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Background The design lines for midfacial filling shift upward with a patient’s position changes from upright to supine during operation. This will cause the actual filled part to deviate from the target area. Objectives This authors aimed to evaluate the effect of positional changes on midfacial landmarks and find the optimal body position for midface filling. Methods The process involved the grading and evaluation stages. The midfacial laxity of each sample in the evaluation stage was graded into minimal, moderate, and severe by the system established in the grading stage. Measured through the 3-dimensional images in each grade, the vertical distances from landmarks C, D, and E (representing the region of the tear trough, infraorbital area, and nasolabial fat pad, respectively) to the horizontal line of the inner canthus and depth of nasolabial fold at an angle of 90° were separately compared with those from the other angles (60°, 45°, 30°, and 0°) of the operating table. Results In the minimal midfacial laxity group, all 3 landmarks significantly moved upward when the angle decreased to 30°. However, landmark E of the moderate and severe and landmark D of the severe midfacial laxity groups both significantly moved upward when the angle decreased to 45°. The depth of the nasolabial fold at a 45° angle was significantly less than that at a 90° angle in the moderate and severe groups. Conclusions In midface filling, a patient’s body position should be optimally selected according to the midfacial laxity and filling area.

Background Lower blepharoplasty is one of the most challenging procedures in aesthetic surgery. In particular, blending the lid-cheek junction and correction of the tear trough are prone to failure and unsatisfactory outcomes. Objectives The aim of this study was to combine lower eyelid blepharoplasty with a novel technique of autologous fat grafting, commonly called segmental fat grafting, and to analyze the safety and efficacy of this approach. Methods A retrospective analysis of 339 lower blepharoplasties was performed to compare the novel technique of segmental fat grafting to traditional fat transposition during lower blepharoplasty. Outcomes were assessed objectively by several measurements as well as via online survey of 148 invited experts in plastic surgery. Statistical analysis included t test for unpaired and paired samples as well as 1-way analysis of variance for matched data. Results There were no differences in baseline characteristics and comorbidities between study groups. After a mean follow-up of 12.9 months (range, 5-120 months), the group that underwent segmental fat grafting had a significant reduction in tear trough width compared compared with the group receiving lower blepharoplasty with fat transposition. Based on an expert (blinded) online survey, segmental fat grafting was superior or equal in 47% and 35% of cases, respectively. Complications (4%) and revision surgeries (9%) did not differ significantly between study groups. Conclusions The novel technique of transplantation of a segmental fat graft during lower blepharoplasty is a safe and effective way to overcome tear trough deformity and blend the lid-cheek junction. Level of Evidence: 4

Background Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit. Objectives The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA). Methods Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months. Results Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being “very satisfied” at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications. Conclusions The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics. Level of Evidence: 4

Background Various procedures to efface age-related lower eyelid/cheek interface depressions, or primary periorbital hollows (POHs), have been reported in the literature. Postsurgical, or secondary, POHs are a distinct contour irregularity that have received little such attention. Dermal onlay grafts (DOGs), a site-specific term for autologous dermis fat grafts, have been used to treat secondary POHs for which less invasive measures have proved unsuccessful. Objectives The aim of this study was to describe the surgical technique and outcomes of DOGs for secondary POHs. Methods A retrospective analysis of patients who underwent DOGs for secondary POHs over a 27-month period was performed. The surgical technique and outcomes are reviewed. Results Thirteen patients (10 women and 3 men; average age, 52 years; average follow-up, 9 months) were included in the study. Nine patients had bilateral surgery, and all had received previous filler or fat injection, or both, with poor outcomes. Generally, surgical complications were minor, required minimal intervention, or were self-limiting. One patient had persistent infraorbital dysesthesia which improved with oral tricyclic antidepressant treatment. Eleven of 13 patients stated satisfaction with hollow effacement and outcome, a finding verified by subjective assessment by a surgeon. Conclusions DOGs yielded good results in this initial description of their utility as a rescue procedure to surgically address secondary POHs. Further quantitative volumetric studies to validate outcome would of value. Level of Evidence: 4

