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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.

Introduction: Tranexamic acid (TXA) is a common adjunct to assist in hemostasis in a wide variety of applications. Although TXA has gained more popularity in facial cosmetic surgery, there are limited studies evaluating the effects of TXA in rhytidectomy patients, especially when used in tumescent solution. Purpose: The purpose of this study was to evaluate the effects of TXA on surgical time, postoperative ecchymosis, and need for aspiration when used in tumescent solution during cervicofacial rhytidectomy procedures. Materials and Methods: The authors designed a retrospective cohort study from an eligible population of all patients treated with cervicofacial rhytidectomy using tumescent solution at Williamson Cosmetic Center in Baton Rouge, LA, from January 1, 2019, to December 31, 2019. The outcome variables were surgical time, need for postoperative aspiration, and the duration of bruising postoperatively. The primary predictor variable was the use of TXA in the tumescent solution. Statistical analysis was performed using t tests and chi-square analyses. Results: Overall, 70 patients were included in the study with a mean age of 61.4 ± 7.2 years and 90% were female. Forty-five patients were in the TXA group and 25 in the non-TXA group. The use of TXA in tumescent solution was statistically significant for reducing ecchymosis ( p < .001). The majority of patients in the TXA group (60%) had bruising cleared by day 7, whereas the majority of patients in the non-TXA group (52%) had bruising cleared by day 28. There was a statically significant reduction in frequency of postoperative aspiration in the TXA group (8.9% in TXA group vs 40.0% in the non-TXA group, P = .002). The study did not demonstrate a significant difference in surgical time between the two groups. Discussion: Although there is a lack of recognition of the potential benefits of TXA, there has been an increased off-label use by numerous surgical specialties. Routes of administration include topical, oral, intravenous, local infiltrative, and by tumescent anesthesia. Improvements in intraoperative hemostasis and postoperative ecchymosis are some of the main benefits of TXA. Conclusions: Utilizing TXA in tumescent solution in patients undergoing cervicofacial rhytidectomy procedures is associated with an improvement in postoperative ecchymosis duration and a decreased need for postoperative aspiration compared with the non-TXA group.

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

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind thi...

Facial rejuvenation procedures have become more commonly performed due to an increasing elderly population and greater general public acceptance. As a result, patients are now increasingly undergoing secondary and tertiary rhytidectomies to treat natural aging and/or to correct complications from prior procedures. Revision face and neck lifts are more complex by nature of the procedure and require a comprehensive preoperative assessment for enhanced outcomes. In this review, we discuss the preoperative evaluation, surgical challenges encountered, primary face and neck lift deformities, and their surgical management for patients undergoing secondary face and neck lifts.

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

The true effect of aging and other patient factors on submandibular gland (SMG) volume is unclear. We sought to evaluate the effects of age, body mass index (BMI), sex and race on SMG volume using computed tomography (CT) imaging. We conducted a retrospective longitudinal study of adult subjects with multiple CT images of the neck at least 7 years apart. Subjects with history of salivary gland pathology, neck dissection, head and neck radiation, active infection or dental artifact were excluded. Three-dimensional volumes were measured. Age, BMI, sex and race data were analyzed to track their longitudinal effect on SMG volume. The study comprised 64 patients (Females n=36; Males n=28) with mean age of 47.1 and 58.5 at each respective time point (mean difference 11.4). Mean SMG volume increased from 10.1 ml to 10.5 ml (P

Dynamic facial reanimation is one of the key treatment goals for lower facial palsy patients. Currently, temporalis myoplasty is the only non-free flap muscle transfer option considered feasible with good outcome. Although masseter transfer has been attempted, it was associated with poor results or considered to be technically challenging. This cadaveric study aimed to re-evaluate the feasibility of masseter transfer by looking at its geometry and offer a new approach to the muscle. Twenty-four masseter muscles were dissected in 12 fresh frozen cadavers through a preauricular rhytidectomy incision and a pre-parotid approach. The muscle’s insertion and origin attachments were divided to allow for rotation toward the modiolus. The angle of rotation, vector of pull, transfer distance, and length of the muscle were measured. The mean angle of rotation was 40.1 degrees, and the mean vector of pull was 66.7 degrees. The mean transfer distance from the muscle’s origin and insertion attachments was 30 and 62.5 mm, respectively. The mean lengths of the muscle’s anterior, posterior, superior, and inferior borders were 55.3 mm, 46.3 mm, 42.6 mm, and 42 mm, respectively. The distance, angle of transposition, and vector of pull measurements support the feasibility of pedicled masseter transfer in achieving optimal contraction vector with less risk of pedicle injury in lower facial palsy reconstruction. Tendon and fascial grafts can be adjuncts in cases where the masseter muscle length is short. The pre-parotid approach to the pedicled masseter transfer allows for a shorter operative time, which is desirable, particularly in the infirm. Level of evidence: Not ratable .

