Basic concepts in facial and neck thread lifting procedures.

In this review article, our objective is to elucidate fundamental principles and offer practical illustrations concerning the procedures involved in facial and neck thread lifting. Moreover, we aim to explore associated concepts such as the fixing point, hanging point, and anchoring point terminologies, along with the elucidation of vectors. Additionally, we will provide anatomically oriented explanations of the lifting process required for each facial region using thread lifting methods like V, U, and I techniques using floating type threads (Secrete line, Hyundai Meditech., Inc., Wonjusi, Republic of Korea). Furthermore, our intention is to delve deeply into the concepts of tensile strength, anchoring strength, and holding strength, contextualizing their practical applications within this specific field.

Comparing the Safety and Effectiveness of Microfocused Ultrasound: Standard vs Targeted Tissue Protocol in Lifting and Tightening the Lower Face and Upper Neck.

BACKGROUND: Micro-focused ultrasound with visualization (MFU-V) delivers energy to specific soft tissue layers beneath the epidermis with the ability to lift and tighten the lower face and neck.  Objective: To determine the efficacy of microfocused ultrasound with visualization (MFU-V) using a standard treatment line protocol versus a customized treatment line protocol based on the patient's unique anatomy targeting the superficial muscular aponeurotic system and fibrous septae for lifting and tightening of the lower face and neck. METHODS: This was a single-center, prospective, randomized, investigator-blinded clinical trial. 51 subjects were randomized to receive a single treatment of MFU-V targeting the lower face and neck using either a standard or custom treatment protocol.   Results: Subjects in both standard and custom treatment groups noted a greater than one-point improvement in jawline laxity. Three-dimensional photography measurements also demonstrated lifting of the lower face and neck in both treatment groups. CONCLUSION: Custom and standard treatment MFU-V protocols produce a safe and effective treatment for tightening and lifting the lower face and neck. Custom treatment protocols aid in maximizing results for patients with variations in the anatomy of the lower face and neck.  J Drugs Dermatol. 2024;23(4):7647.     doi:10.36849/JDD.7647.

SMAS repositioning technique utilizing cog thread: Anatomical perspectives.

INTRODUCTION: Face-lifting surgeries were once common among individuals over 60 years old due to skin laxity, but recent trends favor thread lifting in this age group. Understanding dynamic changes in facial anatomy during postural shifts is essential. METHOD: Fresh cadaver studies have demonstrated the passage of threads through the superficial musculoaponeurotic system (SMAS) layer, confirming the efficacy of the technique. Proper insertion depth targeting SMAS repositioning, rather than superficial skin layers, is crucial. RESULT: The natural movement of tissues secured by thread (N-Cog and N-Fix, N-Finders Inc., Korea) insertion results in lifting effects. However, complications may arise if threads affect deeper facial muscles, leading to discomfort. Fibrous septa play a significant role in guiding thread placement, with different densities influencing thread maneuverability and tissue response during lifting. CONCLUSION: Procedures targeting SMAS repositioning using threads aim to maintain the new position of relocated tissues. Understanding structural variations in facial regions informs thread selection and placement. Aligning threads with tissue movement and the intended SMAS layer positioning is vital to prevent complications. Balancing thread insertion depth and tissue traction is critical for successful outcomes. Modern thread lifting techniques prioritize SMAS repositioning, enhancing lifting effects while ensuring procedure safety and efficacy.

What are filling (volumizing) threads?

Facial aging prompts a shift in the demands for lifting procedures, transitioning from targeted improvements in younger individuals to overall facial contour enhancements as skin elasticity declines in later years. This paper examines the evolution of PDO volumizing threads, delineating their development from initial limitations to contemporary innovations aimed at addressing tissue deformation and maintaining thread integrity post-insertion. Categorizing these threads based on elasticity, shape, and functionality underscores their versatility and application nuances, catering to specific wrinkle correction, contour sculpting, and facial volume restoration. The discussion emphasizes the pivotal role of thread characteristics in achieving optimal outcomes while minimizing potential complications. By delving into historical contexts, mechanisms, effectiveness, and thread classification, this paper equips practitioners with a comprehensive understanding to make informed decisions in selecting threads for volumizing thread procedures. Recommendations for future research directions, including long-term safety assessments and patient-specific outcomes, seek to enhance the clinical utility and applicability of this analysis.

