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Background Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. Objectives This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. Methods A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed. Results Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, –40.0 to –12.7 mL; P Conclusions TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation. Level of Evidence: 4

Background Auricular displacement (AD) and earlobe distortion, such as “pixie ear,” are commonly seen deformities after rhytidectomies. In 2018, the authors of this article published a prophylactic technique (posterior earlobe rotation flap [PERF] and concha-mastoid suspension suture [CMSS]) to prevent such cosmetic-related complications in primary facelift surgery. Here, the authors review the utilization of this technique to correct such deformities in patients receiving revision facelift surgeries. Objectives The authors sought to demonstrate the usefulness of this technique in reconstructive cases suffering from such aesthetic deformities. Methods A total 25 secondary and 15 tertiary rhytidectomies were operated between 2015 and 2018. A combination PERF/CMSS technique was performed bilaterally during each revision facelift surgery (n = 80). A retrospective data analysis (preoperatively; 1 year postoperatively) was conducted to detect any deformities. Results No “pixie ear” deformities were seen in any of our patients postoperatively. AD was detected twice and unilateral hypertrophic scarring once. The postoperative photometric analysis showed a natural ptosis grade I/II in all our patients. The total rate of aesthetic-related complications in our patient cohort was 3.75% (AD: 2.5%; hypertrophic scarring: 1.25%). Conclusions After demonstrating the effectiveness of the PERF and CMSS techniques in primary facelifts, the authors reviewed the technique’s effectiveness for restoring earlobe distortion and AD in secondary or tertiary rhytidectomy cases. In addition to its prophylactic utilization, this method also possesses strong reconstructive power to change tension vectors applied on the face (CMSS) and/or to correct pre-existing aesthetic complications, such as “pixie ear” formation (PERF). 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

Background Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. Objectives The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. Methods A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. Results In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. Conclusions The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

Background The vector of superficial musculoaponeurotic system (SMAS) redraping in rhytidectomy is often described in relation to the zygomaticus major muscle (ZMM), so that suspension prevents distortion of the mimetic musculature and a “facelifted appearance.” There are no data describing the true orientation of this muscle in the midface. Objectives The aim of this study was to define the vector of the ZMM relative to the Frankfort horizontal plane. Methods One hundred patients underwent deep plane rhytidectomy. As part of this procedure the tissues overlying the ZMM are elevated, allowing muscle orientation to be measured as an angle relative to the Frankfort horizontal plane. Results Data for 200 hemifaces were aggregated. The average ZMM angle was 59° (standard deviation, 6°; range, 41–72°) relative to the Frankfort horizontal plane, and showed a statistically significant pattern of change with advancing age, becoming more acute with increasing age below the age of 60 years and more obtuse with age over 60 years. Conclusions The native vector of the ZMM varies significantly between rhytidectomy patients as demonstrated by the high variance in this cohort. Assumptions about its orientation should not be made in rhytidectomy techniques that do not identify its course. Standard vectors of SMAS redraping, such as superior-lateral, vertically oblique, and purely vertical, should be reconsidered and a customized vector implemented in each case. Aging affects the orientation of the muscle, which can potentially be explained by soft tissue and bony changes at its attachments. This furthers the variability of the SMAS vector in each individual case. Level of Evidence: 4

Background Sub-superficial musculo-aponeurotic system (SMAS) rhytidectomy techniques are considered to have a higher complication profile, especially for facial nerve injury, compared with less invasive SMAS techniques. This results in surgeons avoiding sub-SMAS dissection. Objectives The authors sought to aggregate and summarize data on complications among different SMAS facelift techniques. Methods A broad systematic search was performed. All included studies: (1) described a SMAS facelifting technique categorized as SMAS plication, SMASectomy/imbrication, SMAS flap, high lateral SMAS flap, deep plane, and composite; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results A total 183 studies were included. High lateral SMAS (1.85%) and composite rhytidectomy (1.52%) had the highest rates of temporary nerve injury and were the only techniques to show a statistically significant difference compared with SMAS plication (odds ratio [OR] = 2.71 and 2.22, respectively, P < 0.05). Risk of permanent injury did not differ among techniques. An increase in major hematoma was found for the deep plane (1.22%, OR = 1.67, P < 0.05) and SMAS imbrication (1.92%, OR = 2.65, P < 0.01). Skin necrosis was higher with the SMAS flap (1.57%, OR = 2.29, P < 0.01). Conclusions There are statistically significant differences in complication rates between SMAS facelifting techniques for temporary facial nerve injury, hematoma, seroma, necrosis, and infection. Technique should be selected based on quality of results and not the complication profile. Level of Evidence: 2

