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BACKGROUND: One of the most popular short-scar rhytidectomy techniques used nowadays is the minimal access cranial suspension (MACS) lift developed by Tonnard and Vaerpele. The technique uses purse-string sutures in combination with limited skin undermining to obtain a clear vertical tissue repositioning. Since its introduction, the technique has extensively been described and used around the world by facial plastic surgeons. Now, 18 years after its introduction, a systematic review concerning the results and complications of the MACS lift is presented to establish its current position in facial rejuvenation. METHODS: The MEDLINE, Embase, Cochrane Central, and Google Scholar databases were searched for studies evaluating the MACS lift (June 10, 2020). Outcomes of interest were long-term effect, satisfaction, and complications of the MACS lifting as determined by the patient and/or surgeon. RESULTS: Six studies were included, with 739 patients treated with the MACS lift in total. No major complications were reported, four studies did report on the occurrence of minor complications. All of the six studies reported relatively high levels of satisfaction. Three studies reported a shorter procedural duration for the MACS lift compared with the conventional facelift. In three of the six included studies, the level of evidence was low. The effect on neck rejuvenation is limited. CONCLUSION: The MACS lift can be considered a minimally invasive facelift procedure with a relatively low complication rate. The procedure, often combined with additional procedures, results in evident patient and/or surgeon satisfaction. To obtain a better desired result on an aged neck area, additional procedures are warranted.

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

The relationship of the skin, the superficial and deep fat compartments, and the ligaments that connect these structures is key to performing any rhytidectomy. In order to successfully mobilize, elevate, and reposition the facial soft tissues, a detailed understanding of facial anatomy is required. This article details the anatomy of the midface and neck that is essential to understanding and performing the face-lift operation.

The use of energy-based devices as surgical tools during rhytidectomy was introduced in early 2007 to 2008 and occurred when the first fiber laser was approved for laser lipolysis. It became evident that the fiber laser-assisted rhytidectomy could offer several advantages compared with conventional rhytidectomy. The use of energy devices now includes temperature-controlled radiofrequency and helium plasma devices. Energy devices continue to offer advantages compared with knife and scissor approaches: improved hemostasis; an ability to dissect into areas without full flap elevation; and the shrink-wrap late effects of collagen remodeling after energy-based treatment, which improves the results of rhytidectomy.

As a facial plastic surgeon gains experience, further improvements can be gained with more aggressive surgery, but complications begin to occur when more aggressive measures are undertaken. Therefore, the ideal technique is one that maximizes rejuvenation while minimizing adverse effects. The senior author has found that the aggressive techniques in the region of the neck have improved dramatically the overall initial and long-term results for the neck portion of the rhytidectomy. More aggressive treatment of the midface during the modified deep plane rhytidectomy does not necessarily improve the overall long-term results, however, and can increase the complication rate.

The various rhytidectomy techniques share a common goal of safe repositioning of the facial soft tissues with a lasting effect. This article reviews rhytidectomy approaches and the current methods and practice patterns of the senior author. It includes a discussion of the extended sub-superficial musculoaponeurotic system rhytidectomy technique, which, in the opinion of the senior author, offers the best result with respect to neck rhytids, cervicomental angle and jawline definition, and improvement of jowling. With its ability to be readily coupled with a deep plane dissection, when indicated, this technique becomes indispensable in the facial plastic surgeon's armamentarium.

Traditional superficial musculoaponeurotic system (SMAS) facelifting surgery uses a laminar surgical dissection. This approach does not treat areas of facial volume loss, and requires additional volume supplementation with fat grafting or fillers. The novel volumizing extended deep-plane facelift uses a composite approach to the facelift flap. By incorporating a platysma myotomy in the extended deep-plane flap, a novel composite transposition flap can be created that revolumizes the posterior jawline, recreating a defined convex jawline of youth. Special attention is paid to the deep anatomy of the face, and the need for release of the facial ligaments.

Facial aging is a multifactorial process with many articles over decades supporting various theories of varying causes. It is generally thought that aging occurs as a combination of changes in skin quality, gravitational descent of tissue with interaction of retaining ligaments on the ptotic tissue, and facial volume loss or the appearance of volume loss. The most significant cause of volume loss is skeletal remodeling and bone loss, which manifests as characteristic shadows and hollows on the face in conjunction with soft tissue changes that are yet to be completely elucidated.

The use of thread-lift sutures as an alternative to traditional surgical rhytidectomy or neck lifting is becoming a more common practice among surgeons. The Silhouette InstaLift (Sinclair Pharma, London, UK) is marketed as a minimally invasive procedure that immediately lifts and tightens the skin while stimulating fibroblast activation and collagen production. The evidence in the literature to support thread-lift sutures for facial augmentation is limited, with many studies having various degrees of bias. Our intention is to educate the oral and maxillofacial surgeon on the thread-lift suture materials, techniques, and relevant facial anatomy, as well as review the current limited data available. Using thread-lift sutures for facial augmentation is a relatively low-risk procedure that surgeons familiar with facial anatomy can offer patients either as an alternative to or in conjunction with other facial esthetic procedures such as facial filler treatment, neuromodulator treatment, or surgical procedures.