Rotation of a Part of the Composite Flap for Simultaneous Gonion Reduction and Malar Augmentation During Rhytidectomy in Asians.

BACKGROUND: The desired facial shape that Asians aim to achieve through plastic surgery differs from that of westerners. OBJECTIVES: The author facilitates facial volume deflation by using the rotation of a part of the composite flap to the malar area resulting in volumetric augmentation during rhytidectomy; simultaneously, a volumetric reduction was implemented in the gonion. METHODS: Extended deep plane rhytidectomy with the rotation of a part of the composite flap was performed in 49 patients, whereas extended deep plane rhytidectomy without the rotation of a part of the composite flap was performed in 20 patients. For the results, the satisfaction survey of the surgery was conducted in all patients and by 2 surgeons during a follow-up visit 12 months later. To assess the surgical outcome objectively, the author used the Allergan photometric midface volume deficit scale to measure the midface volume. The midface contour and degree of projection were analyzed using lateral view photographs of the patients. The measurement of segment CM (distance between the lateral canthus and mouth corner) and segment MA (distance from segment CM to the most protruding malar area) was performed. RESULTS: The patients who underwent extended deep plane rhytidectomy with the rotation of a part of the composite flap reported higher overall satisfaction and achieved more favorable results, as evaluated by the 2 aesthetic surgeons (P < 0.05). The scores on the Allergan photometric midface volume deficit scale showed a significant increase before and after the surgery in both groups (P < 0.05), also as evaluated by the 2 aesthetic surgeons. However, the change in scores was found to be higher in the extended deep plane rhytidectomy with the rotation of a part of the composite flap group. The midface contour and degree of projection showed an increase of 20.6% on the right face and 22.7% on the left face, respectively (P < 0.001). CONCLUSION: Using the rotation of a part of the composite flap during rhytidectomy resulted in overall satisfactory outcomes for all patients. Based on these findings, it can be concluded that the use of this surgical method is beneficial and effective.

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process. METHODS: Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021. RESULTS: Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001). CONCLUSIONS: A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time. 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 .

Evaluation of Physical Properties of Coated Polydioxanone Threads.

BACKGROUND: Using a thread for wound closure promotes healing and minimizes contamination by foreign substances. Threads have also been employed in esthetic surgery; however, functional threads that can improve wrinkles and rejuvenate the skin are required. OBJECTIVE: To evaluate the suitability of polydioxanone threads coated with polyethylene glycol, hyaluronic acid, and amino acids for use in the medical field because such formulations are expected to promote regeneration and collagen synthesis. MATERIALS AND METHODS: Physical properties (diameter [ n = 20], tensile strength [ n = 20], strength retention rate [ n = 10], and scanning electron microscopy images) and cytotoxicity (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide and lactate dehydrogenase assays) of polydioxanone threads coated with polyethylene glycol, hyaluronic acid, and amino acids were assessed and compared with those of uncoated polydioxanone threads. Analyses were performed using IBM SPSS Statistics (Statistical significance; p values <.05). RESULTS: The size standards for tensile strength (≥63.5 N) and diameter (average 0.570-0.610 mm) were met. There were no differences in the physical properties of the coated and uncoated threads; however, the biocompatibility of coated threads was high owing to low cytotoxicity. CONCLUSION: Threads coated with materials that can promote regeneration are suitable for use in the medical field.

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.

The 3-Level Approach to Facelift Planning: A Simple Paradigm for Surgical Rejuvenation of the Face.