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed. Level of Evidence: 4

Background Tranexamic acid (TXA) is an antifibrinolytic agent shown to decrease intraoperative bleeding, reduce transfusions, and improve outcomes across multiple specialties. Within plastic surgery, initial reports are encouraging but formal studies are lacking. Objectives The aim of this study was to determine whether intravenous (IV) TXA has any effect on intraoperative bleeding or postoperative sequelae in patients undergoing a deep-plane facelift. Methods This is a prospective, randomized, double-blind, case series in a private practice surgery center. The participants were 44 patients undergoing rhytidectomy with the senior authors (R.A.G. or M.J.G). The treatment group received a 1-g dose of IV TXA prior to skin incision and the same dose 4 hours later (vs saline). Bleeding was rated mild, moderate, or severe. Postoperative ecchymosis and edema were subjectively evaluated by patient and surgeon and scores were aggregated for analysis. Results The TXA group showed decreased intraoperative bleeding but this difference did not reach statistical significance. Postoperative ecchymosis/edema ratings were lower for patients who received TXA, including a statistically significant decrease in surgeon-rated bruising. TXA resulted in a statistically significant decrease in postoperative collections in this study and no major complications occurred. Conclusions TXA is a safe, low-cost addition to any existing surgical protocol and may lead to fewer surgical sequelae and improved satisfaction. Although we did not observe a dramatically different intraoperative experience, postoperative bruising and collections were significantly reduced. TXA acid may have great value in the management of patients undergoing rhytidectomy and its use warrants further study. Level of Evidence: 2

BACKGROUND Anesthesia for elective ambulatory procedures must provide appropriate pain control while minimizing perioperative risk. Local anesthesia in combination with oral sedation provides a safe office-based method of anesthesia for rhytidectomy. OBJECTIVES The purpose of this analysis was to identify the incidence of traditional outcome parameters in ambulatory rhytidectomy performed with local anesthesia and oral sedation. METHODS A retrospective chart review was performed on all patients who underwent office-based rhytidectomy under local anesthesia with oral sedation from February 2011 to May 2017. A total of 174 patients were included. The data collected included patient medical and surgical history, medications, body mass index, tobacco use history, operative time, technique, and concurrent procedures. All intraoperative and postoperative complications were recorded. RESULTS One hundred and sixty-five patients were female (94.8%) and 9 were male (5.2%) a mean age of 57.6 years (SD ± 7.90). There were 46 complications, including 23 hematomas (13.2%), 6 seromas, 6 episodes of emesis, 5 infections, 4 scar deformities, and 2 ear deformities. Of the 23 hematomas, only 2 required operative evacuation with local anesthesia in the office procedure room. Twenty-one hematomas were small and managed with percutaneous needle aspiration, followed by surveillance. The 5 infections resolved after oral antibiotics only. There were no thromboembolic events or hospitalizations. CONCLUSIONS The use of only local anesthesia in combination with oral sedation safely permits the performance of rhytidectomy with similar incidence of rhytidectomy-related complications without the risk related to general anesthesia. LEVEL OF EVIDENCE: 4

Background Different technical variations exist for the utilization of quilting sutures (QS) in rhytidectomy. No systematic review or meta-analysis of the studies describing the use of QS in facelifts has been published to date to the authors’ knowledge. Objectives The objective of this study was to summarize all the published data regarding the utilization of QS in rhytidectomy, compare QS techniques, and evaluate their effect on postoperative complications. Methods On April 1, 2019, a systematic search of the Medline, Embase, and Cochrane databases was conducted. All the studies describing the usage of QS in facelifts were included in this review. Studies reporting hematoma rate in a QS group and a control group were included in the meta-analysis part of this study. Results The initial search of the databases yielded 93 results. Four trials were included in the systematic review and 2 were included in the meta-analysis. The total number of included patients with QS was 527. Two studies employed internal QS and the remaining studies utilized external QS. The meta-analysis found a lower rate of hematoma in the QS group (relative risk, 0.02; 95% confidence interval = 0.00-0.13; P < 0.0001). Conclusions QS can be applied either internally or externally and are very effective in reducing hematomas after facelifts. QS could be a great asset in facelifts but should be utilized with caution because additional work is needed to confirm their safety and efficacy. Level of Evidence: 2

