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Background: Despite the central role of the platysma in face and neck rejuvenation, much confusion exists regarding its surgical anatomy., Objectives: This study was undertaken to clarify the regional anatomy of the platysma and its innervation pattern and to explain clinical phenomena, such as the origin of platysmal bands and their recurrence, and the etiology of lower lip dysfunction after neck lift procedures., Methods: Fifty-five cadaver heads were studied (16 embalmed, 39 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology and sheet plastination., Results: In addition to its origin and insertion, the platysma is attached to the skin and deep fascia across its entire superficial and deep surfaces. This composite system explains the age-related formation of static platysmal bands, recurrent platysmal bands after complete platysma transection, and recurrent anterior neck laxity after no-release lifting. The facial part of the platysma is primarily innervated by the marginal mandibular branch of the facial nerve, whereas the submandibular platysma is innervated by the "first" cervical branches, which terminate at the mandibular origin of the depressor labii inferioris. This pattern has implications for postoperative dysfunction of the lower lip, including pseudoparalysis, and potential targeted surgical denervation., Conclusions: This anatomical study, comprised of layered dissections, large histology, and sheet plastination, fully describes the anatomy of the platysma including its bony, fascial, and dermal attachments, as well as its segmental innervation including its nerve danger zones. It provides a sound anatomical basis for the further development of surgical techniques to rejuvenate the neck with prevention of recurrent platysmal banding., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: The hemostatic net, which was initially described as a method to decrease hematoma rates in facelift and necklift procedures, has since increased in practice and applicability. However, despite its demonstrated safety and efficacy, there exists significant skepticism with regard to its necessity; in particular, there is concern that the transcutaneous sutures may restrict dermal perfusion., Objectives: The goal of this study was to assess flap perfusion, both before and after application of the hemostatic net, to determine if there was an objective decrease in tissue perfusion in relation to application of the hemostatic net, as measured by laser-assisted angiography (LAA)., Methods: Eight patients underwent cervicofacial flap reconstruction of cutaneous malignancy defects, after which a hemostatic net was applied. All patients underwent evaluation with LAA both before and after application of the net. The average relative and absolute perfusion of different zones of the flap were calculated., Results: The average absolute change in relative perfusion was +6.41%, +0.31%, and +3.28% for zones 1, 2, and 3, respectively, after application of the hemostatic net. There was no statistical difference in relative tissue perfusion after application of the net. There were no instances of delayed healing, infections, ischemia, necrosis, or hematoma. One patient developed a seroma after the net was removed. No patients had scarring or residual track marks from the transcutaneous sutures., Conclusions: With LAA, we were able to objectively demonstrate no significant decrease in tissue perfusion after the application of the hemostatic net., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Patients undergoing facial rejuvenation surgery are at unique risk of perioperative complications from the anesthetic utilized during the procedure. The ideal anesthetic agent is one that is safe to use in the outpatient population, has analgesic, sedative, and anesthetic properties, yet does not cause respiratory depression or hemodynamic irregularities., Objectives: A retrospective analysis of a large outpatient facelift cohort was performed to determine if dexmedetomidine, an α 2-adrenergic receptor agonist, meets the criteria of an ideal adjunct for propofol in a total intravenous anesthesia protocol., Methods: The charts of 791 patients who underwent rhytidectomy with total intravenous anesthesia were reviewed and data of patients' operative risk factors, perioperative management including medications administered, perioperative vital signs, and postoperative adverse events were recorded. Statistical univariate analyses were performed on the data., Results: Dexmedetomidine resulted in a significant reduction and maintenance of blood pressure from onset of anesthesia until discharge from the postanesthetic recovery unit. The utilization of opioids and anxiolytics was significantly less than previously reported for other anesthetic types. The postoperative nausea/vomiting rate was 0.8% (6 patients). There were no postoperative admissions for inpatient management. Forty-three (5.3%) patients required a conversion to general endotracheal anesthesia and statistically significant risk factors include increased BMI, American Society of Anesthesiologists Class II or higher, preoperative hypertension, and multiple procedures performed., Conclusions: This study demonstrated the safety and efficacy of dexmedetomidine in a large cohort of outpatients undergoing facelift. Dexmedetomidine meets the requirements for an ideal adjunct anesthetic within a total intravenous anesthesia protocol., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: For age-related volume loss, fat grafting is now recognized as an integral adjunctive procedure with facelift surgery. However, when there is continued and unpredicted volume loss postoperatively, the surgeon has limited options for restoring this lost volume., Objectives: Poly-l-lactic acid (PLLA) is a proven biostimulator that creates volumetric enhancement. This study is undertaken to demonstrate that PLLA is a safe and efficacious option for maintenance of post-facelift volume loss., Methods: A retrospective review was conducted to identify all patients who underwent facelift surgery with fat grafting and postoperative PLLA injections from 2010 to 2018 by a single surgeon. Demographic and clinical data were collected and analyzed., Results: This review identified a total of 241 patients who had undergone a facelift with fat grafting and PLLA injections. Of these, 190 patients were treated with PLLA after facelift and fat grafting, while 51 patients received PLLA injections before their operation. We identified 5 common indications for use of PLLA after facelift surgery and fat grafting. These included unexplained early fat graft loss, significant weight loss in the postoperative period, normal aging process, and patients who had a high perioperative lean body mass. Additionally, PLLA was found to be an effective volumizer for site-specific areas that did not undergo fat grafting during the initial operation. There were no complications reported from the PLLA injections related to nodule formation, papules, or granulomas., Conclusions: The high degree of variability in the survival of fat grafts with facelift surgery is an accepted reality. PLLA represents a safe and highly effective solution to restore volume loss in patients who have undergone facelifts with fat grafting., (© 2022 The Aesthetic Society.)

