidate the correct study of platysmal bands along with the most recent surgical treatments. MATERIALS AND METHODS: To identify all articles related to the topic of surgical management of platysmal bands, an extensive search was performed on PubMed and Medline databases for all articles related to platysmal bands from 1990 to 2023. The articles were then reviewed by 2 independent reviewers, and all relevant articles were selected. The search was narrowed down to clinical trials and cohort studies. RESULTS: 6130 articles were identified, of which 21 articles matched the inclusion criteria and were selected for the study totaling 2331 patients. Different surgical procedures were mentioned. Assessment of results was mostly subjective and done by the surgeon. CONCLUSION: Composite platysma-skin flap repositioning as opposed to wide skin undermining with or without submental incisions is being gradually accepted as a valid approach, with closed platysma myotomy and platysma denervation emerging as effective less invasive surgical modalities. Nevertheless, merits of more extensive procedures involving wide skin undermining and anterior platysma plication must not be lightly forgotten. 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 .

Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age.

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

Surgical Correction of Tear Trough Deformity (TTD) with Orbicularis Retaining Ligament Release and Volume Augmentation for Periorbital Rejuvenation: Review of the Literature.

BACKGROUND: Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures. MATERIAL AND METHODS: Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports. RESULTS: A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references. CONCLUSION: Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime. 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 .

Letter to the Editor: An Optimized Method for Adipose Stromal Vascular Fraction Isolation and its Application in Fat Grafting.

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 .

Safety and Efficiency of Minimally Invasive Buttock Augmentation: A Review.

BACKGROUND: Volume restoration and enhancement of the gluteal region appearance has become nowadays a popular concern in particular for many women. Several options are available, none however are without complications and side effects. Volume enhancement with soft tissue fillers of the gluteal region is emerging as a highly attractive minimally invasive modality. It has led unfortunately to more unlicensed, nonmedical practitioners administering illicitly injections for buttock augmentation at relatively low costs. MATERIALS AND METHODS: To determine safety, efficacy, and cost effectiveness of mostly used soft-tissue fillers for buttock augmentation, a systematic literature search of PubMed, Medline, and Embase was conducted to identify the mostly used fillers for gluteal augmentation. It was complemented by searching for each of the identified filler material separately to retrieve any missed reports. References of clinical studies and trials, reviews, and consensus reports were reviewed as well for the same objective. RESULTS: In the final analysis 12, mostly strongly biased clinical reports providing a low level of evidence, were identified for inclusion in the review. Two studies involved Polymethylmethacrylate (PMMA), 5 Poly-L-lactic acid, 1 Calcium hydroxyapatite and 4 hyaluronic acid filler injection. No studies were identified involving liquid silicone or Polyacrylamide hydrogel. The little available evidence provided by this review indicates that a specific brand of PMMA in Brazil has a demonstrable relatively good safety, efficiency, and cost-effectiveness record superior to surgical alloplastic gluteal augmentation or to lipofilling only when injected by experts. CONCLUSION: Gluteal augmentation with soft tissue fillers is not as simple and innocuous as advertised. Serious complications may occur. Moreover, optimal buttock contouring entails not only volume augmentation but also volume removal; thus, volume augmentation with soft tissue fillers may not be ideal. Popularizing this modality must also be approached with great care. Serious complications do occur; they become inevitable when performed illegally by non-specialized, non-authorized, and unscrupulous practitioners in non-accredited facilities. Patients must be warned that adherence to regulations is critical and that only well-trained certified experts practicing legally in accredited facilities can address safely and efficiently their concerns. 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 .

Ptosis and Bottoming out Following Mastopexy and Reduction Mammoplasty. Is Synthetic Mesh Internal Breast Support the Solution? A Systematic Review of the Literature.

