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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

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: 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: 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

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.

Background The development of effective antiretroviral therapy for the treatment of human immunodeficiency virus (HIV) has allowed for prolonged and healthier lives for affected patients. However, significant side effects from the drugs have been well documented, including syndromes of abnormal fat distribution. Cervicodorsal lipodystrophy, or “buffalo hump” deformity, is a common presentation of lipodystrophy syndrome and can cause significant disfigurement to the patient. Surgical correction has been the mainstay of treatment. Objective The authors report on the use of excisional lipectomy to correct cervicodorsal lipodystrophy. Methods Six male patients and one female patient (mean age, 47.2 years) underwent excisional lipectomy for buffalo hump deformity caused by HIV protease inhibitor use. Common complaints on presentation included disfigurement, neck pain, and difficulty sleeping. Deformity had first been observed an average of 4.75 years before presentation (range 2 to 7 years). At the time of consultation all patients were on antiretroviral regimens that included protease inhibitors. Results Excisional lipectomy of the hypertrophied cervicodorsal fat pad was performed on all patients, with suction-assisted lipoplasty (SAL) additionally to optimally contour the nondystrophic fat at the periphery of the resection. One patient also underwent simultaneous abdominoplasty, another underwent rhytidectomy with autologous fat transfer, and one patient received malar autologous fat injections. The average operative time for all procedures was 2.7 hours (range 1.0 to 5.8 hours). Complications included seroma in three cases and wound dehiscence in one patient, none of which required reoperation. At an average of 26.6 months of follow-up, all patients report satisfaction with their results, and there have been no recurrences. Conclusions Cervicodorsal lipodystrophy is a well-described complication of extended use of HIV protease inhibitor therapy. Patients may seek consultation with plastic and reconstructive surgeons for correction of the aesthetic and functional morbidity associated with the deformity. Because of the fibrous nature of the hypertrophied cervicodorsal fat and the high rate of recurrence after SAL alone, an approach with excisional lipectomy (with or without SAL) may provide improved results and superior long-term outcomes.

The author discusses his view that the risks of aggressive subplatysmal surgery are not balanced by substantial benefits. He emphasizes that aesthetic standards for neck contouring should not be based upon unrealistic criteria for the “youthful neck” but modified according to each patient's unique physiognomy. He stresses the need for reporting of large case series, standardized evaluation and surgical technique, and accurate data on complications of aggressive subplatysmal surgery before surgeons embrace these radical contouring techniques.

Background The “pixie-ear” deformity has been described by its “stuck-on” or “pulled” appearance, due to the extrinsic pull of the cheek and jawline skin flaps on the earlobe attachment point (O), the otobasion inferius. The tension results in migration of the earlobe attachment point from a posterior cephalad position to an anterior caudal position. Recently, the 2 components of the earlobe, the attached cephalic segment (I to O distance) and the free caudal segment (O to S distance), have been defined. Objective We describe a novel technique involving differential insetting of the cheek and jawline skin flaps to the earlobe and secondary intention healing to create an aesthetically pleasing cephalic attached segment. Methods Rhytidectomy was performed using an extended superficial muscular aponeurotic system (SMAS) technique along with jawline undermining. The earlobe soft-tissue–retaining ligaments to the mastoid were released to the level of the new otobasion inferius to creat a cephalic attached segment less than 1.5 cm, which allowed the caudal free segment to approximate 0.5 cm. Whereas the cephalic segment was directly repaired, the free caudal segment anterior and posterior skin flaps were not reapproximated and were to heal by secondary intention. Results In a series of 20 consecutive patients, excellent aesthetic results were obtained using this approach without healing complications, hypertrophic scarring, or “pixie-ear” deformity. Conclusions Our approach for cheek and jawline skin flap fixation to the earlobe eliminates any vector of pull on the free caudal segment of the earlobe and, consequently, any potential for “pixie-ear” formation. We advocate allowing the free caudal segment to heal by secondary intention, which results in the medial edge of the free caudal earlobe attaining a curved and blunt-edged appearance that is aesthetically superior to primary repair.