Although the effect of normal aging on the appearance of the ear lobule is well known and defined, this often a neglected aspect of facial rejuvenation. Rhytidectomy offers a great opportunity to surgically enhance the aging earlobe. The objective of this study was to provide a step-by-step description of the execution of the three-triangle rotation flap technique for aesthetic ear lobule reduction. The three-triangle rotation flap technique is described in a step-by-step fashion and illustrated by photographs and videos. All ear lobule reduction procedures that took place at our practice from December 2016 to February 2020 were retrospectively reviewed. A total of 16 patients underwent bilateral ear lobule reduction during face lift, neck lift, or both, and 7 patients underwent bilateral lobule reduction in isolation. None of the patients experienced complications, and revisions were not performed or required. The three-triangle rotation flap technique relies on simple principles that can be adjusted to address all shapes and degrees of true ear lobule ptosis, as well as patient desire. It is employed in isolation or synchronous with rhytidectomy. When performed during rhytidectomy, it provides lobule stability and fixation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Rhytidectomy techniques have evolved significantly since the procedure was first described in the early twentieth century. Techniques vary based on surgeon preference, patient characteristics, and the desired outcome. As facelifts are embraced by the general public and the frequency of rhytidectomy increases, attention to male patient-specific technique is critical. Male and female facelift techniques are fundamentally similar; however, there are nuances to patient selection and technique in males that guide the surgeon to improved postoperative outcomes. Attention to incision placement, trichophytic technique, and adjunct procedures will improve overall cosmesis in the male patient. Understanding of potential risks and their likelihood in the male patient will also minimize complications and allow for rapid recovery.

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.

Rhytidectomy, or facelift in layman's terms, is performed to reverse the appearance of facial aging. A lift can improve volume shifts with age, reposition sagging tissues, and eliminate skin redundancy. There are limitations to what can be accomplished with a facelift alone. Commonly performed adjuncts including surgery to the eyelids or brows, liposuction, and even rhinoplasty can be combined to improve the result. Further options exist that are more commonly overlooked or rarely offered to patients but can greatly enhance the surgeon's ability to remove years from the face. This article will cover some additional options that every facial plastic surgeon should be familiar with and experienced to both describe and perform.

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.

Background Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking. Methods A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors. Results A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events. Conclusions This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices. Clinical question/level of evidence Risk, III.

Patients who have previously undergone superficial parotidectomy may also seek facelift surgery for facial aging and rejuvenation. These patients present unique challenges compared to a standard facelift patient. Most concerning is the location of facial nerve branches, which may be superficial and displaced. In addition, significant contour deformities and abnormal scar patterns may be present. The purpose of the study is to review our series of patients and assess potential morbidity and safety of facelift surgery in superficial parotidectomy patients. A retrospective case series was performed reviewing all patients who underwent facelift surgery following superficial parotidectomy from 2000 to 2017. Data were collected for: postoperative facial nerve deficit, soft tissue contour and scar deformities, facelift technique, ancillary soft tissue augmentation procedures and pre- and postoperative photographs. An evidence-based treatment algorithm to address specific problems in this patient population was developed. A total of seven patients were identified who underwent facelift surgery following parotidectomy. Patients underwent one of the standard SMAS procedure on the non-parotidectomy side, and surgical modifications were made to address the parotidectomy side; soft tissue augmentation was performed in two patients. Precautions to identify the facial nerve and prevent injury, including nerve monitoring and stimulation, were utilized in all seven patients. No permanent postoperative facial nerve injury was noted. Facelift following superficial parotidectomy was safely performed in all cases. Special consideration should be given to contour deformities, facial nerve location and scar placement. However, if approached properly, these patients can still be considered as suitable candidates for facelift surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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 As the pursuit of higher self-attractiveness grows, an increasing number of middle-aged people are unsatisfied with their facial contour and required osteotomy. However, for these patients, performing osteotomy only would accelerate the aging process. Herein, the authors put forward simultaneous surgery for contouring the prominent zygoma and mandible with facelift for elderly patients. Methods Patients were divided into 3 groups: group A with prominent mandible, group B with protruding zygoma, and group C with prominent mandible and zygoma. By implementing intraoral incision, outer cortex grinding, mandibular angle curved osteotomy, and reduction malarplasty were performed. Through facelift incision, the zygomatic arch was reduced and facelift was conducted. Patients were followed up for at least 12 months and were asked to evaluate their experience. Results From March 2009 to January 2018, a total of 55 patients received the surgery: 17 patients received mandibular angle osteotomy and facelift, 22 received malarplasty and facelift, and 16 underwent mandible and zygoma contouring and facelift. The recovery process was uneventful, with only 2 patients in group A and 1 patient in group C who suffered from a hematoma, which relieved without surgical intervene. The postoperative images showed smoother facial contours. Patients were satisfied with surgical outcomes. Significant improvements were seen comparing pre- and postoperative photos. Conclusion Conducting osteotomy and rhytidectomy concurrently results in smooth facial contour and youthful appearance which improves patients' self-image and contributes to high patients' satisfaction. With a low complication rate and no long-term complication, the surgery is safe to perform. Level of evidence Level IV, the case study.