Background Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS Objectives The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS. Methods The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold. Results The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P Conclusions The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

Background Laser skin resurfacing with erbium-doped yttrium aluminum garnet (Er:YAG) lasers is a newer alternative to CO2 laser treatment, and was developed to reduce common complications. Although Er:YAG lasers have been available for years, safety parameters for efficacious resurfacing with these devices have not previously been available. Objectives The aim of this study was to utilize one practice’s laser treatment settings and outcomes data to identify complication rates for various energies and areas of the face and to offer safe energy/depth parameters for treating each area. Methods A retrospective chart review was performed for full-field confluent laser resurfacing patients treated with a Sciton Contour Tunable Resurfacing Er:YAG laser by the senior author. The data were retroactively analyzed with a time range of 8 years (January 2007-December 2015). Results The overall complication rate for MicroLaserPeels (ablation of 50 µm or less) was 10.1% (20 of 198 treatments) and the rate for deep resurfacing treatments was 26.5% (71 of 268 cases). In MicroLaserPeel treatments the cheek area had the highest complication rate, followed by the forehead, nose, perioral, and eyelid areas, in that order (complication rate range, 0%-9.1%). In deep resurfacing treatments the perioral area had the highest complication rate, 38.6% of 145 cases. This was followed by the lids, cheek, nose, and forehead, in that order (complication rate range, 15.2%-20.9%). There is a correlation between increased depth of ablation and increased rate of complication. Conclusions The study confirmed the efficacy of Er:YAG resurfacing and provides guidance for a safer approach to excellent outcomes. Level of Evidence: 4

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. Level of Evidence: 4

Background Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers. Objectives The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. Methods A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: (“fat grafting” OR “lipotransfer” OR “lipofilling” OR “fat transfer”) AND (“facelift” OR “rhytidectomy” OR “SMASectomy” OR “facial rejuvenation”). Data on techniques, outcomes, complications, and patient satisfaction were collected. Results The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub–superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments. Conclusions Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities. Level of Evidence: 3

Fat hypertrophy is a less commonly known complication of autologous fat transfer. We present a 32-year-old female with left hemifacial atrophy associated with systemic sclerosis, who was treated with 7 fat transfer procedures to correct the facial asymmetry. A total of 236.5 mL of fat was injected to the hemiface over a 4-year period to achieve good symmetry. A progressively enlarging, painless, soft mass over the left parotid region was noted at 3 months after the final fat transfer procedure. Magnetic resonance imaging showed a markedly enlarged bulk of subcutaneous fat over the left cheek with no evidence of necrosis, edema, or pathologic enhancement. Concurrent weight gain was noted secondary to additional nutritional input. The patient’s aesthetic, symptomatic, and functional concerns led to the subsequent removal of 115 mL fat by liposuction. Level of Evidence: 5

Background Regardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author’s facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author’s technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit. Objectives The author sought to present the fat pad transposition surgical technique along with objective outcome data. Methods This study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography. Results The average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery. Conclusions The sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology. Level of Evidence: 4