I must say I was pleased when asked by the editor of this journal to write a commentary when I received the title,1 since I developed (and named) the composite facelift. Every surgeon who publishes original work wants to see his contribution accepted by his peers. However, I was baffled when reading this article. The technique the author describes is not a composite facelift, as he has entitled his publication. Perhaps the history of the development of the composite facelift2 will clarify and justify my criticism of this article. I was fortunate to start with the Skoog rhytidectomy in 1973,3 and together with Dr. Mark Lemmon we published the only extensive series on Skoog rhytidectomy4 since Prof. Skoog died in 1974. In 1985, after performing the tri-plane rhytidectomy, which I had published in 1983,5 I continued to be unhappy with the results. This was essentially an extension of the Skoog rhytidectomy, but with a subcutaneous elevation of cervical skin, since we concluded that the subplatysma cervical Skoog rhytidectomy could not create optimal neck contouring. While the jawline was satisfactory, I felt that the nasolabial fold could be better, and then began working on the technique that I wanted to give an original designation. I called it the deep plane rhytidectomy6 since it was an extension of the tri-plane rhytidectomy. The concept was relatively simple, as the cheek fat that was between the zygomaticus major and minor was lifted with the skin and kept in continuity with the platysma of the lower face (SMAS). Thus the skin was the vehicle for moving the cheek fat and the SMAS in the traditional lateral direction toward the ear. This original dissection was published, and met with enthusiasm among aesthetic surgeons everywhere. The result of the deep plane …

Background Jawline aging is a complex process. We believe loss of posterior jawline definition and volume depletion is an underappreciated factor in the aging face. Objectives The aim of this study was to describe a novel composite, rotational flap modification of an extended deep-plane rhytidectomy. We evaluated long-term efficacy on improving jawline contour and volumization of the posterior mandibular region overlying the gonial angle. Methods We performed a prospective study on patients who underwent our modification of extended deep-plane rhytidectomy. We define and introduce the mandibular defining line, a new anatomic metric in evaluating the mandibular contour. We define the area of the posterior lower face overlying the gonion and mandibular angle as the gonial area. Using 3-dimensional photography, we quantify contour changes along the mandibular border and volume change along the gonial area. Results Eighty-nine patients (178 hemifaces) were analyzed. The mean gonial area volume gained was 3.5 cc. Average follow-up was 19 months. There was a statistically significant change in the mean mandibular defining line from 7.1 cm preoperatively to 9.8 cm postoperatively. This represents a lengthening of the visual perspective of the mandibular contour of 2.7 cm. Conclusions Composite, rotational flap modification of extended deep-plane rhytidectomy provides significant long-term augmentation of volume to the posterior mandibular region and lengthens the visual perspective of the inferior mandibular contour, creating a more youthful jawline. In selected cases, this may obviate the need for other volumization procedures used to improve jawline contour, such as autologous fat grafting. Level of Evidence: 4

Background The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures. Objectives The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis. Methods The “related queries” feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Results Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: “eyelid plastic surgery” (ASPS R2 = 0.336, P = 0.048; ASAPS R2 = 0.661, P = 0.001); “facelift” (ASPS R2 = 0.767, P ≤ 0.001; ASAPS R2 = 0.767, P = 0.001); “lip injections” (ASPS R2 = 0.539, P = 0.007; ASAPS R2 = 0.461, P = 0.044); and “rhinoplasty surgery” (ASPS R2 = 0.797, P ≤ 0.001; ASAPS R2 = 0.441, P = 0.01). Several search terms demonstrated no significant relationships or were significant with only one database. Conclusions GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

Background Ear and earlobe deformities after surgical rhytidectomy are common and can significantly diminish the aesthetic outcome. The main causes of ear/earlobe distortion are skin overresection, an imbalance between vertical/horizontal skin-lift vectors, and tractional distortions through superficial muscularaponeurotic system (SMAS) tension. Objectives To demonstrate a new method for earlobe suturing and ear fixation that would prevent aesthetics-related complications after facelift surgery. Methods A total of 105 primary SMAS facelift surgeries were performed between 2015 and 2016 by the first author. A combination technique consisting of a posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) was executed bilaterally within each facelift procedure (n = 210). A retrospective data analysis was conducted (preoperatively and one year postoperatively) using our hospital information system and a photometric data analysis to assess auricular displacement, earlobe distortion, and hypertrophic scarring. Results Pseudoptosis of the earlobe was noted in two cases, and auricular displacement was observed in four cases. Bilateral mild hypertrophic scarring was seen in one patient. The postoperative photometric analysis showed a natural ptosis grade I/II in all the patients, with a statistically significantly reduced postoperative earlobe size (P < 0.05). The total rate of aesthetics-related complications was 4% in our cohort (earlobe distortion with pseudoptosis: 1%; auricular displacement: 2%; hypertrophic scarring: 1%). Conclusions Our modification of the facial flap anchoring at the ear base in combination with a CMSS stabilizes the natural position of the ear and prevents distortion while allowing better control over the earlobe’s aesthetic shaping. This novel method reduces the incidence of ear/earlobe deformities and hypertrophic scarring at the ear base after rhytidectomy and, therefore, promises to be a valuable advancement. 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: Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies. Objectives: This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures. Methods: A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility. Results: Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥25 (relative risk 2.8) increased infection risk. Conclusions: Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥25, and combined procedures are independent risk factors.

This article outlines a new rhytidectomy technique, developed by the author, that utilizes bidirectional self-retaining (barbed) sutures for superficial musculoaponeurotic system (SMAS) plication and, in some instances, skin closures. Short-scar and traditional versions of the procedure are presented, and the history of purse-string SMAS plication and the advantages for using self-retaining sutures in this application are discussed.

Background Facial aging is a complicated process that includes volume loss and soft tissue descent. This study provides quantitative 3-dimensional (3D) data on the long-term effect of vertical vector deep-plane rhytidectomy on restoring volume to the midface. Objective To determine if primary vertical vector deep-plane rhytidectomy resulted in long-term volume change in the midface. Methods We performed a prospective study on patients undergoing primary vertical vector deep-plane rhytidectomy to quantitate 3D volume changes in the midface. Quantitative analysis of volume changes was made using the Vectra 3D imaging software (Canfield Scientific, Inc, Fairfield, New Jersey) at a minimum follow-up of 1 year. Results Forty-three patients (86 hemifaces) were analyzed. The average volume gained in each hemi-midface after vertical vector deep-plane rhytidectomy was 3.2 mL. Conclusions Vertical vector deep-plane rhytidectomy provides significant long-term augmentation of volume in the midface. These quantitative data demonstrate that some midface volume loss is related to gravitational descent of the cheek fat compartments and that vertical vector deep-plane rhytidectomy may obviate the need for other volumization procedures such as autologous fat grafting in selected cases. Level of Evidence 4![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Background Fibrin glue has widespread use in multiple fields of surgery. There have been numerous studies on the use of fibrin glue in facelifts, with no consensus regarding differences in outcomes. Objectives This study compared the risk of hematoma, seroma, and the 24-hour drainage volume in all published prospective controlled trials. Methods A MEDLINE search of English-language articles on fibrin glue and rhytidectomy published up to July 2013 yielded 49 citations. After screening, we examined 7 relevant controlled trials. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Results Seven controlled trials measuring the outcomes of fibrin glue in facelifts were used to estimate the pooled relative risk of complications and confidence intervals. Hematoma formation was four times less likely with the use of fibrin glue (relative risk 0.25, P = .002). There was no significant reduction in seroma formation (relative risk 0.56, P = .19). There was not enough data to properly measure 24-hour drainage and ecchymoses. Conclusions This analysis suggests that fibrin glue reduces the rates of hematoma formation, but does not significantly reduce the rates of seroma development. Level of Evidence 3![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Background The cervical retaining ligaments anchor the platysma and soft tissues of the neck to the deep cervical fascia and deeper skeletal structures. The cervical retaining ligaments tether the platysma and prohibit free mobilization and redraping of the platysma muscle in rhytidectomy. This ligament system has previously been described in the literature only qualitatively. Objectives To define the anatomic dimensions of the cervical retaining ligaments and their relation to the platysma muscle in order to better understand the cervical retaining ligament system and how it limits motion of the platysma during rhytidectomy. Methods Extended deep plane rhytidectomy was performed on 20 fresh cadaveric hemifaces. The extent cervical retaining ligaments were dissected and measured. The anterior extent (width) of the cervical ligament were recorded at three anatomic points on each hemiface: (1) at the level of the inferior border of the mandible; (2) at the top of the thyroid cartilage at the thyroid notch; and (3) at the level of the cricoid. Results The average width of the cervical retaining ligaments in the neck was 15.3 mm. The width significantly decreased as they became more inferiorly positioned from the top of the neck at the anatomic measurement points, measuring 17.1 mm, 16.1 mm, and 12.6 mm (P Conclusions The cervical retaining ligaments are the support mechanisms of the platysma muscle in the neck. While previously described in only a qualitative manner, this study quantifies the anterior extent of these ligaments and how they invest the lateral platysma muscle. As these ligaments tether the platysma for an average of 1.5 cm, lateral platysma elevation of this distance during rhytidectomy surgery can improve platysmal redraping during rhytidectomy and potentially improve neck rejuvenation.

Background: Some practitioners have criticized the unpredictable retention associated with autologous fat transfer. Potential causes of variations in predictability include intrinsic (patient-related) or extrinsic factors, such as harvesting, processing, and graft-delivery technique. Objectives: The authors sought to determine the long-term retention of autologous fat graft processed with a closed-membrane filtration system, to compare this retention with centrifuge-processed fat, and to analyze factors that affect graft retention. Methods: This was a prospective analysis of 26 female patients (representing 52 hemi-midfaces) who underwent autologous fat transfer to the midface via the closed-membrane filtration system. The Vectra 3D camera and software were employed for all photography, which was then analyzed to compare immediate preoperative images with long-term follow-up images (obtained at least 10 months postprocedure). The authors compared the findings with data from their previous study of centrifuge-processed fat grafts (historical controls). Results: Mean values were as follows: age, 55 years; follow-up period, 17 months; amount of autologous fat injected, 8.88 mL; absolute volume augmentation measured at the last postoperative visit, 3.71 mL; and retention, 41.2%. Results of Welch’s t test, in which the membrane-filtration data were compared with the previous centrifuge data (31.8% long-term retention), showed a significant difference ( P = .03). Retention in this study was significantly higher in patients younger than 55 years (53.0% vs 31% for older patients; P = .001) and lower in patients who underwent rhytidectomy (23.8% vs 47.6% for nonrhytidectomy patients; P < .001). Conclusions: Autologous fat processed by closed-membrane filtration had a significantly higher long-term retention rate than did centrifuged-processed fat injected by the same surgeons. Level of Evidence: 3 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Facelifts are consistently one of the most common aesthetic operations performed by plastic surgeons in the United States (US). In 2013, 133,320 procedures were recorded, a rise of 6% compared with the previous year, making facelift the fifth most commonly performed cosmetic procedure.1 Further, rhytidectomy has been found to be safe in a wider, older range of patients,2 making it more popular with the aging baby boomer generation. However, despite the expansive number of procedures performed, authors and aesthetic surgeons alike acknowledge the lack of comprehensive data on current trends in facial rejuvenation.3 Alsarraf et al noted the severe lack of data on cost outcomes/trends in facial plastics or the market forces behind them.4 The authors aimed to report current national data and recent trends in inpatient facelifts over the last decade using the Nationwide Inpatient Sample (NIS) database. A retrospective serial cross-sectional study of data from the NIS database for the 2000 to 2010 time period was performed.5 The database was queried in January 2014. Sponsored by the Agency for Healthcare Research and Quality, the NIS contains all payer discharge data from inpatient hospitalization from roughly 20% of all hospitals in 37 participating US states. The NIS utilizes data from roughly 1000 hospitals each year to create a sample representing >95% of the US population.6 Hospital admissions involving facial rhytidectomy were examined. Data were extracted using ICD-9 codes for facial rhytidectomy (86.82), and relevant data were obtained. Data collected included patient and hospital demographics, hospital outcomes, and …

Background: Suction drains are commonly placed after rhytidectomy to avoid seroma formation that may result from dead spaces between skin layers. Fibrin sealants promote tissue adherence by crosslinking with extracellular matrix proteins, which may reduce the dead space under skin flaps. Objectives: The authors evaluate the safety and efficacy of the fibrin sealant (FS) VH S/D 4 s-apr (Artiss; Baxter Healthcare Corp, Deerfield, Illinois), added to standard-of-care (SoC) treatment, in improving flap adherence and reducing dead space in patients undergoing rhytidectomy. Methods: Patients with planned facial rhytidectomy were enrolled in this phase 3, prospective, controlled, randomized, patient-blinded, multicenter trial. They received SoC treatment on 1 side of the face and adjunctive FS VH S/D 4 s-apr on the other. Results: Seventy-five patients completed the trial. The mean (SD) drainage volume was 7.7 (7.4) mL from the sides treated with sealant and 20.0 (11.3) mL from the SoC-only sides ( P < .0001). Rates of hematoma and seroma were similar for the 2 treatments, as were changes in postoperative skin sensitivity. Adverse events generally were mild; 2 serious adverse events were reported (wound abscess, dehydration). Conclusions: Adjunct use of FS VH S/D 4 s-apr in rhytidectomy was proven safe in this study. It significantly reduced drainage volumes without increasing the incidence of hematoma or seroma, which suggests that it eliminates dead space through improved flap adherence. Level of Evidence: 2 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Background: Suction drains are commonly placed after rhytidectomy surgery to avoid seroma formation that may result from dead spaces between skin layers. Fibrin sealants promote tissue adherence by cross-linking with extracellular matrix proteins, which may reduce the dead space under skin flaps. Objectives: The authors evaluate the safety and preliminary efficacy of the fibrin sealant (FS) VH S/D 4 s-apr (ARTISS; Baxter Healthcare Corp, Deerfield, Illinois), added to standard-of-care (SoC) treatment, on tissue plane adherence and local hemostasis in rhytidectomy patients. Methods: In this phase 2, prospective, controlled, randomized, evaluator- and patient-blinded, multicenter study, 45 patients (of 56 possible enrollees) received SoC treatment on 1 side of the face and adjunctive FS VH S/D 4 s-apr treatment on the other side. Outcomes measures included visual assessments of ecchymosis (by blinded reviewers), grading of ecchymosis and edema, drainage volumes, occurrence of hematoma/seroma, safety evaluations, and patient-reported assessments of pain, numbness, and treatment preferences postoperatively. Results: Mean patient age was 55.1 years. Rates and grades of ecchymosis and edema were similar for the 2 treatments. The mean (SD) drainage volume 24 hours after surgery was 11.5 (13.7) mL from the FS VH S/D 4 s-apr–treated sides of the face and 26.8 (24.0) mL from the SoC-only sides ( P < .0001). Patient assessments of pain, numbness, and preference favored treatment with FS VH S/D 4 s-apr. Adverse events were mild to moderate in severity. Conclusions: Adjuvant use of FS VH S/D 4 s-apr appears to be safe and results in lower drainage volumes than SoC treatment alone. Level of Evidence: 2 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

The GalaFLEX Scaffold (Galatea Surgical, Inc., Lexington, MA) for plastic and reconstructive surgery belongs to a new generation of products for soft tissue reinforcement made from poly-4-hydroxybutyrate (P4HB). Other members of this new family of products include MonoMax Suture (Aesculap AG, Tuttlingen, Germany) for soft tissue approximation, BioFiber Scaffold (Tornier, Inc., Edina, MN) for tendon repair, and Phasix Mesh (C.R. Bard, Inc., Murray Hill, NJ) for hernia repair. Each of these fully resorbable products provides prolonged strength retention, typically 50% to 70% strength retention at 12 weeks, and facilitates remodeling in vivo to provide a strong, lasting repair. P4HB belongs to a naturally occurring class of biopolymers and fibers made from it are uniquely strong, flexible, and biocompatible. GalaFLEX Scaffold is comprised of high-strength, resorbable P4HB monofilament fibers. It is a knitted macroporous scaffold intended to elevate, reinforce, and repair soft tissue. The scaffold acts as a lattice for new tissue growth, which is rapidly vascularized and becomes fully integrated with adjacent tissue as the fibers resorb. In this review, we describe the development of P4HB, its production, properties, safety, and biocompatibility of devices made from P4HB. Early clinical results and current clinical applications of products made from P4HB are also discussed. The results of post-market clinical studies evaluating the GalaFLEX Scaffold in rhytidectomy and cosmetic breast surgery demonstrate that the scaffold can reinforce lifted soft tissue, resulting in persistent surgical results in the face and neck at one year, and provide lower pole stability after breast lift at one year.

Background: Rhytidectomy is fundamentally an operation of tissue release and resuspension, although the manner and direction of suspension are subject to perpetual debate. Objectives: The authors describe a method for identifying the angle of maximal rejuvenation during rhytidectomy and quantify the resulting angle and its relationship to patient age. Methods: Patients were prospectively enrolled; demographic data, history, and operative details were recorded. Rhytidectomies were performed by the senior author (AAJ). After complete elevation, the face-lift flap was rotated in a medially-based arc (0-90°) while attention was given to the submental area, jawline, and midface. The angle of maximal rejuvenation for each hemiface was identified as described, and the flap was resuspended. During redraping, measurements of vertical and horizontal skin excess were recorded in situ. The resulting angle of lift was then calculated for each hemiface using trigonometry. Symmetry between sides was determined, and the effect of patient age on this angle was assessed. Results: Three hundred hemifaces were operated (147 women; 3 men). Mean age was 60 years (range, 37–80 years). Mean resulting angle for the cohort was 60° from horizontal (range, 46–77°). This was inversely correlated with patient age ( r = −.3). Younger patients (

Background: Surgical rejuvenation of the aging face is common in aesthetic surgery, and many surgical techniques have been described for accomplishing it. The keys to consistent results are the surgeon’s judgment and ability to individualize a treatment plan according to the patient’s needs. To obtain natural-appearing results, the surgeon must consider the morphological characteristics of the aging face. Objectives: The authors describe their approach for “round” facelift technique and strategies for avoiding complications. Methods: This retrospective study included 8788 consecutive patients who underwent facelift procedures in a single clinic between 1958 and 2010. All cases involved the round-lifting technique. Results: Patients in this series ranged in age from 28 to 84 years. The percentage of male patients increased in later years (6.3% in 1970–1974 vs 18.6% in 1986–2010), and there was a trend toward increasing age after 1979 (17.7% of patients aged 60 years or older vs 8.3% before 1980). Submental liposuction was the most common facelift procedure performed (92.2% of patients, 1990–2010). Up to 97% of the cases treated after 1999 underwent repositioning of the malar fat pad. The overall complication rate was 4.5%, with the most frequent complications being hematoma (3%) and cutaneous slough or necrosis (1%). Conclusions: Repositioning the vector connecting the tragus with the Darwin tubercle provides more natural correction of aging tissues than do other techniques. The authors’ intent was to keep the structures in their natural location, as they had been prior to aging. Superficial musculo-aponeurotic system (SMAS) plication, malar fat pad repositioning, and correct traction of facial tissues showed satisfactory results. This technique is less aggressive than undermining of the SMAS and deep-plane techniques. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Background: It has commonly been assumed that deeper facelift dissection causes greater and more prolonged swelling. Objectives: In this preliminary report, the authors compare the lymphatic reconstitution after multiple techniques of rhytidectomy by means of dynamic lymphoscintigraphy. Methods: Three patients were enrolled in this study. All three were female, were similar in age, and exhibited similar signs and degrees of facial aging. Each woman underwent a facelift with a different technique: (1) subcutaneous dissection with superficial musculoaponeurotic system (SMAS) plication, (2) subcutaneous dissection with SMASectomy, and (3) a “high SMAS” composite facelift. Postoperatively, 99mTc-sulfur colloid was injected into a standardized infraorbital location in each patient to compare patterns of lymphatic drainage using lymphoscintigraphy. Postoperative scans at two weeks, six weeks, three months, six months, and one year were compared to the preoperative scans taken seven days prior to surgery. Results: All rhytidectomy techniques appeared to temporarily create a significant and similar degree of interruption in lymphatic drainage. There was a subtotal recovery of lymphatic pathways within three months and complete return to baseline drainage pattern after six months, regardless of surgical technique. Conclusions: Based on the results of this study, it appears that the extent of facial dissection, rather than the depth, is the most significant factor in postoperative edema.