BACKGROUND The improvement of nasolabial folds by either lateral superficial musculoaponeurotic system rhytidectomy or minimal access cranial suspension lift alone is commonly performed, but patient satisfaction is often limited in East Asians. An innovative technique, termed the cable-stayed face lift, which combines the strengths of lateral superficial musculoaponeurotic system rhytidectomy and minimal access cranial suspension lift, was developed for improved results. METHODS Between 2016 and 2019, 20 cable-stayed face lifts were performed in a single hospital. Two plastic surgeons independently evaluated postsurgery outcomes using a five-point Likert scale, where 5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse. Patient satisfaction was assessed by relevant items from the FACE-Q questionnaire. RESULTS Twenty patients with a mean age of 51 years underwent face-lift surgery. The mean follow-up ± SD was 11.3 ± 9.8 months. The five-point Likert scale score evaluated by surgeons was 3.65 ± 1.08. Patient-perceived age visual analogue scale (7.8 ± 4.4) exhibited a difference between preoperative actual age and postoperative apparent age. Patients demonstrated high satisfaction with outcome (67.5 ± 16.2) and satisfaction with lower face and jawline (76.2 ± 14.9). No major complication, hematoma, or seroma was observed. CONCLUSION The authors' approach-cable-stayed face lift-offers a good alternative to provide a more effective effacement of nasolabial folds, by lifting the nasolabial folds with parallel vector and lower face and neck with the vertical vector. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Resident Aesthetic Clinics (RACs) are an important element for training in plastic surgery residency programs. RACs provide increased exposure to aesthetic surgery as well as greater autonomy in clinical decision making. In an effort to increase RAC volume and thereby enhance resident education, we made two important changes to our operations. First, we reduced the resident surgeons’ fees by 75%, and second, we began utilizing social media to promote our residency program and their involvement in aesthetic surgery. Total RAC cases were queried using a RAC specific billing code and individual chief resident case logs for quality control. To generate an accurate timeframe, cases and procedures were compared from 18 months before and after the implemented changes. We found that the number of cases and procedures increased by 135% and 255%, respectively. The five most commonly performed procedures were liposuction, augmentation mammoplasty, abdominoplasty, mastopexy, and rhytidectomy. By both reducing the resident surgeons’ fee and promoting the RAC on social media, we have demonstrated a pronounced increase in both cases and procedures performed by residents. As other institutions seek to increase resident exposure to aesthetic surgery, they may consider similar changes to these. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors: www.springer.com/00266 ."

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.

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.

OBJECTIVE(S) To characterize procedural trends in facial plastic and reconstructive surgery procedures in relation to the United States economy. METHODS Retrospective cohort study examining annual procedure rates were determined from the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Procedural Statistics from January 1 2007 to December 30, 2017. Procedures were compared to economic activity of the United States as measured by gross domestic product (GDP) were compared using Kolmogorov-Smirnov goodness of fit testing and piecewise multivariate regression modeling. RESULTS Annual trends in procedural rates showed an overall decrease in the rates of rhinoplasty (284,960 to 218,924), blepharoplasty (240,660 to 209,571), and otoplasty (28,571 to 23,433) from 2007 to 2017. Total cosmetic surgery remained fairly stable, while minimally invasive cosmetic surgery increased in frequency over the study period. On piecewise regression analysis, rhinoplasty (P = .02), rhytidectomy (P = .007), invasive cosmetic surgery (P