Background: Statistics published by The American Society for Aesthetic Plastic Surgery report a 48% increase in cosmetic procedures for 2000-2001 and a 14% increase for rhytidectomies alone. Patients aged 35 to 50 account for 30.2% of all rhytidectomies performed. Many of these patients undergo secondary rhytidectomy. Objective: We investigated differences between patients undergoing secondary rhytidectomy and those undergoing a primary rhytidectomy, and between older (more than 60 years) and younger (60 years or less) patients undergoing secondary rhytidectomy. Methods: A retrospective descriptive research design with the computer cross-filing system of the senior author (A.M.) was reviewed for patients undergoing secondary or more (ie, tertiary, quaternary, etc) rhytidectomy. A total of 113 consecutive patients were identified; charts from 98 female patients and 3 male patients, were available for review. Ages at the time of surgery ranged from 40 to 81 years, with an average of 60. Results: Among patients older than 60 undergoing secondary face lift, 41 of 53 patients (77%) had combined procedures with their most recent face lift; 39 of 53 (74%) of these patients had at least one comorbid medical condition. Among patients aged 60 or younger undergoing secondary face lift, 37 of 48 patients (77%) underwent multiple procedures along with their most recent face lift, and 16 of 48 patients (33%) had at least one comorbid medical condition. The overall complication rate was 2/101 (2%). Conclusions: There is a statistically significant increase in the number of comorbid medical conditions in older patients. The overall complication rate in patients undergoing secondary rhytidectomy compares favorably to that traditionally quoted for patients undergoing primary rhytidectomy, who on average are younger at the time of surgery. This suggests that in properly screened patients, even in older patients with combined ancillary procedures, secondary face lifting is both common and safe. (Aesthetic Surg J 2002;22:526-530.)

Although an endotragal incision is used in rhytidectomy to avoid a visible pretragal scar, patients may not understand that the superior and inferior portions of the preauricular scar cannot be hidden inside the ear. The endotragal incision is also more likely to distort normal external ear anatomy. The author explains his preference for the pretragal incision and presents his face lift technique. (Aesthetic Surg J 2001;21:564-568.).

Background: The evolution of the author's technique for minimal incision rhytidectomy is reviewed. Objective: The purpose of this article is to outline the indications, advantages, and disadvantages of this technique. Methods: A total of 749 cases covering more than 10 years of clinical experience are reviewed. A classification of patient types is proposed that includes indications and surgical programs appropriate for each patient category. Results: In properly selected patients, the technique is safe, reliable, and reproducible. Complication rates are similar to those of other standard techniques. Conclusions: Minimal incision rhytidectomy with lateral SMASectomy is a useful technique that the plastic surgeon can add to his or her armamentarium.

Minimal incision rhytidectomy has the primary advantages of preserving the posterior hairline and avoiding retroauricular scars. This short-scar face lift with lateral SMASectomy and platysma resection, performed by the author on more than 500 patients in the past 3 years, provides the versatility of traditional SMAS flap undermining and the safety and rapidity of SMAS plication.

Background: Patients who have successfully undergone gender reassignment surgery seek further aesthetic refinements to suit their new gender role. Objective: The study evaluated secondary aesthetic procedures, laryngeal surgery, and adjuvant hormone therapy in 22 male-to-female gender reassignment change patients. Methods: Thirty-two aesthetic procedures performed in 22 patients were evaluated for operation type, surgical technique, complications, and satisfaction rates. Aesthetic procedures included rhytidectomy, platysmaplasty, rhinoplasty, brow lift, blepharoplasty, cheek or chin surgery, and body contouring. Results: A wide range of secondary aesthetic procedures was successfully performed with only 1 minor complication and 1 major psychological depressive episode. Conclusions: Secondary surgery in gender reassignment patients extends the frontier of aesthetic surgery and provides lessons that can be extrapolated to facial and body con-tour aesthetic surgery in the general patient population.

Background: Many men seek treatment for excess submental tissue—the so-called “turkey gobbler” deformity. However, these patients are frequently unwilling to undergo the definitive treatment, a rhytidectomy and platysmaplasty with submental lipectomy. Objective: The purpose of this article is to present an update on an alternative treatment, originally reported in 1971, called the T-Z-plasty. Methods: The procedure, which is performed with the patient under local anesthesia, entails excision of excess fat and skin, tightening of the platysma, a Z-plasty to prevent contracture, and wound closure with excision of redundant skin. Results: In a series of more than 100 patients, the results have been consistently superior with extremely low morbidity. There was 1 postoperative hematoma requiring exploration and, in the same patient, a subsequent seroma requiring multiple aspirations. In addition, 2 patients required scar revision. Conclusions: The T-Z-plasty is a simple outpatient procedure with consistently low morbidity and high rates of patient satisfaction. Although the procedure does not offer the same result as the definitive treatment, rhytidectomy and platysmaplasty, it is a reasonable compromise that directly and effectively addresses the primary complaint.