Complications of rhytidectomy are well known, yet often preventable. A thorough preoperative history and physical along with realistic patient expectations provide the surgeon and patient with insight into potential complications and postoperative management. Understanding of surgical pitfalls and avoidance are crucial in beginning to manage facelift complications. Possible complications of facelift techniques should not discourage surgeons from pursuing a particular technique as the majority of complications are temporary. Though, a strong patient-physician relationship is critical when complications occur. Complications may be frustrating for both the patient and surgeon, yet are overwhelmingly temporary and manageable without surgical intervention.

The focus of modern face-lifting has shifted from isolated superficial musculoaponeurotic system (SMAS) manipulation to providing necessary volume restoration and overall facial shaping. Volume deflation is a major component of facial aging but cannot be corrected solely by rhytidectomy. This article presents a detailed overview of facial fat compartment anatomy and examines its role in facial rejuvenation. A good understanding of facial fat compartment anatomy cannot be overemphasized. In combination with methodical preoperative visual analysis, this allows surgeons to target the specific areas that have undergone deflation with fat grafting before selective SMAS manipulation.

An aesthetically pleasing neck contour remains the cornerstone for facial rejuvenation. In this article a detailed description of the anatomy pertaining to the necklift surgery is provided, with supplemental cadaver video dissections going over the most common and novel necklift techniques.

The minimal access cranial suspension (MACS) facelift is a minimally invasive face and neck lift that uses the understanding of the changes in facial anatomy as it relates to facial aging. The MACS facelift uses a shorter incision with limited subcutaneous undermining. It achieves a resuspension of the underlying neck and midface soft tissues with the use of looped, purse-string sutures in the superficial musculoaponeurotic system and platysma. These attenuated structures are anchored to the deep temporal fascia. In the properly selected patient, the MACS facelift is an effective technique with high levels of physician and patient satisfaction.

Absorbable suture suspension is one of the newest minimally invasive treatment trends for lifting and repositioning ptotic facial tissue. The Silhouette Instalift is a convenient in-office procedure that provides a unique and advanced clinical treatment for a natural looking midfacial lift. Research has shown that most patients characterized the Silhouette Instalift as immediately effective and were pleased by enhancements. The procedure has an improved safety and efficacy profile over the predecessor, barbed suture thread lifting, coupled with reduced risk of complications and recovery time compared with rhytidectomy. Absorbable suture suspension should be considered a workhorse in nonsurgical esthetic treatments.

Purpose Pyoderma gangrenosum (PG) is an uncommon autoimmune, neutrophilic, ulcerative skin condition of uncertain etiology believed to result from dysregulation of the immune system. Although this entity is well recognized by dermatologists, other specialists are less familiar with diagnosis and treatment. This report describes a severe PG reaction to an elective cosmetic facelift, which is believed to be the second reported case of PG after facelift surgery. A second case after otoplasty surgery is described. Materials and Methods An unusual presentation of PG after cervicofacial rhytidectomy (facelift) is presented and discussed with a review of the literature. Results The present case was a rare complication after facelift surgery and followed the natural progression of PG. Delayed diagnosis and treatment extended the disease process. Conclusions PG can mimic other surgical complications and delay diagnosis and treatment. This case is believed to represent the second reported incidence of PG after elective facelift surgery.

Objectives Facelifts are among the most common facial plastic procedures performed. Given the existence of a variety of surgical approaches and the proximity of key anatomical structures, the development of proper surgical skills and knowledge is necessary to ensure positive outcomes. Many surgical learners utilize YouTube videos as supplemental tools in their education. Our aim was to gauge the quality and quantity of available YouTube videos describing the surgical approach to rhytidectomy. Methods The YouTube video platform was searched using predefined keywords. Videos meeting inclusion criteria were reviewed and scored by 3 practicing facial plastic and reconstructive surgeons. Thirteen different intraoperative, pre/postoperative, and video quality characteristics were scored on a binary scale by each grader. Descriptive statistics were obtained and interrater reliability was assessed using Kappa's coefficient. Results Thirteen videos met criteria for analysis. A high degree of interrater reliability was confirmed using Kappa's coefficient, with κ values = 0.73, 0.75, and 0.59 for each combination of scorers. In general, YouTube videos were found to be deficient in discussing key criteria of rhytidectomy, particularly with regards to pre/postoperative points such as indications, patient selection, and possible complications. Intraoperative benchmarks were also lacking, with 8/13 videos not discussing the facial nerve and 8/13 failing to demonstrate an appropriate facelift incision. Conclusions YouTube instructional videos depicting rhytidectomy lack discussion of key tenets of successful facelift surgery. Until improvement in the educational quality of such material occurs, surgical trainees should implement discretion when choosing YouTube videos to complement their learning. Level of Evidence: Not Applicable.