Touraine–Solente–Gole syndrome (pachydermoperiostosis [PDP] or primary idiopathic hypertrophic osteoarthropathy [HOA]) is a rare hereditary disorder that is characterized by a triad of manifestations that consists of skin changes (pachydermia), abnormal bone and joint manifestations (periostosis and/or artritis), and digital clubbing (acropachia). Here, we report the case of 24-year-old male who presented with severe bilateral true eyelid ptosis. Physical examination revealed severe ptosis with poor function of the levator palpabrae superioris muscle, thickening of and deep grooves in facial skin (especially at the frontal region), and abnormal appearance of the scalp with accentuating folds and deep furrows (cutis verticis gyrata). Abnormal bone enlargement of the hands, knees, and feet was also observed. Frontal rhytidectomy and levator resection and advancement were performed to alleviate symptoms. At the short-term follow-up, the patient described being satisfied with the outcome of treatment. This patient will be routinely followed over the long term to evaluate disease progression. Although the cause of ptosis in most PDP is mechanical process or dysfunction, this case of PDP had bilateral true eyelid ptosis due to poor levator palpabrae superioris muscle excursion with coexisting signs and symptoms of complete form PDP. This finding highlights the need to investigate for bilateral true eyelid ptosis caused by abnormal levator palpabrae superioris muscle function in patients diagnosed with PDP. Keywords: Touraine–Solente–Gole syndrome, Clinical manifestation, Bilateral true eyelid ptosis, Pachydermoperiostosis (PDP), Primary idiopathic hypertrophic osteoarthropathy (HOA)

Facelift or rhytidectomy has been performed in some form for over 100 years. This article seeks to explore the evolution of this surgical procedure, focusing on the advances of the most recent 40 years. From minimal intervention to aggressive techniques and back to the minimally invasive again, the authors follow the journey of surgical intervention for facial rejuvenation and discuss some thoughts for the future.

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.

This article presents the data on the structural peculiarities of the mastoid region, the dependency between the thickness of the epidermis, dermis, subcutaneous fat, and size of the structural elements of the skin at various stages of its deformation that allows us to determine the digital indices for the depth of skin peeling and skin amount dissected when planning plastic and reconstructive operations skin that is carved. In order to achieve the optimal result of plastic operations, and, in particularly, of cosmetic otoplasty and lower rhytidectomy, and to minimize the development of postoperative complications, the manual skills of the surgeon are not sufficient. It is essential to know exactly morphofunctional characteristics of layered structure of certain topographic and anatomical sites, especially within mastoid area, where the main incisions are made when performing on the above-mentioned surgical interventions. After stretching the test samples of the skin taken from the mastoid region within 5 mm, we observed subtle differences between them even in the state of physiological rest. The study of the structure of the skin-fat flap samples after stretching within 15 mm demonstrated the occurrence of pathological processes in the skin epithelium and dermis. The morphological picture indicated the development of balloon dystrophy that is known as the morphological equivalent of focal necrosis. Investigation of microslides of the skin taken from and exposed to stretching within 20 mm made it possible to reveal the intensification of the previously described changes and the development of qualitatively new pathological changes both in the epidermis and in the dermis. The results obtained enable us to conclude that during operations in the mastoid area, the biomechanical properties of the skin-fat flaps should be taken into account. When the skin was stretched within 5 – 10 mm, irreversible changes did not occur, and these are optimal indicators during surgical interventions. With a flap deformation within 15-20 mm, pathological changes were observed, in some cases they were classified as irreversible that led to necrosis in the postoperative period.

The objective is to evaluate the safety of performing multiple combined facial plastic surgical procedures affecting various planes of the face including rhytidectomy, forehead contouring with browlift, cheek implants, rhinoplasty, and mandible contouring in a single setting. This is a retrospective study of patients undergoing facial plastic surgery with the senior author at Boston Medical Center from 2005 to 2017. Patients were included if they underwent all of the above procedures in one setting and had not had previous facial surgery. The primary outcome measure was local postoperative complications of tissue necrosis and wound dehiscence. The secondary outcome measures were general postoperative complications of venous thromboembolism and prolonged intubation. A total of 25 patients met inclusion criteria. Four patients experienced an infection—two patients had cheek implant infections delayed by months, one had a facelift hematoma that became infected, and one had an intraoral incision infection. One patient suffered from pulmonary embolism 2 months after surgery in the setting of hormone replacement therapy. All patients were extubated at the end of the case and none required reintubation. All patients had good cosmetic results. Despite elevating multiple planes of the face at the same time, there were no complications related to vascular supply in any of the patients. Complications were limited to those known to occur with the individual procedures. This study demonstrates that concurrent procedures that elevate multiple planes in the face in a single setting may be performed safely and with good cosmetic outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

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.