Background: Despite several studies that indicate the potential harmful effects of combined procedures, simultaneous rhytidectomy and skin resurfacing have been used with increasing frequency as surgeons seek efficient ways to treat facial aging. Objective: In this study we examined the effects of combined cutaneous flap elevation and skin resurfacing in the rabbit model. Methods: Rabbits were divided into 1 control and 4 treatment groups, with 6 rabbits in each group (n = 6). Rabbits in the control group underwent elevation of a 10 × 18-cm flank pedicle flap based on the thoracodorsal vessels, with shortening of the flap length by 10% and suturing of the flap back into its original position. Rabbits in the treatment groups underwent additional skin resurfacing by CO 2 laser with 3, 4, or 5 passes or chemexfoliation with a single application of Baker-Gordon phenol peel solution. Seven days later, tissues were harvested from distal, middle, and proximal regions at the superior, intermediate, and inferior areas of each flap, as well as from proximal and distal regions of the superior incision. Results: Fluorescein injection revealed defects in flap perfusion only in flaps that underwent phenol peel. Histologic examination of tissues revealed increasing degrees of skin injury and delay in skin healing with an increasing number of passes with the CO 2 laser. Extensive inflammation, delayed reepithelialization, and skin healing were noted with phenol peel. Increased depth of injury and delay of healing correlated with the most dependent portion of the flap. Furthermore, incisional tensile strength was significantly diminished with a greater number of laser passes as well as with phenol peel. Conclusions: Our data suggest that caution must be used when flap elevation and skin resurfacing are performed simultaneously, especially with application of skin resurfacing in the dependent region of the flap. Incisional strength can be diminished, and skin healing delayed, to the extent that wound dehiscence may occur, compromising the desired result.

Background: Characteristics of the aging face include not only senescence and flaccidity of the skin, but also sagging of deeper tissues, especially in the fascial and fatty layers. Objective: This study was undertaken to evaluate the different surgical approaches to the aging face, specifically the techniques available for correction of the prominent nasolabial fold, which is a significant sign of facial aging. Methods: Through a total of 7446 cases in more than 40 years of experience in the surgical correction of the aging face, the senior author has emphasized the importance of the repositioning of the skin and the facial soft tissues. After appropriate treatment of the superficial musculoaponeurotic system (SMAS) and the malar fat pad has been completed, adequate placement of the skin flaps is done by rotation, as described in the round-lifting technique, rather than by direct traction. The anatomic basis of this correction is discussed. Results: Traction of the SMAS was found to soften the appearance of the nasolabial fold to varying degrees, but other complementary procedures such as collagen injection or fat grafting often were necessary to achieve a more satisfactory correction. Durability of nasolabial fold correction with simple SMAS traction varied with each individual and his or her unique aging process. Simple traction of the SMAS did not include treatment of the fascial fatty layer. The senior author has included the treatment of the fascial fatty layer in his standard rhytidectomy over the last 2 years, with improved aesthetic results. Again, long-term correction by this technique is related to the aging process, and the final result was deemed superior to treatment of the SMAS alone. Direct excision of the nasolabial fold was performed in patients ranging from 35 to 60 years of age who had extremely prominent folds. In these very select cases, the results were considered satisfactory to both the surgeon and patient, with correction of the fold and acceptable scars. Conclusions: There is as yet no ideal solution for the surgical correction of the naso-labial fold component of the aging face. However, all of the techniques described are considered safe and have precise indications. It should be stressed to the patient that the nasolabial fold is part of the anatomy of the face and that the goal of treatment is to soften the appearance of the fold, not to eliminate it completely.