Our role as aesthetic surgeons demands individualized surgical planning that maximizes patient input and understanding. The value of such shared decision-making (SDM) in aesthetic surgery is becoming increasingly appreciated. This is particularly true for potential patients seeking surgical rejuvenation of the face, where the volume of "educational" information available on the internet, and through various social medial channels, may be overwhelming and even misleading. Presented is a "3-Level approach to facelift planning" named for the facial subregions targeted. This novel paradigm maximizes SDM with its simplicity and reproducibility, serves as an invaluable educational tool for patients, novice and seasoned surgeons alike, and facilitates communication between senior surgeons through its descriptive standardization. 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 .

Comprehensive Assessment of Lower-Face Volume Reduction Using Laser-Assisted Liposuction as an Additive Procedure in Asian Rhytidectomy.

The most important factor that distinguishes a youthful appearance from an aged one is the shape of the lower face. This study aimed to examine the outcome of volume reduction of the lower face using laser-assisted liposuction (SmartLipo) at the time of rhytidectomy in Asians. There were 20 patients (Group 1) for whom only extended deep-plane rhytidectomy were performed, while extended deep-plane rhytidectomy with laser-assisted liposuction was performed on 42 patients (Group 2). This study was performed retrospectively. The FACE-Q questionnaire was given to evaluate the subjective result of the patient. Efficacy was evaluated by measuring the fat quantity at the midpoint and anterior border of the masseter muscle on each side by using an ultrasound scan in Group 2. Then, the correlation between the change in the quantity of fat and the FACE-Q was investigated. The overall satisfaction, and satisfaction for the lower face, jawline, and the area under the chin were significantly higher for Group 2 for which the procedure was concurrently performed in comparison to Group 1. In Group 2, change in the fat was reduced by 21.2% (Rt.) and 22.5% (Lt.) at the mid-point and 24.5% (Rt.) and 26.4% (Lt.) at the anterior border of the masseter muscle. Changes in the fat quantity and lower face satisfaction displayed a significant correlation. With a greater reduction in fat quantity, the score of lower face satisfaction was higher. In addition, with a higher level of satisfaction for the lower face and jawline, the overall satisfaction score displayed a higher positive correlation. Laser-assisted liposuction was useful for the additive procedure at the time of rhytidectomy and improved patient's satisfaction after surgery.

Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science.

SUMMARY: The scientific study of facial aging has transformed modern facial rejuvenation. As people age, fat loss in specific fat compartments is a major contributor to structural aging of the face. Autologous fat grafting is safe, abundant, readily available, and completely biocompatible, which makes it the preferred soft-tissue filler in the correction of facial atrophy. The addition of volume through fat grafting gives an aging face a more youthful, healthy, and aesthetic appearance. Harvesting and preparation with different cannula sizes and filter-cartridge techniques have allowed for fat grafts to be divided based on parcel size and cell type into three major subtypes: macrofat, microfat, and nanofat. Macrofat and microfat have the benefit of providing volume to restore areas of facial deflation and atrophy in addition to improving skin quality; nanofat has been shown to improve skin texture and pigmentation. In this article, the authors discuss the current opinions regarding fat grafting and how the evolving science of fat grafting has led to the clinical utility of each type of fat to optimize facial rejuvenation. The opportunity exists to individualize the use of autologous fat grafting with the various subtypes of fat for the targeted correction of aging in different anatomic areas of the face. Fat grafting has become a powerful tool that has revolutionized facial rejuvenation, and developing precise, individualized plans for autologous fat grafting for each patient is an important advancement in the evolution of facial rejuvenation.

Novel Clinical Anatomical Consideration of the Superficial and Deep Layers of the Deep Temporal Fascia.

BACKGROUND: The deep temporal fascia provides anchoring during thread lifting, which is a minimally invasive face-lifting procedure. However, anatomical studies involving the deep temporal fascia in addition to effective and safe thread-lifting procedures are scarce. The authors clarified the anatomy of the superficial layer of the deep temporal fascia and its surrounding structure using ultrasonography, histologic sections, and cadaveric dissection to propose an effective thread-lifting procedure guideline. METHODS: The authors included 20 healthy young participants from the Republic of Korea. Real-time, two-dimensional, B-mode ultrasonography was performed. Longitudinal scanning was performed along three vertical lines: the line passing through the jugale, the anterior margin of the condylar process of the mandible, and the midpoint between the jugale and anterior margin of the condylar process. Histologic samples from three fresh adult cadavers were harvested from 2.5 cm above and below the zygomatic arch. Eighteen fresh adult hemifaces of cadavers from the Republic of Korea (six men and three women, aged 67.3 ± 7.2 years) were used to confirm the morphology of the deep temporal fascia. RESULTS: The superficial layer of the deep temporal fascia crossed the zygomatic arch and was connected to the origin of the zygomaticus major muscle at the line passing through the jugale. The superficial layer continued inferiorly to the parotidomasseteric fascia at the line passing through the midpoint and condylar process of the mandible. CONCLUSION: This study yielded the novel anatomy of the superficial layer of the deep temporal fascia, and this anatomical structure may be used for an ideal thread-lifting procedure.

Complete Hemifacial Paralysis Post-facelift: Making Sense of a Plastic Surgeon's Worst Nightmare.

BACKGROUND: Postrhytidectomy hemifacial paralysis is a frightening clinical condition affecting the proximal facial nerve and most often associated with Bell's palsy. Associated symptoms are common and include auditory, salivary, vestibular, and gustatory complaints. OBJECTIVES: The aim of the study was to provide increased awareness of postrhytidectomy hemifacial paralysis secondary to Bell's palsy in the plastic surgery community. METHODS: Following a roundtable discussion with the senior author's (J.C.G.) plastic surgery colleagues located all over the world, 8 surgeons reported having had firsthand experience with hemifacial paralysis in patients following facelift. Descriptions of their cases, including preoperative, intraoperative, and postoperative courses were collected and reported. RESULTS: A total of 10 cases of postrhytidectomy hemifacial paralysis were analyzed based on results of a clinical questionnaire. Eight of the 10 cases involved all facial nerve branches, with 2 cases sparing the marginal mandibular branch. The vast majority of cases were referred to a neurologist and steroids initiated. Two patients were returned to the operating room for exploration. Associated symptoms reported included pain in the ear, hearing loss, ocular symptoms such as tearing or dryness, vestibular symptoms such as vertigo, changes in taste, and in 1 patient an electric-shock type sensation to the face. CONCLUSIONS: Hemifacial paralysis associated with Bell's palsy following rhytidectomy is a rare but known clinical entity that should be included in the preoperative informed consent process before facelift. Current management trends are neurology referral and steroid initiation.

Is Bipolar Radiofrequency-Assisted Liposuction Equivalent to Open Anterior Platysmaplasty in Facelift Surgery?

BACKGROUND: During facelift surgery, anterior platysmaplasty (AP) has been used for decades, but it limits lateral advancement and can induce contour irregularities. Radiofrequency (RF)-assisted-liposuction in the anterior neck can avoid these disadvantages by tightening skin without open surgery. PURPOSE: The purpose of the study was to compare the esthetic outcomes of facelift surgery with those of AP and RF. STUDY DESIGN, SETTING, SAMPLE: A 5-year retrospective cohort study was performed on facelift patients treated by a single surgeon. Exclusions were single-side surgery, previous facelift, chin/lip augmentation/reduction, and inadequate data. PREDICTOR VARIABLE: The predictor variable was neck management technique (AP vs RF). MAIN OUTCOME VARIABLES: The primary outcome variable was the change in cervicomental angle (CMA) following surgery as measured on facial photographs. Secondary outcomes included distance changes from the central CMA point in vertical and horizontal planes to repeatable reference planes. COVARIATES: Covariates were age, body mass index, American Society of Anesthesiologists classification, smoking, and simultaneous procedures. ANALYSES: The statistical analysis was performed using Wilcoxon rank-sum, Fisher's exact, Kruskal-Wallis tests, Pearson's correlation, and linear regressions. The level of statistical significance was P < .05. RESULTS: There were 132 patients included in the study; 67 received AP and 65 received RF. AP trended toward better performance in CMA change in the unadjusted analysis (-18.7° ± 13.8° vs -22.3° ± 13.7°, respectively, P = .08). AP and RF performed similarly in the adjusted analysis (P = .29). Techniques were similar in horizontal distance change to the CMA (P = .31). RF was associated with less change in the vertical distance to the CMA in the unadjusted analysis (-11.9 mm ± 11.0 mm vs -6.7 mm ± 8.7 mm, respectively, P = .01) and adjusted analysis (ß = 4.3 mm, 95% confidence interval .8 to 7.9 mm, P = .02). CONCLUSION AND RELEVANCE: Utilization of the RF technique for management of the anterior neck in facelift surgery is associated with similar outcomes to the AP technique in horizontal distance to the CMA, but AP performed better in CMA change and vertical distance to the CMA.

Limited Incision Facelifts: A Contemporary Review of Approaches and Complications.

Limited incision facelifts (LIFs) have gained popularity as an alternative to traditional facelift procedures. While surgical techniques vary, these approaches share a common goal: to rejuvenate the face while minimizing scar visibility. Previous studies also suggest that the reduced tissue dissection in LIFs can lead to decreased postoperative swelling, shorter recovery periods, and fewer complications. In this systematic review we delved into the literature on LIFs, shedding light on the various surgical approaches and their respective safety profiles. A systematic review was conducted by independent evaluators who followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A random-effects model was utilized to summarize complications data, and meta-regressions were conducted to analyze associations with operative variables. The analysis encompassed a total of 20 articles, comprising data from 4451 patients. The vast majority (84%) of these patients underwent either local wide-awake surgery or conscious sedation, while the remaining 16% underwent general anesthesia. Our analysis revealed an overall complication frequency of 3.2%, with hematoma being the most common complication (2%), followed by temporary nerve injury (0.2%), and skin necrosis or wounds (0.06%). Notably, hematomas rarely required operating room interventions. Use of drains or tissue sealants was associated with an 86% decrease in complications. Limited incision facelifts can be performed with a low complication rate, utilizing a variety of techniques. Utilization of tissue sealants and drains may limit hematoma formation, which is the most common complication.

Nasal Sill Flap for Lip Lifting.

BACKGROUND: Over the years, different techniques have been developed to reduce the number of incisions and scars in subnasal lip lifting and to increase the amount of lifting. The aim of this study was to present a new technique to hide the scars at the nasal base in subnasal lip lifting procedures and to review the literature. METHODS: The file of patients who underwent subnasal lip lifting between January 2019 and January 2021 were examined. In all patients, the nasal sill flap that was designed was elevated, and the nasal sill flap that was prepared was adapted to its new location when the excision had been completed. Two different plastic surgeons evaluated the patients in the postoperative 12-month follow-ups. The scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height. RESULTS: The study included 26 patients. While 21 patients had no histories of lip lifting, five patients had had previous lip lifting history. The mean operation time was 37.11 minutes. Patients' skin types were determined as Type 3 in 18 patients and Type 4 in eight patients according to the Fitzpatrick classification. The mean follow-up period of the patients was 13.11 months. At the end of the 12-month period, the mean scar score of the patients was calculated as 11.15. The mean scar score of primary cases was 11.14, and the mean scar score of secondary cases was 11.20 (p = 0.983). There was no statistically significant difference in terms of complications among smokers (p = 0.356). The mean scar score was calculated as 12.17 in patients who had Type 3 skin and 8.88 in patients with Type 4 skin (p = 0.075). CONCLUSIONS: This technique is beneficial for patients because the scars are discrete and easier for patients to accept.