Background: In certain patients there is an imbalance between the volume of the anterior neck and the mandibular confines that requires reductional sculpting and repositioning of the hyoid to optimize neck-lifting procedures., Objectives: A quantitative volumetric analysis of the impact of the management of supraplatysmal and subplatysmal structures of the neck by comparing surgical specimens was performed to determine the impact of reduction on cervical contouring., Methods: In 152 patients undergoing deep cervicoplasty, the frequency of modification of each surgical maneuver and the amount of supraplatysmal and subplatysmal volume removed was measured by a volume-displacement technique., Results: The mean total volume removed from the supraplatysmal and subplatysmal planes during deep cervicoplasty was 22.3 cm3 with subplatysmal volume representing 73% of the total. Subplatysmal volume was reduced in 152 patients. Deep fat volume was reduced in 96% of patients by a mean of 7 cm3, submandibular gland volume in 76% of patients by a mean of 6.5 cm3, anterior digastric muscle volume in 70% of patients by a mean of 1.8 cm3, perihyoid fascia volume in 32% of patients by a mean of <1 cm3, and mylohyoid volume in 14% of patients by a mean of <1 cm3. The anterior digastric muscles were plicated to reposition the hyoid in 34% of cases. Supraplatysmal fat reduction was 6.3 cm3 in 40% of patients., Conclusions: The study provides a comprehensive analysis of the impact of volume modification of the central neck during deep cervicoplasty. This objective evaluation of neck volume may help guide clinicians in the surgical planning process and provide a foundation for optimizing cervicofacial rejuvenation techniques., (© 2021 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: The ideal anesthetic adjunctive agent is one that has sedative, analgesic, and anxiolytic properties and produces a predictable hemodynamic response without respiratory depression., Objective: We sought to determine the efficacy of dexmedetomidine as a multifunctional sedative agent for patients undergoing facial rejuvenation surgery., Methods: A retrospective study was conducted of 50 randomly selected, nonintubated patients undergoing extended superficial musculoaponeurotic system (SMAS) face lifts by the same surgeon. Forty-seven of the 50 patients were women; the mean age was 56.1 years. All patients received dexmedetomidine as the primary sedative agent. A total of 73 ancillary procedures were performed. Intraoperative and postoperative respiratory rate, hemodynamic stability, postoperative emergent rates, and adverse events were evaluated., Results: A continuous, titrated infusion of dexmedetomidine (0.2-0.7 mug/kg/h) controlled blood pressure with a systolic blood pressure of 120 mm Hg or less over the course of the 3- to 6.7-hour procedure in all but 8 patients, who required an intraoperative antihypertensive agent. The mean (SD) dose of midazolam and fentanyl was 4.4 (1.3) mg and 201 (64) mug, respectively, and a propofol drip was titrated for additional sedation. All patients maintained a normal respiratory rate, without obstruction or desaturation, and were taken from the operating room directly to a stage 2 recovery area. No patient required antiemetics for postoperative nausea or emesis. There was one complication consisting of a hematoma that occurred 72 hours postoperatively., Conclusions: In our population of nonintubated patients undergoing facial rejuvenation surgery, dexmedetomidine fulfilled the properties sought in a sedative agent.