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 The demand for facial plastic surgery has dramatically been increased in recent years. Over the last decade, numerous methods have been improved for facelift surgery. Despite these modifications, skin excision technique has not changed significantly. In this study, authors have tried to introduce a new technique regarding skin excision at the initial step of facelift surgery. METHODS A prospective study from 2012 to 2017 on 52 patients was carried out to apply a new technique for facelift ''Prefabricated skin excision method'' for all eligible patients undergoing facelift surgery. The skin calling for excision was marked by the surgeon, and then, an analgesic drug was administered. Then, excision of the marked part of the skin was performed and afterward the dissection of the superficial musculoaponeurotic system (SMAS) was performed with the direct exposure. RESULTS All patients were female, and 50 (96.1%) cases were primary face lift and 2 (3.9%) cases were secondary. There were no complications among the patients. CONCLUSION Facilitating the manipulation of deep layer, using this technique led to the further exposure of the surgical site, and more preferable hemostasis was achieved as well.

BACKGROUND Postoperative hematoma remains the most common complication in rhytidectomy, prompting surgeons to use a multitude of adjunctive measures to prevent its occurrence. The goal of this systematic review was to determine which of these measures are supported by strong evidence, and to highlight those that remain unsubstantiated and require further investigation. METHODS A systematic search was performed of the PubMed and Embase databases for English literature from 1975 to March of 2020 containing designated keywords, and focusing specifically on adjunctive measures aimed at preventing hematoma in rhytidectomy. The resultant articles were then systematically screened according to predefined inclusion and exclusion criteria to determine eligibility for inclusion in the study. RESULTS The keyword search yielded a total of 2391 articles. Title and abstract screening resulted in 103 articles that were eligible for full-text review. Ultimately, 48 articles met final inclusion criteria. The articles were categorized into their particular mode of intervention: fibrin tissue sealants, perioperative medications (anesthetics, antihypertensives, miscellaneous medications), and intraoperative maneuvers (hemostatic agents, preinfiltration, intraoperative maneuvers, and drains). Nine studies were indexed as evidence Level II and 24 as evidence Level III. The remainder of studies constituted Level IV evidence. CONCLUSIONS Adjunctive interventions have been borne out of necessity in efforts to reduce postoperative hematoma after rhytidectomy. Although many of these interventions have promising results, the current literature supports the senior author's (R.J.R.) experience that an evidence-based, multimodal approach is ideal to minimize the rates of hematoma after rhytidectomy.

The procerus is the main muscle across the radix that needs to be operated during rhytidectomy, however, it is unclear whether transecting it can morphologically affect the nose. A retrospective study of Asian patients who underwent procerus transection during rhytidectomy in our single institution was performed to assess whether the radix profile had any change postoperatively. The procerus was transected at a plane above the nasion. Ninety-four patients were included. All of them were female with an average age of 50.7 ± 5.2 years and a mean follow-up time of 7.8 ± 3.2 months. Twenty-seven (28.7%) had moderate horizontal wrinkles preoperatively, and sixty-seven (71.3%) had severe rhytides. Different degrees of wrinkle improvement were seen on 91 (96.8%) patients, and no improvement occurred to 3 (3.2%) patients after procerus transection. The anthropometric measurements on these patients did not find any significant difference between the preoperative and postoperative nasal heights, radix projections, nasal lengths, or nasofrontal angles (all p >0.05). Procerus transection primary contributes to wrinkle improvement. The morphological change of the radix following this operation is too subtle to be observed. This conclusion should be further verified on large samples as well as on other ethnic cohorts in a long-term follow-up. This journal requires that authors 10 assign a level of evidence to each article. For a full 11 description of these Evidence-Based Medicine ratings, 12 please refer to the Table of Contents or the online 13 Instructions to Authors www.springer.com/00266 .