Facial stigmata associated with one's assigned gender can be very distressing for the gender dysphoric patient. The lower face and neck contain several structures that play a significant role in their ability to "pass" as their desired gender. Clinical recognition and modification of these structures will allow the patient to have facial and neck features that are consistent with their desired gender. This article reviews the techniques of mandibular angle contouring, genioplasty, chondrolaryngoplasty, facelift, and neck lift as they pertain to the feminization and masculinization of the face and neck of the patient with gender dysphoria.

This article describes our extended, deep plane facelift technique. This procedure releases 4 key retaining ligaments in the face and neck, the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments. Once released, the composite deep plane flap is repositioned to volumize the midface and gonial angle. Important anatomic considerations during deep plane dissection are discussed. In the neck, focus is on extending the deep plane dissection of the platysma, releasing the cervical retaining ligaments, creating a platysmal hammock to support the submandibular gland, defining the inferior mandibular contour, and minimizing the need to open the neck.

Submental intubation has been used as an alternative to conventional intubation in the field of oral and maxillofacial surgery since its introduction by Francisco Hernández Altemir in 1986. A review of submental intubation was performed using data from all case reports, case-series, and prospective and retrospective studies published between 1986 and 2016. The indications, variations in incision length, incision sites, types of endotracheal tube used, methods of exteriorization, and complications were recorded and analyzed. A total of 70 articles reporting 1021 patients were included. The main indication was maxillofacial trauma (86.9%, n=887), followed by orthognathic surgery (5.8%, n=59), skull base surgery (2.8%, n=29), and rhinoplasty and rhytidectomy (1.5%, n=15). The complication rate was relatively low: 91.0% of patients (n=929) were complication-free. The most common complication was infection, occurring in 3.5% (n=36) of the total number of patients, followed by scarring (1.2%, n=12) and formation of an orocutaneous or salivary fistula (1.1%, n=11). In summary, submental intubation is a good alternative airway with minimal complications.

Summary Objective Recently, water jet-assisted liposuction (WAL) was successfully applied by several other authors to remove fat and induce skin contraction in nonfacial body areas. Extending the range of indications for this new method, the authors of this article report on their first experience with its use in facial contouring, fat harvesting, and hydrodissection of the facial skin flap in rhytidectomy in a case series of 25 patients. Methods Twenty-five patients (median age: 56 years) had facelift surgery under sedation, and the WAL technique was used for facial contouring, fat harvesting for facial lipotransfer, and hydrodissection of the facial skin flap. Patients were monitored for discomfort during the procedure. Complications such as bleeding, postoperative swelling, and hematoma formation were observed during a 1-week follow-up period, and intensity was rated by two independent surgeons using a special grading system. Furthermore, a patient survey (FACE-Q) was performed to analyze the patients' satisfaction and perception of the postsurgical esthetic results. Results The WAL technique can be applied under intravenous sedation without causing any discomfort in all treated patients [mean 1.16, standard deviation (SD) 0.31]. Intraoperative bleeding during WAL-assisted facial dissection was judged as not present at all times (mean 1.3, SD 0.32). Postoperative swelling (day 1: mean 1.82, SD 0.28; day 7: mean 1.18, SD 0.28) and hematoma formation following surgery (day 1: mean 1.58, SD 0.34; day 7: mean 1.18, SD 0.31) were judged as minor in all cases. Overall, no skin necrosis was detected. There was no need for revision surgery. More than half of our treated patients (n = 13) answered the FACE-Q questionnaire, verifying a high satisfaction rate with beneficial treatment results without the occurrence of any major complications. Conclusions The WAL technique seems to offer a safe and efficient treatment approach for facial contouring, facial fat harvesting, and simultaneous facial flap hydrodissection with only minor postoperative swelling and hematoma formation. Therefore, the authors believe that the WAL technique is a powerful and useful tool and should be used in modern facial plastic surgery.

Rhytidectomy is the most common surgical procedure used to rejuvenate the appearance of the aging face and neck. Necrotising fasciitis is a rapidly progressing, life-threatening, bacterial infection of the skin, the subcutaneous tissue, and the fascia. We report a case of necrotising fasciitis of the face caused by a group A streptococcal infection after rhytidectomy on a healthy female patient. An abscess on her hand that had been caused by an infection related to a venous catheter had provided a potential entry for the pathogen, and treatment combined both surgical debridement and antibiotics. The operation had resulted in large tissue losses around the ears, which we treated by healing by second intention.

Introduction The parotid duct drains the parotid gland, the largest of the human salivary glands. The PD receives an accessory PD from the accessory PG, a variation of the PG often mistaken for a soft tissue mass. The PD's superficial location contributes to the occurrence of iatrogenic and traumatic duct injuries. Case reports suggest that variations in the form of duplicated PDs, have resulted in clinical complications. Therefore, an observational, cross-sectional study was designed to determine the anatomical variations in the PG drainage pattern via the PD. Materials and methods The left and right parotid regions of 20 embalmed cadavers (N = 40) at Stellenbosch University were dissected. Latex was injected into the oral papilla for better visualisation of the duct. The duct lengths were measured and classified. The anatomical variations of the PD were documented. Results Six of the 40 parotid regions were excluded due to damage. Bilateral PD duplication was observed in one cadaver (5.88%), while the remaining 94.12% presented with single PDs. The mean duct length on the left and right sides were found to be 48.5 mm and 45.9 mm respectively. Additionally, accessory PGs were identified in 50% of cadavers. Conclusions While rare, bilateral double PDs were identified in this sample. This highlights the importance of understanding anatomical variations of the PG drainage pattern via the PDs, including the incidence of accessory PGs, to limit the occurrence of unnecessary iatrogenic injury, such as compression of the duct causing salivary retention in the PD following a Rhytidectomy, and effectively repair traumatic duct injuries. Further research should be conducted to investigate the branching pattern of the PD within the PG.

The peeling-assisted volume-enhancing (PAVE) lift is a single-stage approach that combines superficial musculoaponeurotic system (SMAS) plication techniques with fat grafting and different peeling agents. To evaluate the safety of this approach, we analyzed the records of 159 patients who underwent surgery between 2008 and 2014. The percentage of complications observed was not higher than values reported in the literature for each treatment entity: surgical facelift: n=3 haematomas (1.89 %), n=2; temporary apraxia of the mandibular branch (1.26%); fat transfer: minor asymmetry in n = 5 cases (3.14%); peeling: temporary hyperpigmentation in trichloroacetic acid (n = 5; 3.8%) and phenol peels (n = 4; 3.1%), permanent hypopigmentation (n = 6; 5.6%), formation of skin miliae persisting longer than 2 to 3 months (n = 5; 4.6%) and prolonged erythema (n = 3; 0.28%) in phenol peels. The single-stage use of chemical peels, autologous fat transfer, and surgical rhytidectomy was safe.

In facial plastic surgery, attaining hemostasis may require adjuncts to traditional surgical techniques. Fibrin tissue adhesives have broad applications in surgery and are particularly useful when addressing the soft tissue encountered in facial plastic surgery. Beyond hemostasis, tissue adhesion and enhanced wound healing are reported benefits associated with a decrease in operating time, necessity for drains and pressure dressings, and incidence of wound healing complications. These products are clinically accessible to most physicians who perform facial plastic surgery, including skin grafts, flaps, rhytidectomy, and endoscopic forehead lift.

Purpose The purpose of this study was to investigate the adequacy of a modified facelift incision combined with an SMAS flap for the resection of benign parotid lesions in terms of cosmesis and incidence of Frey's syndrome. Materials and methods A hundred patients who underwent superficial parotidectomy were divided into 2 groups according to approach: Blair incision (57 cases) and modified facelift incision (43 cases). In the latter group, 36 patients were reconstructed with a superficial musculoaponeurotic system (SMAS) flap. During follow-up, patients were asked to rate their satisfaction with their postoperative appearance using a 1 to 3 scale. Results Clinical Frey's syndrome was present in 8.5% of patients with SMAS flap, and in 19% patients without SMAS flap ( p = 0.16). The average cosmetic outcome score for patients who underwent a modified facelift approach combined with an SMAS flap was 2.87, whereas patients whose tumors were approached through a Blair incision reported a lower score of 2.1 ( p Conclusion A modified facelift incision combined with an SMAS flap improved the cosmetic appearance of patients who underwent extrafacial or superficial parotidectomy. In addition, this flap seems to reduce the occurrence of Frey's syndrome.

Summary Background The combination of simultaneous surgical rhytidectomy with ablative resurfacing has been a controversial procedure due to the concern of postoperative wound healing. Traditional ablative resurfacing lasers are believed to have higher rates of complications, leading to delayed healing and skin flap loss when combined with face rhytidectomy surgeries. With the development of fractionated ablative laser therapy, there has been increased interest in combining these two procedures. The objective of this study is to evaluate the clinical outcomes of patients undergoing simultaneous full-face rhytidectomy in combination with fractionated ablative skin resurfacing. Methods A retrospective chart analysis was performed for all patients who had a combined procedure of facelift and ablative fractional laser resurfacing from 2008 to 2013 by the senior author (SKS). Postoperative recovery and complications were recorded. The surgical technique used for performing the facelift was an extended supraplatysmal dissection with SMAS plication. Fraxel Re:Pair 10,600-nm fractional carbon dioxide laser was used to perform an ablative resurfacing including the elevated skin flaps. Results A total of 86 patients were included. Average age was 60.01 years (range of 45–78 years). Longest follow up was five years. The average size of the elevated skin flaps was 100 cm 2 . Average skin type was a Fitzpatrick type 2. All patients had complete re-epithelialization by one week after their procedure. Four patients (4.6%) experienced acne outbreaks. Four patients (4.6%) had facial erythema that persisted greater than two weeks. Of these four patients, all resolved by five weeks postoperatively. There was no delayed wound healing or skin flap loss observed. Conclusion Our results indicate that simultaneous rhytidectomy with fractionated ablative laser resurfacing does not cause an increase in wound healing or skin loss. Due to improved patient outcomes with combining these procedures, we believe that this can be increasingly offered as a safe combination.

Systematic reviews and meta-analyses hold a unique position in the pyramid of evidence. They can provide transparent and rigorous summaries to answer many clinical questions in facial plastic surgery. They can also identify areas of research deficiency, create new knowledge, and support guidelines or policies. A well-conducted systematic review follows a structured process to minimize bias and ensure reproducibility. When appropriate, a meta-analysis is incorporated to provide a statistical synthesis that combines the results of individual studies. This powerful quantitative method is becoming more prevalent in facial plastic surgery. This article provides a practical framework to understand and conduct this valuable type of research.

Summary Background The great auricular nerve (GAN) is often sacrificed during parotidectomy, rhytidectomy, and platysma flap operation. Transection of the nerve results in a wooden numbness of preauricular region, pain, and neuroma. The aim of this study was to describe the branching patterns and distribution area of the GAN. Methods Twenty-five embalmed, adult hemifacial Korean cadavers (16 males, nine females; mean age 62.5 years) were used in this study. The branching of the GAN was determined through careful dissection. The histological structure of the GAN was also examined by harvesting and sectioning specimens, and then viewing them with the aid of a light microscope. Results The branching pattern of the anterior, posterior, deep, and superficial branches of the GAN could be classified into five types: type I (20%), where the deep branches arose from the anterior branch; type II (24%), where all branches originated at the same point; type III (28%), where the deep branch arose from the posterior branch; type IV (8%), where the superficial branches arose from the posterior branch; and type V (20%), where the anterior and posterior branches ran independently. A connection between the GAN and the facial nerve trunk was observed in all specimens, and a connection with the auriculotemporal nerve was observed in a few specimens. The total fascicular area of both regions decreased from proximal (1.42 mm 2 ) to distal (0.60 mm 2 ). There were 2.5 and 5 fascicles in the proximal and distal regions, respectively. Conclusion The results reported herein will help toward preservation of the GAN during surgery in the region of the parotid gland. Furthermore, the histologic findings suggest that the GAN would be a good donor site for nerve grafting.

The deep-plane midface lift offers many advantages in midface rejuvenation. Anatomic analysis of aging and embryologic evidence both support surgical facial “degloving” in the sub-SMAS plane and resuspension of the platysma/SMAS unit. This approach offers more complete repositioning of facial soft tissue compared with nonsurgical techniques, delivering accurate, direct treatment of deeper anatomic aspects of facial aging. The well-vascularized deep-plane flap minimizes complications. Outcomes can be maximized because tension exists “invisibly,” only at the fascia level. Consistent, natural,and long-lasting aesthetic results are achieved.

Aging of the face is inevitable and undeniable. This process includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. The contribution of these 3 factors varies between individuals with noticeable hereditary influence. Characteristic ethnic features have been described in the literature, but as societies have changed, many of these ethnic variations have blended together. Facial cosmetic procedures must to be tailored to address these variations in anatomy, and consideration must be given to enhancing the facial skeleton, adequately lifting the soft tissues, and planning careful incisions to be closed under no tension.

Jowling, submental lipoptosis, and platysmal banding can affect self-image and reduce quality of life, leading one to seek facial and neck rejuvenation. With realistic expectations, a facelift can provide the desired improvement in appearance and sense of well-being. Before any intervention, a detailed history, focused examination, communication of expected outcomes with the assistance of preoperative digital imaging, and discussion of perioperative instructions are of utmost importance. Although many techniques exist, the modified deep plane extended superficial muscular aponeurotic system rhytidectomy with submentoplasty reliably delivers a significant improvement with lasting results.

Purpose Microvascular surgery has become the preferred method for mandibular reconstruction. A neck incision frequently is required for malignant tumor resections to carry out the dissection. The authors suggest a rhytidectomy approach for mandibular reconstruction with microvascular free flaps after the resection of benign tumors. Patients and Methods Seven patients with lateral mandibular defects resulting from resection of benign mandibular tumors were treated in the author's department. A combined rhytidectomy approach with an intraoral incision was used for mandibular resection and reconstruction of the defects using vascularized free osseous flaps. Results The study was comprised of 3 men and 4 women with a mean age of 37.57 years (range, 28 to 50 years). Follow-up ranged from 9 to 87 months after surgery (mean, 56.28 months). The iliac crest was used for reconstruction in 6 patients, whereas the fibula was used in 1 patient. Transient paresis of the marginal nerve was observed in 2 patients. Flap loss occurred in 1 patient and required repeat microvascular reconstructive surgery. Dental rehabilitation with osseointegrated implants was performed in 4 patients. At the end of the follow-up period, successful mandibular reconstruction was achieved in all patients. Functional outcome was regarded as excellent in all patients, whereas esthetic outcome was judged excellent in 6 patients and good in 1 patient. Conclusions A rhytidectomy approach combined with an intraoral incision for microvascular mandibular reconstruction after the resection of benign tumors is a feasible technique that provides good exposure of the anatomic structures, an inconspicuous facial scar, and adequate facial contour and symmetry. Excellent clinical results are reported with the use of this technique, which should be included in the surgical armamentarium for mandibular reconstruction.

Rhytidectomy remains a challenging surgical procedure for even the most experienced aesthetic plastic surgeons. The challenges are compounded by complications that are inherent to this procedure and place added pressure on the doctor-patient relationship. Expectations for both parties are high and the margin for error nil. This article presents a personal approach to the avoidance and management of complications associated with facelift surgery. It presents the author's personal approach as a plastic surgeon in the practice of aesthetic plastic surgery over the past 25 years. Clinical pearls are provided to obtain optimum results in rhytidectomy and limit associated sequelae.

The sections on the face, neck, and brow include descriptions of facelift, neck lift, and open brow lift techniques, anesthesia, treatment goals, procedural approaches, complications, management, preoperative and postoperative care, rehabilitation, recovery, and outcomes. The approach to facial rejuvenation the midface and periorbital area is detailed. These operations are often and easily performed entirely with the use of local anesthesia and mild oral sedation. There are very high satisfaction rates.

Because modern facelift patients desire a less-invasive approach or minimally invasive approach to reduce visible scarring and decrease the recovery phase, achieving the surgeon's goal of optimal, reliable, and long-term aesthetic results with few complications becomes a challenge. The authors use the terms minimal access and traditional access to describe rhytidectomy approaches based solely on incision size. A short-incision, minimal-access approach with a deep-plane extended dissection is presented. A preoperative physical examination maneuver to evaluate a patient's candidacy for a minimal-access approach and guidelines for when to include platysmaplasty with the procedure to further improve cervicomental contour are described.

A incisao tipo ritidectomia modificada para a abordagem da glândula parotida mostrou-se uma alternativa a classica incisao cervicomastoideofacial, permitindo-se camuflar a cicatriz em areas pouco visiveis com melhor resultado estetico. Todavia, ainda existem poucos estudos comparando os resultados funcionais e a incidencia de complicacoes em pacientes submetidos a parotidectomia utilizando-se essas diferentes vias de acesso. Objetivo: Comparar a incidencia de complicacoes e os resultados funcionais de pacientes com neoplasias benignas da parotida abordados pela incisao classica ou ritidectomia modificada. Metodo: Estudo de casos tipo coorte historica longitudinal incluindo sessenta pacientes submetidos a parotidectomia e igualmente distribuidos entre as duas formas de incisao avaliadas, comparando-se os dados de idade, sexo, tempo de internacao, volume drenado, tamanho tumoral, volume da parotida ressecada, ocorrencia de disfuncao de motricidade facial e fistula salivar pos-operatoria. Resultados: Nao foram observadas diferencas significativas para complicacoes e resultados funcionais entre os dois grupos, exceto pela menor ocorrencia de disfuncao da motricidade facial imediata em pacientes submetidos a cirurgia via ritidectomia modificada, com a chance desta ocorrencia ser 86% menos frequente neste grupo. Conclusao: A incisao tipo ritidectomia modificada apresenta incidencia de complicacoes comparaveis a abordagem classica, associada a menor ocorrencia de disfuncao da motricidade facial imediata.

The ability to bring aesthetic harmony back into the ageing face requires the blending of surgical technique, anatomic knowledge and artistic sensitivity to individualise the surgical approach for each given patient. Since the advent of endoscopic techniques for facial rejuvenation, there has been an increase in the number of patients who seek alternative facial procedures, refusing a conventional face-lift. Limited-scar rhytidectomies offer patients with mild-to-moderate facial ageing an alternative to traditional face-lift surgery. The authors present a prospective study using the endoscopically assisted limited-incision face-lifting technique. Indications for using this technique include young patients with a relatively small amount of skin excess, older patients with thick skin and minimal skin redundancy, smokers and bald people. A set of incisions in the forehead, pre-auricular area, ear lobe and post-auricular area are done. Frontal and temporal endoscopic lifting is performed, followed by middle third and cervical undermining and transposition of a 2×5.5 cm rectangular pre-auricular superficial musculo-aponeurotic system (SMAS) flap. Overall satisfaction with the facial appearance after this procedure was rated on a scale of 1 to 5. A total of 54 patients were operated upon during January 1997 and January 2007, which represents 13% of the total number of face-lifting procedures performed during that period. Their age ranged from 28 to 55 years old (mean 38 years), and 35% of them were men. There were two cases of haematoma formation (1%) and four patients (2%) required further liposuction of the submental region. There were no cases of nerve injury or infection. Six patients (3%) requested revision surgery after 2-4 years after the first procedure (median 3.5 years). They underwent a secondary round of face-lifting. The mean follow-up period has been 5.5 years (range 1-9 years). Sixty-nine percent reported that their appearance after limited-incision rhytidectomy was 'very good' to 'excellent' and 22% responded that their appearance was 'good'. Only 9% of patients thought their appearance was less than good. This is not a mini-lift technique but rather a full face-lift performed through minimal incisions and assisted by the use of the endoscope. Although the endoscopically assisted limited-incision rhytidoplasty is reserved for a specific category of patients and requires a learning curve, it appears to be a procedure with a low rate of complications and a high patient satisfaction.

Photodocumentation in facial plastic surgery is essential in the perioperative setting, and with meticulous uniformity and standardization it serves as the primary tool for surgical planning and critical analysis of results. Accurate photodocumentation is dependent on strict and consistent use of equipment, lighting, and patient positioning. The purpose of this article is to review the principles of standardization in perioperative patient photography for common facial plastic procedures and to provide the facial plastic surgeon with the tools necessary to develop consistent and accurate patient photographs.

Aesthetic improvement of the neck and cervicomental angle remains one of the most challenging aspects of surgical facial rejuvenation. Individuals may become dissatisfied with the appearance of their neck because of changes in skin quality, submental fat, and muscle tone or anatomic position related to aging, weight gain, weight loss, sun damage, and other causes. To achieve the patient's desired result, surgeons use various techniques, either in isolation or in combination. Careful preoperative evaluation of the patient's anatomy dictates the most appropriate procedure, ranging from laser skin resurfacing to sub-superficial muscular aponeurotic system (sub-SMAS) rhytidectomy with an extended platysmaplasty. This article reviews the techniques that are available and the decision-making process in choosing the appropriate technique for the individual patient.

The composite facelift represents a comprehensive technique for facial rejuvenation with tissue repositioning of essentially every deep structure of the aging face, addressing the neck, lower face, mid face/lower eyelid junction, and forehead. The superior lateral vector of the lower face is "balanced" with a superior medial vector of the cheek and lower eyelid region. Patients who have stigmata of a previous facelift, such as the lateral sweep and hollow eyes, may be corrected with the composite facelift. The composite facelift is distinguished from all other facelift procedures in the unique "balance" of facelift vectors, yielding a natural and complete facial rejuvenation.

Rejuvenation of the mid- and lower face in the male patient can be challenging. Historically, most of these procedures were performed on female patients. However, an increasing number of men are seeking rejuvenative procedures and because of this trend, it is imperative that facial plastic surgeons become facile with the nuances of male mid- and lower facial rejuvenation. Failing to understand the important differences between male and female patients can lead to pitfalls during the perioperative period. The conscientious surgeon should be mindful of these differences, beginning with the male cosmetic consultation and proceeding through to the postoperative period. The goal of this article is to review the principles of male mid- and lower facial rejuvenation.

Procedures combining a short scar with superficial musculoaponeurotic system (SMAS) manipulation are increasingly popular for patients with early signs of mid- and lower-facial laxity seeking rhytidectomy. We present the senior author's experience with a short scar volumetric malar imbrication rhytidectomy, which avoids post-auricular incisions and sub-SMAS dissection.Between January 2004 and April 2007, 54 patients underwent a short scar volumetric rhytidectomy (9.6% of all facelifts). These procedures were primary in 38 and secondary in 16 patients, at a mean age of 49 years (range 35-77 years). Average operating time was 90 min. Resultant vertical and horizontal skin movement at the helical root was recorded. Concurrent procedures included blepharoplasty, canthoplasty, endoscopic forehead rejuvenation and fat grafting. Minimum follow up was 3 months. Pre- and 3 month postoperative photographs of 25 randomly selected patients were rated by three independent surgeons. A seven-point scale was used to grade the improvement in the malar eminence, melolabial fold, jowls and cervicomental angle. The overall aesthetic result was assessed using the MDACS grading system. Statistical analysis was performed using Student's t-tests and general estimation equations where appropriate.There were no significant complications. Three patients developed minor cheek swellings which all settled with antibiotics. Mean postoperative aesthetic outcomes were rated as 'Good' using the MDACS scale (mean score 0.64), with no 'Poor' results. Vertical skin lifting was significantly greater than the horizontal skin lifting (P0.001). Mild postoperative improvements were noted in the malar eminence soft tissue volume, nasolabial fold diminishment, jowl diminishment and cervicomental angle.In the appropriately selected face, short scar volumetric malar imbrication rhytidectomy is a straightforward, safe and effective procedure for improving the early signs of ageing.

The subperiosteal face-lift is a procedure designed to rejuvenate the middle third of the face. We present in this study the technical procedure we have developed, based on the subperiosteal detachment of the soft tissues of the midface and their attachment to the deep temporal fascia with a vertical vector of suspension. We reviewed 69 patients who undergone superiosteal temporomalar rhytidectomy, between March 2002 and January 2006, ranged in age from 42 to 65 years (mean 46). All of the patients presented preoperatively prominents nasolabial folds, malar fat pad ptosis. None of them presented a cervical soft tissue ptosis. The mean follow-up period was 32 months. The postoperative complication rate was 11.5 percent and included transient temporal branch weakness (N=4), transient infraorbital nerve paresthesia (N=1), asymmetrical result (N=1); scleral show (N=1) and ectropion (N=1) which required a secondary surgery. The overall aesthetic results were good; with attenuation of the prominent nasolabial folds in 100 percent and diminution of the height of the lower eyelid in 80 percent of the patients. In conclusion, the subperiosteal midace lift is a procedure designed to rejuvenate the middle third of the face.

Summary Background The minimal access cranial suspension (MACS)-lift is a short scar rhytidectomy with vertical purse string suture suspension of the facial tissues. It exists in a simple and extended version. The simple MACS-lift achieves a vertical lifting of neck and lower half of the face with two purse string sutures. The action of a third, malar suture gives additional correction of the middle third of the face, and results in the extended MACS-lift. Objective To draw attention to the power and advantages of the ‘third' malar suture in the extended MACS-lift in achieving volumetric restoration of the midface, softening of the nasolabial fold and enhancing support of the lower eyelid. Methods The core principle of this technique is the use of strong purse string sutures in a pure antigravitational direction for correction of the ageing neck and lower two-thirds of the face. In a simple MACS-lift the neck is corrected by a first narrow vertical purse-string suture. The volume of jowls and cheeks is repositioned in a cranial direction with a second, slightly oblique purse string suture. To achieve better control over the midface an extended MACS-lift is performed by adding a third malar vertical purse string suture between the paracanthal area and the malar fat pad. Results 557 MACS-lift procedures have been performed by the two senior authors, of which 183 were simple and 374 extended. A retrospective review of this technique revealed high patient satisfaction, only one major complication and a minor complication rate of 6%. Both versions of the technique deliver a vertical vector correction of sagged facial features. The third suture restores the volume of the midface and malar mound and provides strong support of the lower eyelid. Conclusions The third suture in the MACS-lift short scar rhytidectomy produces a natural midface lifting through a short scar, with adequate softening of the nasolabial fold and good support of the lower eyelid.

Purpose It is well-recognized that postoperative hematoma is the most common complication of cervicofacial rhytidectomy (facelift surgery), and several strategies aimed at reducing the incidence of hematoma have been developed and studied. Other common complications include skin necrosis, seroma, motor and sensory nerve injury, alopecia, auricular deformity/displacement, and dyspigmentation. The purpose of this study was to retrospectively analyze the incidence of complications after superficial cervicofacial rhytidectomy performed by a single surgeon and his fellows and to compare our findings with those reported in the literature. Materials and Methods Based on a retrospective chart review of patients who underwent cervicofacial rhytidectomy, 178 consecutive patients were enrolled in this study. The charts were reviewed for any notable complications after facelift surgery, especially postoperative hematoma. The charts of those patients with complications were reviewed to identify the presence of perioperative anomalies that may have increased the risk of such complications. Our findings were then compared with those reported in the literature. Results Of 178 patients who underwent cervicofacial rhytidectomy, 11 (6.2%) had a postoperative complications. These 11 complications included 5 cases (2.8%) of a major postoperative hematoma requiring surgical intervention, 3 cases (1.7%) of minor hematomas (“microhematomas”), and 1 case each of hypertrophic scarring necessitating surgical excision and steroid injection, superficial skin necrosis, and dehiscence. There were no cases of seroma, parotid pseudocyst, or permanent motor nerve injury. Conclusion The incidence of postoperative complications associated with superficial plane rhytidectomy is very low, with hematoma the most common complication.

Osseous genioplasty remains an important technique in the surgical alteration of the chin. Additionally, it is an extremely stable procedure associated with a relatively low risk of complications. The technique is an excellent adjunctive procedure when combined with other aesthetic procedures such as rhinoplasty, cervical liposuction/lipectomy, and rhytidectomy. Despite the recent popularity of the alloplastic chin implant, osseous genioplasty provides superior versatility in surgical alteration of chin morphology and has the distinct advantage of being an autologous technique. Several variations of the technique may be utilized to address various morphologic deformities of the chin. A thorough understanding of mandibular anatomy is critical to perform osseous genioplasty in an appropriate manner and avoid complications.

Liposuction of the lower face and neck regions is a time-honored technique associated with aesthetically pleasing long-term results in the majority of patients. The keys to achieving an excellent outcome remain, as always, appropriate patient selection and proper execution. Modern ideals tend to favor more natural, blended results rather than the skeletonized appearance noted often in the past. Particular attention in the preoperative assessment must be directed at evaluation of the position of the hyoid bone and submandibular glands as well as the patient’s overall body habitus. Concurrent rhytidectomy, neck lift or platysma plication may be required if significant skin laxity is present.