BACKGROUND: Relying on soft tissues with low structural strength to provide long-term support of the breasts following aesthetic mammoplasty may be inadequate in many instances. To address the inherent weakness of tissues still present after surgery, use of synthetic non-autologous additional tissue reinforcement has been described. The current review is aimed at analyzing available evidence about safety and effectiveness of mesh support in various reduction mammoplasty, mastopexy, or augmentation-mastopexy. METHODS: An advanced PubMed and Medline search was conducted to identify clinical studies about the use of synthetic mesh in aesthetic breast surgery. An additional search of breast symmetrization and synthetic mesh was also conducted. Ten studies were identified and judged to be relevant to this review. RESULTS: Retrieved studies were relatively few, characterized by marked heterogeneity, lack of well-defined outcome end points, poor outcome measures, and inherent bias in outcome documentation providing low level of evidence. CONCLUSION: Despite reported relative safety and some promising results, available data indicate that meshes do not effectively prevent recurrent ptosis and bottoming out; they may not be superior to described techniques with superior pedicle and hammocks or "balcony" flaps. Well-conducted studies are yet to be conducted comparing internal bra technique to procedures with innovative autologous tissue support. 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Nanofat Cell-Mediated Anti-Aging Therapy: Evidence-Based Analysis of Efficacy and an Update of Stem Cell Facelift.

BACKGROUND: Fat grafting has been extensively applied as natural filler and has been very promising in restoring volume loss. Lipografting has also been credited to reduce age-related skin changes due to the regenerative potential of adipose derived stem cells. Cell-mediated therapies in plastic surgery are rapidly evolving with growing applications. Nanofat, a bio-regenerative liquid suspension rich in stromal vascular fraction cells without viable adipocytes, has been described as an efficient cutaneous anti-aging therapy. We have published in 2013 a review entitled "stem cell facelift: between reality and fiction." Available clinical evidence at that time did not substantiate marketing and promotional claims of "stem cell facelift". The same year, the report about nanofat was published demonstrating striking clinical outcome. The current literature search is aimed at reviewing any evidence that has emerged since then regarding clinical efficacy of this modality. METHODS: A thorough PICO tool-based comprehensive literature search of PubMed database for "the efficacy of nanofat cell-mediated anti-aging therapy" was conducted with a time frame from 2013 till present. RESULTS: Despite apparent increasing popularity of stem cell rejuvenation, well-controlled clinical studies about this modality are surprisingly very scarce. Only seven papers published after 2013 were identified and were included in this review CONCLUSION: Though considered to be a safe procedure, and despite documented histologic improvement and striking clinical outcome in some reports, available evidence can hardly support clinical improvement of skin quality. Before cell-mediated aesthetic rejuvenation applications can be routinely undertaken, more robust evidence with well-defined primary outcome end points and objective outcome measures is required. LEVEL OF EVIDENCE: IV.

Medium-depth Trichloroacetic Acid and Deep Phenol-Croton Oil Chemical Peeling for Facial Rejuvenation: An Update.

ABSTRACT: Face-lift is an established rejuvenation modality; however, when performed alone, it lacks the ability to improve the appearance of fine wrinkles and dyschromias that are an important component of facial rejuvenation. Although it is only natural to be attracted by the latest technologically advanced innovative skin resurfacing techniques, chemical peeling has been proven to be a simple and effective method with a relatively good safety profile. Unfortunately, the practice of chemical peeling has relied for a long time on dogmas perpetuated by early reports without any real scientific basis. Moreover, application of peels has been hindered by difficult estimation of penetrance and control of depth. Three decades ago, a shift has occurred from early dogmatic empirical application to better understanding of the peeling formulations and mechanism of action together with appreciation of the interaction between the various components of the peeling formulations in addition to better estimation of clinical end points and peel depth. Given the increasing demand for none or minimally invasive cosmetic procedures, the current review is aimed at highlighting the recent applications of available medium-depth and deep chemical peels for optimal facial rejuvenation and for the treatment of photo-related aging skin changes.

Platelet-Rich Plasma Facial Rejuvenation: Myth or Reality?

Platelet-rich plasma (PRP) rejuvenation's efficacy has been reported by numerous uncontrolled clinical case studies of inconsistent quality rather than large randomized and placebo-controlled trials. It was suggested that PRP could be considered as a valid anti-aging and rejuvenation treatment modality. The current literature review summarizes available evidence so far described in the literature with special critical attention to higher quality comparative studies published over the last 10 years. The few studies that could be retrieved and included in this review documented less favorable results. So far, there is no international consensus on clinical PRP use for esthetic rejuvenation. Whether a mix of growth factors does in fact generate a clinically significant more youthful look and whether PRP injections result in comparable or better rejuvenation than what can be expected from other simpler non-surgical modalities. LEVEL OF EVIDENCE IV: 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 .