Purse string sutures in superficial musculoaponeurotic system (SMAS) plication facelifts may cause technique-related problems, such as soft tissue deformities, dimpling, and bulkiness inside and between the independent sutures. Therefore, the authors have developed a new approach named the multiple rhomboid vector (MRV) suture. A total of 103 patients (89 female, 14 male patients; median age: 57 years) received a primary rhytidectomy with the MRV SMAS plication suture in our clinic (2015–2017). Intraoperative time to perform the suture per side was recorded. Postoperative complications and dimpling and bulkiness of subcutaneous tissues were judged by three independent surgeons from 1 (= none) to 4 (= extreme) after 1 week, 1, 3, 6, and 12 months. A standardized survey, the FACE-Q questionnaire, was performed to evaluate postoperative patient satisfaction. Mean time to perform the suture was 5:14 minutes per side (minimum: 3:20 minutes, maximum: 5:53 minutes; standard deviation: 0:51 minutes). During the follow-up period, four complications were detected (two cases of temporary neurapraxia of the marginal branch of the mandibular nerve {n = 2 [1.9%]} and two cases of retroauricular hematoma {n = 2 [1.9%]}). Postoperative dimpling or bulkiness of subcutaneous tissues was judged as absent. Overall patient satisfaction rate, after the surgery was performed, was measured as “very high.” The MRV suture offers a combined horizontal and vertical suspension approach, which effectively addresses the different vectors of age-related facial soft tissue descent with complication rates equal to other surgical lifting techniques. Apart from that, it may help reduce the possibility of contour irregularities, whereby it must be noted that a thorough preoperative assessment together with the patient and surgical planning is crucial to ensure realistic expectations of the surgical outcome.

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

Background Minimally invasive procedures, such as thread suspension techniques, are a growing trend for facial rejuvenation. However, not enough data are available on the efficacy, outcomes, and morbidity of suture suspension techniques in mid-face reshaping. Aims Our goal was to assess treatment outcomes and patient satisfaction following mid-face reshaping using threads with bidirectional convergent barbs (DefinisseTM free floating threads). Patients/methods We performed a retrospective analysis of 60 patients who underwent treatment for mid-face reshaping using DefinisseTM free floating threads. Response to treatment was assessed at 6 months using the mid-face-specific Mid-Face Volume Deficit scale (Allergan® ), Global Aesthetic Improvement and FACE-QTM scales. Results Sixty patients underwent mid-face treatment with the suspension thread technique (mean age 51.3, 90% female). No concomitant procedures were done. A reduction by one point or more in the Mid-Face Volume Deficit Scale (MDFVS) score treatment was seen in all patients after 6 months. Mean overall MFVDS and FACE-QTM scores were significantly improved. On the GAIS, most patients were rated as improved or better both by the evaluating investigators and during self-assessment. No major complications were observed, and none of the patients requested the removal of the threads (mean follow-up 9.8 months, range 6-14 months). Conclusion Our results suggest that mid-face reshaping with DefinisseTM free floating threads is a safe and reliable procedure characterized by low complication rates and good esthetic results. This minimally invasive procedure is a good alternative for normal or combination skin patients who refuse or want to delay the need for traditional rhytidectomy.

Secondary rhytidectomy is a routine procedure in plastic surgeons’ offices, which represents two groups of patients: one of them is well-operated patients, satisfied with the initial result, who return to the same professional usually 10–15 years after the first intervention. The other group consists of patients dissatisfied with the initial result and seeking a surgical solution. In both groups, there is a need for meticulous evaluation of the previous result and then adequate surgical planning.

The number of patients classified as overweight or obese is increasing, generating a demand for rhytidoplasty in this public. The recommendation of rhytidoplasty after massive weight loss is given when they achieve stability at their target weight. Nutritional changes are not uncommon for these patients. The histopathological analysis of the skin, adipose tissue, and SMAS of postbariatric patients show increased edema, perifollicular lymphohistiocytic inflammatory activity, and severe hypotrophy in the epidermis; increased inflammatory activity and edema throughout the adipose tissue; a decrease of fibrous collagen tissue in its thickness; and the presence of fibroconjunctive tissue with decreased vascularity in the SMAS, when compared to non-bariatric patient skin. In addition to the usual complications that accompany the rhytidectomy procedure, we can include the influences of the difficulty of nutrient absorption, exacerbated local inflammation, and disruption of the collagen fibers in the healing process, as well as the possible loss of skin tone in the months following the procedure. We noticed that the postoperative surgical technique of the postbariatric surgery patient supported specific details, with a satisfactory postoperative surgical result, a skin of worse histological quality, with perioperative complications within the expected and with the need for further studies to evaluate the durability of the procedure.