A modification of the tumescent technique for body contouring has been adapted for patients undergoing face lift. Thirty women, average age 56 years, were prospectively studied, with a 1-year follow-up. All surgery was performed in a private ambulatory operating room facility. The patients were under intravenous sedation with a board-certified anesthesiologist in attendance at all times. The preferred solution was 0.3% lidocaine 1/250,000 epinephrine (average volume injected 500 mL). The solution was a mixture of Ringer’s lactate 400 mL plus 2% lidocaine 50 mL and 1% lidocaine 50 mL plus 1:1000 epinephrine 2 mL. The average lidocaine dose per patient was 29.4 mg/kg. Serum lidocaine levels demonstrated a 1-hour peak at 2.7 μg/mL (no value exceeded 3.3 μg/mL). The technique began with superficial liposculpture followed by independent skin-lateral superficial musculoaponeurotic system-ectomy/platysmaplasty with wide skin undermining. Average operating time was 1 hour and 48 minutes. No operative complications were encountered. Excellent anesthetization was achieved in all patients without postoperative hematomas or nerve injuries. Tumescent cervicofacial rhytidectomy has been found to be a safe and effective rhytidectomy procedure that offers several advantages when compared with nontumescent techniques: avoidance of general inhalational agents, reduced operative bleeding and operative time, improved technical ease of superficial liposculpture and surgical dissection, and minimal postoperative bruising and swelling.

Because of the many individual differences that patients with large breasts have (e.g., age, breast size and shape, degree of ptosis, distribution of breast tissue, skin elasticity and resiliency, body habitus, nipple sensitivity and projection, and potential to breast feed), I don't believe that any one reduction mammaplasty technique is ideal for every individual. Recently I was a guest at an excellent plastic surgery residency program. During a presentation on reduction mammaplasty, I asked the residents which techniques they favored. They responded that they perform a large number of reductions and used the inferior pedicle technique routinely. They also said that they rarely used a free nipple grafting technique on patients. During residency, one needs to learn what “works” consistently and meets with a high degree of patient satisfaction. Nowhere is it more true than in surgical training that repetition first instills competence, then confidence. Well-founded confidence resulting from a routinely successful surgical procedure provides an excellent basis for future critical analysis of long-term results and consideration of other options that may lead to even better results in a given patient. This is especially true in reduction mammaplasty, as well as in rhytidectomy and other aesthetic plastic surgery procedures for which a variety of proven techniques exist. During the past several months, I have performed superior pedicle, inferior pedicle, vertical bipedicle, and free nipple graft reduction mammaplasties on patients in my practice. Each procedure was selected with regard to what would give the patient the best result. I do not use either the circumareolar reduction or the circumareolar and vertical scar techniques, but I appreciate efforts to minimize scarring. ### Horizontal Bipedicle (Figure 1) Figure 1 Illustration of short pedicle demonstrates the difficulty sometimes encountered in the folding process. When the horizontal pedicle is longer, it is easier to fold and bring the medial and lateral …

Ninety-seven women seeking rhytidectomy, blepharoplasty, or both completed two measurements of body image prior to their initial consultation. Results were compared with the normal scores for each of the measurements and with a sample of 32 women seeking rhinoplasty. Results indicated that women seeking rhytidectomy, blepharoplasty, or both to improve aging facial features reported a greater investment in and satisfaction with their overall appearance than women in a normattive sample. As was consistent with the findings of previous investigations, when asked about the specific body feature for which they were considering surgery, patients who wished to improve the appearance of aging facial features reported significantly greater dissatisfaction with their appearance feature than the normative sample but significantly less dissatisfaction than patients undergoing rhinoplasty. Patients wishing to improve the appearance of aging facial features seem to present for cosmetic surgery with different body image concerns than patients undergoing other types of cosmetic surgery.

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgery procedures and concepts. After studying this article, the participant should be able to: 1. Recognize the characteristic features of postoperative facial disharmony created by the classic facialplasty techniques. 2. Appreciate the potential advantages of endoscopic subperiosteal mid facial dissection techniques for secondary and tertiary facialplasty based on the authors’ experience. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 27. We are seeing an increasing number of patients for secondary and tertiary rhytidectomy. Conventional techniques for secondary rhytidectomy exaggerate central oval laxity and lateral tightness. Endoscope-assisted subperiosteal techniques in a “virgin” plane of dissection permit a vertical lift to correct aging facial changes without objectionable aesthetic sequelae. In the past 3 years we have performed secondary and tertiary rhytidectomies on 23 patients using endoscope-assisted subperiosteal techniques. Results have been excellent with minimal complications.