Background Buccal fat pad (BFP) excision is a procedure in which the fat pad is extracted in order to achieve a more youthful appearance. Objectives The aim of this study was to describe an alternative technique that utilizes hydrodissection to extract the BFP. Methods This is a controlled, prospective, randomized clinical study involving 2 groups. Group A (n = 27) underwent BFP excision with hydrodissection, during which 15 mL of a vasoconstricting anesthetic solution was injected into the BFP. Group B (n = 27) underwent BFP excision, during which 3 mL of lidocaine 2% with epinephrine was injected. All procedures were performed by the same surgeon. Variables analyzed were surgical time, intraoperative bleeding, and postoperative pain directly following surgery 2 hours after the procedure, as well as maximum pain within 72 hours of surgery and complications. Postoperative care was standardized, and patient follow-up extended over a 6-month period. Results Pain scores for 54 patients were recorded on a visual analog scale (0–10). Mean ± standard deviation transoperative pain scores were 0.5 ± 0.8 for Group A and 1.3 ± 1.3 for Group B (P = 0.01); 2 hours postoperation the scores were 1.2 ± 0.7 for Group A and 2.6 ± 1 for Group B (P < 0.0001). Maximum pain occurred within 72 hours, and scored 1.6 ± 0.6 for Group A and 3.1 ± 1 for Group B (P < 0.0001). Mean operative time was 8:18 ± 0:47 minutes for Group A and 14:08 ± 2:28 minutes for Group B (P < 0.0001). There was a positive correlation between operative time and pain. Overall, 5.5% of patients suffered postoperative complications. Conclusions BFP excision by hydrodissection is an effective procedure that decreases surgical times by facilitating extraction of the BFP with less manipulation, thereby resulting in decreased postoperative pain and a more tolerable recovery. Level of Evidence: 2

BackgroundLower blepharoplasty has been used for rejuvenating lower eyelids, and diverse modifications have been used to treat conjunct deformities at the tear trough/lid-cheek junction. Strategies for recontouring prominent tear trough/lid-cheek junctions, including orbital fat manipulation, have been reported with good results in the literature. Micro-autologous fat transplantation (MAFT) is a previously unevaluated, potentially advantageous approach to blending the prominent tear trough/lid-cheek junction.ObjectivesWe determined the long-term results after 3-step transcutaneous lower blepharoplasty with MAFT for patients with aging eyelids and prominent tear trough/lid-cheek junctions.MethodsWe evaluated 205 patients with aging lower eyelids who underwent transcutaneous lower blepharoplasty with MAFT between October 2010 and September 2016. The 3-step procedure involved a subciliary elliptical skin excision, resection of 3 orbital fat compartments, and MAFT for the tear trough/lid-cheek junction employing a MAFT-GUN under intravenous anesthesia.ResultsThe mean patient age was 52 years (range, 34-78 years). The mean operating time was 61 minutes. The mean fat volumes delivered to the tear trough/lid-cheek junctions were 2.80 mL and 2.76 mL for the left and right sides, respectively. The average weights of the 3 resected orbital fat compartments were 0.58 g for the left side and 0.56 g for the right side. Patients showed significant improvement and maintenance at an average follow-up of 60.2 months (range, 18-90 months).ConclusionsThree-step transcutaneous lower blepharoplasty with MAFT is an effective, reliable, and promising method with high patient satisfaction and minimal risk of complications. Long-term results demonstrated its utility for aging lower eyelid treatment.Level of Evidence: 4

Background East Asian faces vary in shape but only oval faces seem to be considered attractive. Many patients with wide faces seek removal of part of the mandibular angle and/or zygoma to achieve an ideal facial contour, but the procedure is high risk and the recovery period is relatively protracted. Objectives We sought to achieve ideal facial contours through the use of autologous fat grafting (AFG) combined with masseter botulinum toxin (BTX) injection for patients with wide faces and masseter hypertrophy. Methods Fourteen patients with wide faces underwent AFG of the forehead, temporal region, cheeks, zygomatic body, nose, nasolabial fold, tear trough, and chin; and BTX injection into the masseter muscles. Each patient was photographed more than 6 months after the operation. The pre- and postoperative ratios pertaining to the facial aesthetics of the face were calculated. The Hollowness Severity Rating Scale (HSRS) and Ricketts’s E-line were used to evaluate the photographs. Patient satisfaction was also investigated. Results All patients received AFG and 1 to 3 BTX injections. The face length:bizygomatic breadth, bigonial breadth:bizygomatic breadth, and lower-face height:middle-face height ratios improved greatly after treatment. The mean HSRS score decreased from 2.214 preoperatively to 1.071 postoperatively. The chin and nose became more prominent than before. Facial swelling persisted for an average of 11.929 days. All patients were satisfied with the treatment outcome. Conclusions A combination of AFG and BTX injection was able to achieve an ideal oval face in East Asian patients with wide faces and masseter hypertrophy, with very few complications. Recovery was rapid and patient satisfaction was high. Level of Evidence: 4