Facial contour is a very wide concept concerning treatment of unaesthetic abnormalities of the face and neck. Since the early last century when rhytidoplasty became a new and special field in plastic surgery, localized adiposity was quite a difficult problem to be solved during operation. Lipectomy of submental and submandibular regions was performed under quite aggressive traumatic and bleeding procedures due to vascular trauma caused by complex dissection to remove adipose tissue. However when liposuction (A new technique. (Une nouvelle technique) Communication a la Societe Francaise de Chirurgie Esthetique, Juin, Sao Paulo, 1978), it was evident that it would be possible to also apply that technique in order to remove accumulated adiposities of the submandibular and submentonian regions. As soon as I learned the technique, it was clear to me how to proceed the removal of the local fat by using the new method (Avelar JM. Submentonean and submandibular adiposity – Liposuction Versus Lipectomy (Adiposidade submentoniana e submandibular – Lipoaspiracao x Lipectomia). Annal of the Brazilian Symposium on Facial Contour. (Anais do Simposio Bras. do Contorno Facial), Sposored by Brazilian Society of Plastic Surgery – Regional of Sao Paulo (Patrocinio da Sociedade Brasileira de Cirurgia Plastica – Regional Sao Paulo) Ed. By Avelar JM pg. 69–72, 24–25 setembro 1983; Avelar JM. Flankplasty and torsoplasty – a new surgical approach. Rev Bras Cir Cardiovasc. 1999;88/89(1/6):21–35). At that time I already suggested that the cannula tip should be turned towards the depth, on the platysma muscle, in order to preserve the subdermal layer underneath the cutaneous covering. This way, avoids any damage on it, which could cause ungraceful and unaesthetic surgical results. Since the beginning one may achieve a great improvement with minimal rate of complications employing liposuction technique, isolated or combined with rhytidoplasty surgery remodeling submental and submandibular regions (Avelar, Aesthet Plast Surg 9:257–63, 1985; Liposuction of the submandibular and submental regions. (Lipoaspiracao das Regioes Submentoneana e submandibular). In: Avelar JM, Illouz YG, editors. Liposuction (Lipoaspiracao). Sao Paulo: Hipocrates; 1986. p. 139–47).

The satisfaction of the patient following a rhytidectomy is directly influenced by the correct treatment of skin laxity and facial volumization and the absence of any visible sign that an operation was performed. The young plastic surgeon is trained to avoid these untoward results, placing well-hidden incisions and avoiding excessive traction on the skin flaps. Widened and noticeable scars, dislocation, and interruption (i.e., step-off) of the hairline are considered stigmas of a face-lift and may require the attention of a hair restoration specialist. Follicular transplantation for the reconstruction of the hairline will be described in this chapter, and other techniques will also be discussed.

Introduction: The nasolabial folder is one of the most difficult face correction structures in rhytidectomy surgery [5, 22]. Anatomical studies have shown that the ptosis of the cheek region and the deepening of the nasolabial sulcus and the formation of skin bags and jowls, at the level of the mandible border, are the first signs of facial aging (Yousif, Plast Reconstr Surg. 93:60-8 1994). The author presents a new flap, using the deep temporal fascia, with the purpose of supporting and suspending the middle third of the face, reinforcing the SMAS treatment (Erfon, Rev Bras Cir Plast. 12:65-7, 1997) and also facilitating traction of nasolabial sulcus, labial commissure and jowls, defining a jovial aspect to this area, and believing to be an important ancillary method in rhytidoplasty. Method: A retrospective study was performed with patients submitted to rhytidectomy with the deep temporal fascia flap from January 1995 to December 2018. The flap can be used in classic or endoscopic rhytidoplasty. It is drawn rectangular in the deep temporal fascia, 3 cm wide and throughout the fascia, to the upper temporal line. Folded 180 degrees above the zygomatic arch is fixed beyond the suture lines of the SMAS-plasty, in the middle third of the face. Results: In the period studied, 1070 flaps were performed in 535 patients, 500 (93.45%) female and 35 (6.55%) male. The mean age was 58 years. The open approach was used in 503 (94.02%) of the cases and the endoscopic in the remaining 32 (5.98%). The incidence of hematomas occurred in seven (1.30%) of the patients. Four patients (12.50%) of the endoscopic approach underwent re-interventions, while in the open approach they were only 5 (0.99%). Conclusions: We concluded that the use of the deep temporal fascial flap allows adequate suspension and fixation of the mid-face, reinforcing SMAS-plasty, with longer results and without an increase in surgical complications, which can be used by open or video-endoscopic approach.

Surgical and non-surgical procedures are performed for both cosmetic and reconstructive situations in order to optimize the form and function of the face, head, and neck. In modern times, the facial plastic surgeon has become a target of both the patient and attorney, both of whom are hoping for financial gain secondary to a real or perceived fault with the actions of the practitioner. Despite extensive five-year training in Otolaryngology and, in many instances, additional specialized training in facial plastic and reconstructive surgery, the threat of medical malpractice looms significantly for facial plastic surgeons. Lack of proper informed consent and poor cosmetic outcome are cited most frequently as the reasons litigation are enacted. Familiarizing oneself with the details and scenarios of medical malpractice and litigation in facial plastic surgery is extremely important for those who practice in the United States today.

As quality of life improves for people, it becomes one of their goals, whatever their age and social status, to become more beautiful. Minimally invasive procedures are growing in popularity in every area of aesthetic practice that affects the face [Jung GS. JPRAS Open 20:94–100, 2019]. Thread lifts and injection of neurotoxins are supplanting rhytidectomy, whilst fillers are replacing the more invasive and radical types of facial surgery that used to be popular. As well as suture lifting of the nose, every different type of filler may be tried to improve nasal aesthetics. Such interventions appear to be straightforward and swift and do not involve significant discomfort. They are often treated as though they were free of complications, despite this not being the case. The majority of ENT practitioners, as well as facial cosmetic surgeons, have begun to pivot towards such interventions. These minimally invasive aesthetic procedures have even begun to be carried out by non-medically trained personnel, such as hairdressers and beauty technicians, who now carry out injections of fillers, neurotoxins vitamins, homoeopathic solutions or plant extracts (collectively known as mesotherapy), into the face. In this chapter, fillers are presented.

Facelift surgery has become a beautifully predictable, safe, and extremely effective operation. Our patients can expect natural and long-lasting results as a direct outcome of our improved understanding and applications of surgical facial anatomy. Rhytidectomy, once an operation of simple well-placed elliptical skin excisions, evolved to include longer skin flaps, skin and platysma flaps with various superficial muscular aponeurotic system (SMAS) manipulations, and various deep plane techniques involving the skin and SMAS as a single unit composite flap. Extended deep plane rhytidectomy and vertical vector neck and SMAS lifting have emerged in recent years as techniques that extend the traditional deep plane dissection into the neck in a subplatysmal plane to allow for release of the platysma from the cervical retaining ligaments. This, ultimately, allows for the creation of a dramatically more youthful appearing face, neck, and jawline.

Energy-based facelifting techniques are a relatively new genre of surgery. In this approach, the energy-based device—whether laser, radiofrequency plasma, or ultrasound—can be used in the superficial plane to elevate skin flaps before performing more traditional facelift techniques involving the superficial musculoaponeurotic system (SMAS) or platysma. The initial reports of utilizing fiber lasers as surgical tools date back to approximately 2007 and initial lipolasers were used to elevate facial skin flaps. The other energy-based devices were also tested. The author has probably the largest series of energy-based facial rejuvenation procedures, having performed over 3,000 of these procedures. The advantages of laser-assisted rhytidectomy include hemostasis, facilitated dissection in areas hard to elevate conventionally such as nasolabial folds or distal neck and the remodeling and tightening of tissue that results from the activation of the wound healing cascade of neocollagenesis and wound contraction. The author currently has a preference for energy device used during rhytidectomy and it is a high frequency ultrasound energy delivered by a five-ring 2.9- and 3.7-mm probe. The use of the ultrasound dissector in both superficial and deep procedures is highlighted in this article with emphasis on its use for deep cervicoplasty and subplatysmal procedures as well as sub-SMAS elevations of the facial deep plane.

Patients frequently access online resources for medical information. The National Institutes of Health and the American Medical Association recommend that to be understood by the average American, patient information should be presented at or below the sixth to seventh academic grade level. The popularity of rhytidectomy (facelift) is rising, and providers are frequently using the Internet to attract patients. All rhytidectomy information provided by 100 private practice Web sites in New York City, Los Angeles, Chicago, Houston, and Phoenix was analyzed using Readable.io software. The information was also assessed using the Flesch-Kincaid Grade Level, Gunning-Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook, Automated Readability Index, Flesch Reading Ease Score, and Fry Reading Graph tools. Analyzed material was written at a higher academic grade level than recommended for the average American. The overall average grade level was 10.99 ± 1.39. Online patient education materials about rhytidectomy provided by private practice clinics in 5 major cities of the United States were written at academic grade levels above the National Institutes of Health and American Medical Association recommended levels. This may lead to rhytidectomy patients having unrealistic or inaccurate expectations related to their surgical procedure.