Vincent C. Giampapa, MD, Montclair, NJ, is a board-certified plastic surgeon. The underlying mechanisms involved in the aging neck include increased laxity in the skin, buildup of subcutaneous fat in the subdermal, submental, and preplatysmal planes, and a lack of tone and lengthening of the platysma muscle.1 Due to these factors, loss of a well-defined cervicomental angle and a decrease in the definition of the inferior mandibular border can be observed. Traditional surgical techniques focus on the redraping of the skin through preauricular incisions and the tightening or plicating of the muscle through a myriad of techniques, all which fail to achieve reliable long-term results.2–4 Key elements for long-term success with the suspension technique include proper patient selection and appropriate attention to the technical details of the procedure. The suture suspension technique is an excellent option for the patient who would like to avoid a face lift incision and whose primary signs of aging have occurred in the neck and mandibular area. It is also an excellent choice for a patient who has undergone a previous rhytidectomy with an unsatisfactory result at the level of the cervicomental angle and mandibular border. When I examine a patient with neck laxity, the first step is to check the depth of the natural cervicomental angle. This can be easily accomplished with a cotton applicator and gentle pressure. The deeper the cervicomental angle, the better suited the candidate for this procedure. A deep cervicomental angle will take up the excessive skin and muscle laxity and allow for a new neck contour with no postoperative redundancy of either of these key structures. The suture suspension technique is an excellent option for the patient who would like to avoid a face lift incision and whose primary signs of aging have occurred in …

Carl Troilius, MD, Malmoe, Sweden , is an ASAPS corresponding member. Until recently, surgeons had few options for facial rejuvenation in younger patients who were not ideal candidates for rhytidectomy. Tissue fillers now offer many advantages for these patients, who do not have advanced skin laxity, jowls, nasolabial folds, or platysmal bands but who do have early subcutaneous ptosis and atrophy, skin folds, and wrinkles. Today's market offers a variety of soft-tissue fillers, which can be divided into 3 types: autologous, allogenic, and synthetic. The ideal soft-tissue filler would be biologically inert and noncarcinogenic, and it would elicit no immune response. It would be resistant to resorption, would not migrate, and would not support growth of microorganisms. It would be easy to shape, remove, and sterilize. Unfortunately, our options today are less than ideal. There is no soft-tissue filler in existence that meets all of these criteria; the selection process therefore requires a compromise with respect to some of them. When one reviews the published literature, it is evident that different physicians emphasize different characteristics regarding the selection of a soft-tissue filler. Several authors1,2 have reported aesthetically pleasing and stable long-term results with autologous free-fat transplantation. Good results have also been obtained by injecting a …

Anterior belly of the digastric muscle (ABDM) variations have been reported to occur in as few as 2.7% to as many as 69.6% of individuals. Therefore, it is important to understand the anatomical diversity of ABDM variants, particularly with regard to head and neck surgery. The report documents a unilateral duplication of the ABDM with an oblique belly which crosses the midline. Measurements of muscle length, width, orientation and inferior surface area are documented. ABDM variants may cause confusion during surgeries, including submental lipectomy, rhytidectomy, surgical alteration of the cervicomental angle via partial resection of the ABDM, muscle transfer for reanimation of the mouth and submental artery flap procedures. Therefore, knowledge of this particular variant may aid in surgical planning as well as prevent confusion and disorientation during operations in the submental region.

I completely agree with using a more superficial technique for the neck and lower portions of the face. I will often undermine all the way around, defat, and perform superficial musculoaponeurotic system work in the lower portions of the face. But when it comes to correcting midfacial aging, primarily nasolabial fold problems, inferior locations of the nasal jugal line, concavity in the lower lid, and laxity in the lateral canthal area, I perform the subperiosteal dissection. My approach can be performed either through a subciliary lower lid incision or through a gingival buccal incision. Subperiosteal dissection is then carried out over the maxilla, malar zygomatic, and lateral orbital rim area; the arch itself is dissected subperiosteally in an anterior-to-posterior direction. Through the temporal incision, the plane of dissection is superficial to the deep temporal fascia. This is carried inferiorly to the sentinel vein. The posterior one third of the arch is then identified. The periosteum …

The superficial/skin level rhytidectomy is a safe procedure, with a reasonably short recovery time and predictably excellent results. My dissection is above the superficial musculoaponeurotic system (SMAS) plane over the checks, the mandibular border, the chin, and the neck. I dissect through the nasolabial crease on to the upper lip, and all the way across the neck, through a submental incision. This allows direct removal of fat from the labial mandibular fold and the jowls to improve the contour in those areas. Obviously a sub-SMAS dissection technique prohibits the surgeon from individualizing the fat contouring. Differential vectors are used for tension on the skin and tension on the SMAS. This is very important. Across the cheeks, the SMAS vector is superolateral, whereas …