Background The mainstream facelifts in Western countries always involve the superficial fascia/superficial musculoaponeurotic system treatment. Meanwhile, subcutaneous face and neck lifts are widely applied among Asians. Objectives The authors sought to evaluate outcomes of subcutaneous face and neck lift, including patient-reported and 3-dimensional (3D) measurement outcomes, and report on details of surgical procedures. Methods Patients who received a subcutaneous face and neck lift from January 2017 to June 2019 were asked to complete FACE-Q scales, and facial information was collected by the Vectra 3D imaging system preoperatively and postoperatively. Volume changes in midface and possible displacement of facial landmarks were measured. The range of dissection and the amount of skin removed were recorded intraoperatively. Results In total, 119 patients (median age, 46 years, interquartile range, 40-53 years) received a subcutaneous face and neck lift. Among them, 88 patients completed pre- and postoperative FACE-Q scales. Patients’ satisfaction with facial subunits improved and wrinkles were significantly relieved (P < 0.001). Nineteen patients (38 midface sides) completed 3D image data collection. Postoperatively, zygomatic volume increased, and nasolabial and lateral cheek volumes decreased (volume change of 2.2 ± 1.3 mL). Mouth, nose, and eye displacements were negligible postoperatively. The widths of skin removed at the middle temporal, front of the sideburns, upper helix, earlobe, and retro-auricular were 13.8 ± 1.9 mm, 19.6 ± 3.1 mm, 27.6 ± 3.9 mm, 16.4 ± 3.9 mm, and 32.2 ± 4.0 mm, respectively. Conclusions The authors’ subcutaneous face and neck lift was effective in relieving nasolabial sagging, improving wrinkles, and achieving facial rejuvenation. Level of Evidence: 4

Background Many therapeutic options are currently available for facial skin rejuvenation, but little evidence exists about the efficacy of combining such procedures. Objectives The aim of this study was to assess and investigate the synergistic effect of hyaluronic acid (HA) and autologous platelet-rich plasma (a-PRP) injections on facial skin rejuvenation. Methods For this randomized controlled prospective study, 93 eligible patients were enrolled and randomized into 3 intervention groups to undergo a series of 3 treatment sessions with either a-PRP, HA, or a mixture of a-PRP and HA (Cellular Matrix; Regen Lab) injected into facial cheeks. Results A total of 93 patients were included. Treatment with Cellular Matrix led to a very significant improvement in the overall facial appearance compared with treatment with a-PRP or HA alone (P Conclusions Combining a-PRP and HA seems to be a promising treatment for facial rejuvenation with a highly significant improvement in facial appearance and skin elasticity compared with a-PRP or HA alone. Level of Evidence: 3

Background Although the excision of the buccal fat pad has become very popular for achieving a slimmer midface, not all patients are good candidates for this procedure. Unfortunately, studies that provide guidelines by emphasizing volumetric and technical details are limited. Objectives The study compared preoperative and postoperative volumetric data to identify the amount of tissue that can safely be removed and important technical concepts involved in lower cheek contouring with buccal fat pad excision. Methods Patients complaining of cheek fullness were evaluated to determine if they were good candidates for the procedure. Eligible patients were screened with transbuccal ultrasound to determine tissue volumes and anatomical details. Intraoperative and postoperative, 6th-month volume measurements were undertaken and residual tissues and vascular pedicles reevaluated. Results Ultrasound imaging showed that the mean preoperative volume of the fat pads was 11.67 ± 1.44 mL, and the mean postoperative volume was 8.58 ± 1.07 mL. The mean volume of the excised tissues was 2.74 ± 0.69 mL. Postoperative buccal fat pad volume values correlated with the reported average in the literature for the same age group. Conclusions Buccal fat pad removal is an effective technique for refining the facial silhouette that should be reserved for patients with increased buccal fat pad volume. Removal of only the excessive portion of the fat pad is important because this structure provides significant volume in the midface that can be difficult to restore once aging affects the surrounding soft and bony tissue. Level of Evidence: 4

Paradigms in the treatment of aging have evolved to address volume loss as a central and primary hallmark of the aging face. The concept of "composite volumization" was recently proposed by Dr. Z. Paul Lorenc to describe the effect of Radiesse (Merz Aesthetics, Inc., Raleigh, NC), when placed on bone in the supraperiosteal plane, on all overlying tissues (skin, superficial and deep fat compartments, and muscle). The physiochemical properties of Radiesse make it especially well suited for efficient and effective volumization of areas especially prone to volume loss; the temple, zygomatic arch, anterior cheek, pyriform aperture, and prejowl sulcus. Placement of Radiesse on bone in these areas creates a scaffold upon which additional restoration of fine lines and wrinkles may be accomplished, restoring a youthful appearance.

Background Midfacial volumizing procedures are increasingly common in facial rejuvenation. However, the changes that occur in midfacial fat with aging are poorly understood. Objectives The aim of this study was to determine how deep cheek fat volume is predicted by age. Methods We conducted retrospective cross-sectional and longitudinal studies of patients based on facial computed tomography (CT) scans. In the cross-sectional cohort, multiple linear regression analysis was performed to model the relations between age and deep cheek fat volumes. In the longitudinal analysis, changes to deep cheek fat volumes were tracked among subjects who underwent multiple facial CT scans. Results The cross-sectional cohort comprised 109 patients. The mean (SD) age of the subjects was 59.7 (15.0) years (range, 21.7-91.1 years). A linear regression analysis showed that increasing age was associated with increasing deep cheek fat volume (β = 0.015, P < 0.001). Additional regression analyses showed that the gain of fat with aging was more pronounced in the caudal aspect of the cheek (β = 0.007, P < 0.001) than in the cephalad (β = 0.005, P < 0.001). Twenty-three subjects were identified for longitudinal analysis. The mean (SD) ages at initial and final imaging time points were 50.0 (5.8) and 60.3 (5.2) years. In the deep fat compartment, there was an average gain of 0.23 mL over 10.3 years (P = 0.03). Conclusions Age is an important predictor of midfacial deep cheek fat volume. In this study, there is no evidence of adipose volume loss in the deep cheek compartment. Rather, aging was associated with an increase in deep cheek fat, possibly reflecting pseudoherniation of buccal fat. Level of Evidence 2

Background Lower blepharoplasty is one of the most commonly performed aesthetic surgeries in the world. However, there are no studies to directly compare patients who had fat excision vs fat transposition. Objectives The authors sought to compare and contrast aesthetic results of fat excisional and fat transpositional lower blepharoplasty. Methods A retrospective review was conducted of 60 patients (120 eyelids) who underwent transconjunctival lower blepharoplasty, either with fat excision or fat transposition into a preperiosteal plane. Marginal reflex distance-2, lower eyelid length, nasojugal fold depth, and pretarsal orbicularis definition were measured. Results Mean follow-up was 5.6 months. Mean marginal reflex distance-2 did not significantly differ after either fat excision or fat transposition. Mean lower lid length decreased after fat excision only (P < 0.001), and postoperative fat excision patients had a shorter lower eyelid length than patients who underwent fat transposition (13.5 ± 2.1 mm vs 16.1 ± 1.9 mm, P < 0.0001). Pretarsal orbicularis definition increased after both surgeries (P < 0.001), and the groups did not differ (1.0 ± 0.8 vs 1.1 ± 0.9, not significant). Mean nasojugal fold depth was effaced after surgery in both groups (P < 0.001), although the nasojugal fold was significantly more effaced after fat transposition (1.5 ± 0.7 vs 0.48 ± 0.6, P < 0.001). Conclusions In lower blepharoplasty, fat excision resulted in a shorter lower eyelid, and fat transposition resulted in a more effaced lid-cheek junction. Surgeons should be able to balance both techniques to deliver a customized aesthetic result. Level of Evidence: 3

BACKGROUND Although many facelift techniques incorporate fat grafting with tissue repositioning and removal, the intermediate and long-term changes in facial volume after these techniques is unknown. Whereas fillers for facial volume have predictable life spans, we know little about the facial volume changes following fat grafting with facelift surgery. OBJECTIVES The authors sought to track the short-term and long-term effects on midfacial volume change. METHODS We evaluated a subset of patients who were followed by 3-dimensional (3D) photometric imaging 18 to 24 months after facelift with fat grafting to the deep midfacial fat compartments and buccal fat pads. Volume changes were measured preoperatively and postoperatively every 1, 3, 6, 12, 18, and 24 months using the 3D photometry. RESULTS At the 1- to 2-month follow-up period, average facial volume was 49.60% of the initial fat injected. At the 18- to 24-month follow-up period, average facial volume was 73.64% of the initial fat injected, indicating an increase in midfacial volume. Upon graphing available photometric data, dynamic changes in facial volume were observed. In 5 midfacial zones, facial volume appeared to initially decline (average decline, 49.0% of original fat injection), troughing at 10 months (range, 2-15 months), but later inclined (average increase in volume, 95.9% of original fat injection), peaking around 16 months (range, 4-24 months). CONCLUSIONS Progressive improvement in midfacial volume in part may be explained by the graft replacement theory of Suga and Yoshimura, which suggests that grafted adipose tissue immediately dies after transplantation and is replaced by adipose-derived stem or progenitor cells. LEVEL OF EVIDENCE: 4

PMID: 29509842 Background: Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches. Objectives: In the authors’ surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study. Methods: Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated. Results: Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach. Conclusions: This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.

Background Juvederm Voluma XC is a volumizing hyaluronic acid filler used for correction of age-related midface volume deficit (MVD). Objectives The effectiveness of Juvederm Voluma XC was examined from the patient perspective. Methods Patients with moderate to severe age-related MVD (N = 235) received Juvederm Voluma XC. At quarterly follow-up visits for 2 years, patients rated treatment outcomes on the Global Aesthetic Improvement Scale (GAIS), overall satisfaction with facial appearance, satisfaction with midfacial regions, achievement of treatment goal, Look and Feel of the Midface (LAFM), and Self-Perception of Age (SPA). Patients recorded treatment-site responses in 30-day diaries. Results At 6 months and 2 years after treatment, 92.8% and 79.0% of patients, respectively, rated their cheek volume as improved/much improved on the GAIS. Improvement in satisfaction with facial appearance was noted by 89.8% of patients at 6 months and 75.8% at 2 years. Increased satisfaction with outer and lower cheek areas and cheek-bone projection and clinically significant improvements in LAFM were noted through month 24. Treatment goals were achieved by 67.8% of patients at 6 months and 49.0% at 2 years. Patients reported looking, on average, 5 years younger at 6 months and 3 years younger at 2 years. The most common treatment site responses were tenderness, swelling, firmness, and lumps/bumps; most were mild to moderate in severity and lasted ≤2 weeks. Conclusions Juvederm Voluma XC for age-related MVD is effective and well-tolerated from the patient perspective, with results lasting up to 2 years. Level of Evidence 4![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Background The plunging tip refers to a deformity in which the nasal tip plunges on smiling. Objectives To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. Methods Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. Results Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. Conclusions This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation. Level of Evidence 2![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif