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The aim of this study was to evaluate the use of autologous fat graft injection to correct lower eyelid position METHODS: A retrospective, observational, single blind, case-control study was carried out on 94 patients, presenting with lower eyelid retraction in 159 eyes. In the sub-population with monolateral eyelid retraction, the not affected site has been considered as a control and compared with the outcomes recorded after treatment of the contralateral side Follow-up at 12 months was performed with a subjective assessment carried out by a questionnaire administered to patients while objective result assessment was performed 12 months after surgery by two independent blind examiners.The eyelid upward reposition has improved one year after fat grafting in both bilateral (1,52 mm) and unilateral (1,7 mm) population: the latter allowed to statistically validate (P0.05) the result with respect to the not affected site.This is the first paper that highlights the outcomes of sole fat injection in the treatment of lower eyelid retraction: blind objective evaluation of surgical outcomes along with a patient assessment of both functional and aesthetic improvement one year after surgery confirm its efficacy and reliability along with the first case/control outcome evaluation of the technique carried on in the sub-population of 29 patients affected by unilateral lower eyelid retraction that validate the average improvement of the retracted eyelid one year after fat grafting as statistically significant. Nevertheless, longer follow-up periods and a larger sample size are needed to thoroughly confirm surgical outcomes and statistical results.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.

Breast reduction is a time-consuming procedure with a relatively high complication rate. Furthermore, recurrent breast enlargement can occur in case of postoperative weight gain. The authors describe a breast reduction technique based on liposuction, followed mostly by skin resection alone, which makes this operation easier, faster, and safer, with more stable results.Two hundred thirty-three patients were treated by breast liporeduction between 2006 and 2017, with an age range of 18 to 70 years (average age, 42 years). The patients were selected after careful clinical and instrumental assessment among those in whose breasts the fat component was prevalent over the gland. Most of the soft-tissue reduction consisted of fat aspiration. The follow-up ranged from 12 months to 9 years (average, 4.5 years).The results of this study have been extremely satisfactory. Most of the patients healed uneventfully and were happy with the final outcome. Very few complications were encountered, among which were small steatonecroses and partial nipple-areola complex necroses.For the past 15 years, all four authors have preferred this breast reduction technique over others. Fat only is selectively removed by aspiration with a blunt cannula, sparing the vascular network and easily mobilizing the nipple-areola complex. Liporeduction provides a good stable result because any postoperative weight variation will not change the volume of a breast consisting mainly of glandular and fibrous tissue.Therapeutic, IV.

Although permanent fillers have been introduced in order to get long-lasting results, many studies have shown numerous severe and disfiguring complications. Nonsurgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. A total of 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline, and lips. Magnetic resonance evaluation was performed with the exception of lip patients who were evaluated with ultrasound. Postoperative follow-up was 12 months to 6 years. Subjective and objective methods were used for outcome evaluation according to the FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale (GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the GAIS. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permanent facial fillers. A proper preoperative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases.

Background The “time variable” assumes paramount importance, especially regarding facial rejuvenation procedures. Questions regarding the length of recovery time before returning to work, how long the results will last, and the ideal time (age) to undergo this particular type of surgery are the most commonly asked by patients during the initial consultation. Objectives The authors endeavored to determine the healing time, optimal age to perform the surgery, and duration of the results after cosmetic face surgery. Methods A 35-year observational study of 9313 patients who underwent facial surgeries was analyzed. The principal facial rejuvenation interventions were divided into 2 subgroups: (1) eyelid and periorbital surgery, including eyebrow lift, blepharoplasty, and its variants and midface lift; and (2) face and neck lift. Significant follow-ups were conducted after 5, 10, and 20 years. To evaluate the course of convalescence, the degree of satisfaction with the intervention, and the stability of the results, a questionnaire survey was administered to a sample of 200 patients who underwent face and neck lifts. Results The answers given indicated that surgery performed according to rigorous standards allowed for a relatively rapid recovery, and the positive results were stable up to 10 years after surgery. The level of patient satisfaction also remained high even after 20 years. Conclusions The “right time” for a facelift, taking into account age, recovery time, and the longevity of the results, is an important consideration for both the patient and the cosmetic surgeon. Level of Evidence: 4

Objectives As the face ages, cosmetic changes in the periorbital region including eyebrow ptosis, sagging in the lateral temporo-orbital region with superior eyelid hooding, ptosis of orbicularis oculi muscle associated with drooping of the malar area with multiple “crow feets”, a deeper lid-cheek junction, and malar festoons also occur. All these periorbital structures should be considered as a single anatomical entity. Methods Numerous techniques have been described to correct brow aesthetics in facial rejuvenation. We report the senior author's (M.P.) current approach utilizing a temporal subcutaneous brow lift (TSBL) associated with an orbicularis oculi muscle (OOM) elastic flap. Furthermore, a systematic review of the literature was performed comparing the different surgical approaches striving to clarify its terminology. A total of 298 patients underwent this procedure in 4 years period. Of these, 230 patients, with at least 12 months of follow-up, were submitted to subjective and objective methods to evaluate the self-perception of scar and their overall aesthetic satisfaction. A committee of experts, blinded to each other's assessment, evaluated the same outcomes. Total eyebrow's tail lift was measured and recorded for each patients. Results The most satisfying aspect of these techniques is the dramatic periorbital rejuvenation and preservation of the patient's original youthful identity. In fact, the postoperative results appear very natural and do not suffer from an “operated” look. This aspect is noticeable from both the surgeon's and the patient's perceptions. There were no major complications in any of the cases. Conclusions The proposed TSBL with OOM elastic flap technique, in the hands of senior author (M.P.) has emerged as a reliable, effective, and highly reproducible method to treat sagging and aging of the lateral region of the orbit, even without associated blepharoplasties.

As facial aging occurs, aesthetic changes of the nasal tip and the senile upper lip include tip ptosis, increase in skin length, loss of vermillion height and Cupid's bow, and vertical wrinkles.Regardless of the rejuvenation procedure, the lips are not to be considered as a single anatomical entity, instead they should be placed in a strong correlation with the nose. The aim of this study is therefore to demonstrate the effectiveness of the association of primary closed rhinoplasty together with indirect subnasal lip-lifting technique.A total of 45 patients were enrolled in this study and underwent primary closed rhinoplasty with indirect subnasal lip-lifting. The result showed an overall average nasolabial angle width reduction of 10.9% and lip length shortening of 23.5%, as assessed 1 year after the surgical procedure. When comparing before and after photographs and using the Subjective Global Aesthetic Improvement Scale (sGAIS), the overall satisfaction was rated 4.4 on 5, as “much improved.”The authors show that lips should not be considered as a single anatomical entity but that they indeed must be placed in a strong correlation with the nose since a droopy nasal tip is likely to be considered unattractive and is often associated with the appearance of a long nose with covered philtrum and upper lip.Tip rotation to a normal nasolabial angle width could grant a beneficial impact on overall nose aesthetics; however, it may not fully balance the midface profile as it is the “lip position-to-incisal show” ratio that defines beauty, whereas the balance among forehead, nasal tip, upper lip, and chin is what defines the contour of harmonious profiles.This is the first patient series to show that the combination of closed rhinoplasty and indirect lip-lifting is a highly effective, safe, and reliable procedure to address profile rejuvenation.

Background Aesthetic surgery has recently become popular also among men. The ever-increasing number of bald men wishing to undergo facial surgery represents a challenge for the surgeon, as the scars cannot be hidden in the hair and must therefore be as short as possible. The authors present their experience in face lifting in bald male patients and propose an innovative technique to handle the skin excess to achieve practically invisible scars. Methods A 10-year observational study was carried out on 68 bald male face-lift patients. All patients underwent deep plane lifting with a specific method for handling skin excess. This technique is the innovation presented in this article. Subjective and objective methods were used to evaluate the results. The well-known FACE-Q questionnaire was sent to all the patients together with an explanatory letter. Three ad hoc questions were added to the questionnaire to assess the degree of satisfaction with the scars. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury. The average follow-up period was 12 months. Results All patients showed a high degree of satisfaction with the final appearance of the surgical scars and appreciation of the overall quality of the result, 1 year after face-lift surgery. No patient expressed regret about choosing to undergo this type of surgery. Very high scores were registered for the overall facial appearance and for the various critical areas examined, including scars, from patients and experts alike. Conclusion The face-lifting technique for bald men proposed by the authors, involving a peculiar and innovative way of handling the skin excess, has proven to be reliably effective in obtaining virtually invisible scars.

While the use of crushed cartilage is now universally recognized as a valid procedure in rhinoplasty to mask irregularities and eliminate slight deficits, there is still no consensus as to the optimal degree of crushing and the rate of graft resorption over time. With a view to casting light on these 2 important aspects and providing some guidelines, the authors present a study of 123 patients subjected to grafts of cartilage with different degrees of crushing in the different areas of the nasal pyramid: upper third (45 patients), middle third (40), and lower third (38). The degree of crushing was medium for 95 patients and high for 28 who presented thinner and less elastic skin. Comparison of the performance over time of the cartilage grafts inserted in the same areas but with different degrees of crushing provides important indications as regard the best way of preparing the material. The results proved satisfactory with improvements for all of the 95 patients subjected to grafts of moderately crushed cartilage. The initial defect was instead still present, albeit with some partial improvement, at a distance of 12 months in 17 of the 28 patients where highly crushed cartilage was used. The study suggests that a moderate degree of crushing offers better results as regard flexibility and stability over time.

The aim of this work is to discuss the anatomy of the tear trough region with relative danger areas, and to describe 2 different options to correct this deformity.The tear trough is a concave deformity of the orbital fat that is noticeable as a result of inherited anatomic differences and aging. However, the periorbital region is a complex area with its own septa and ligaments, fat compartments, muscles, vascularization, and lymphatic drainage and presents anatomic characteristics that must be taken into account in order to achieve good results and avoid complications.The use of hyaluronic acid gel or autologous fat for soft tissue correction is a good option.A total of 96 patients with periorbital hollowing were divided into 2 groups; each group received a different treatment, from December of 2013 to December of 2015, with hyaluronic- or lipo-filling.

Background Lower eyelid retraction can be the unfortunate result of aesthetic surgery, trauma, disease, or the aging processes. The purpose of this article is to assess whether midface lifting based on purely vertical repositioning constitutes an effective procedure for its correction. Methods A retrospective study was carried out on 199 patients (311 eyelids) operated on between January of 2004 and January of 2014. The various causes of eyelid retraction in this population included cosmetic blepharoplasty (56.8 percent), involutional ectropion (23.1 percent), tumor resection (9.5 percent), facial nerve paralysis (8.5 percent), and trauma and related surgery (2 percent). The study was restricted exclusively to cases of moderate and severe lower eyelid retraction addressed by means of midface lifting. The mean follow-up time was 16.8 months. All of the patients were subjected to midface lifting with strengthening of the lateral canthus. A spacer graft was also used in 37.7 percent of the cases. Results One hundred ninety-five patients (97.9 percent) displayed objective improvement of the eyelid retraction and a marked degree of improvement both in aesthetic terms and as regards the functional disorders reported. Only four patients (2 percent) presented complications such as needing another operation. Conclusion Midface lifting based on purely vertical repositioning makes it possible to recruit a considerable amount of "new" skin at the lower eyelid, thus ensuring a decrease in vertical distraction and correct recovery of the height of the external lamellar plane. Clinical question/level of evidence Therapeutic, IV.

Dome division can still be regarded as a valid surgical procedure today in some particular cases of revision rhinoplasty where the scarring is so extensive as to make precise isolation of the alar cartilages impossible. The presence of asymmetry of the nasal tip, a recurrent feature in the results of rhinoplasty, constitutes the primary indication, as division makes it immediately possible to restore balance between the two domes in such cases. The technique also proves useful in cases of overprojection of the tip as a result of rhinoplasty. Moreover, the procedure has been improved by precise suturing of the cartilaginous stumps so as to avoid its frequently reported complications, arising essentially from the vulnerability of the domal arch to the distorting forces of cicatricial retraction and its resulting lack of stability over time. In this connection, the authors attach crucial importance to direct suturing of the cartilaginous stumps in accordance with a now standardized method that is easy to execute and offers lasting, stable results. This approach makes it possible to re-establish continuity of the cartilaginous domal arch in a form unquestionably closer to the physiological anatomical conformation.

Developing cartilage constructs with injectability, appropriate matrix composition, and persistent cartilaginous phenotype remains an enduring challenge in cartilage repair. Fourteen patients with minor contour deformity were treated with fluid cartilage filler gently injected as autologous fluid graft in deep planes of defect of the nose that were close to the bone or the cartilage. A computerized tomographic scan control was performed after 12 months. Pearson&rsquo, s Chi-square test was used to investigate differences in cartilage density between native and newly formed cartilages. The endpoints were the possibility of using fluid cartilage as filler with aesthetic and functional improvement and versatility. Patients were followed up for two years. The constructs of fluid cartilage graft that were injected in the deep plane resulted in a persistent cartilage tissue with appropriate morphology, adequate central nutritional perfusion without central necrosis or ossification, and further augmented nasal dorsum without obvious contraction and deformation. This report demonstrated that fluid cartilage grafts are useful for cartilage regeneration in patients with outcomes of rhinoplasty, internal nasal valve collapse, and minor congenital nose aesthetics deformity.

In blepharoplasty and facelift procedures, different methods may be used to reduce postoperative complications and the need for draining, including the use of complete haemostatic, quilting sutures, heterologous glue, compressive dressing, and tissue sealants. Different types of surgical adhesives have emerged as alternatives capable of fixing and guaranteeing adhesion of tissue. Among these, biological sealants (or fibrin sealants) are produced by recurring to a combination of material from a pool of known donors and bovine thrombin, whereas platelet-rich plasma (PRP) glue is an autologous preparation obtained from the patient’s own blood and which acts as a growth-factor reservoir during treatment.

Context: Several studies showed, from the clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation. A few studies have highlighted the satisfaction or not of patients who underwent a traditional facelift; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet. Aims: The aim of this study is to measure individual patient satisfaction with the midface lift, to find out from each patient his/her level of satisfaction 1 and 5 years after the operation and to compare the results to assess the benefits of the surgery. Background: Several studies showed, from a clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet. Materials and Methods: Between January 2005 and January 2010, 163 patients underwent a midface lift. All patients were asked to complete a standardised survey 1 and 5 years after surgery, in order to measure outcomes among facial aesthetic patients. Statistical Analysis Used: The paired t-test. Results: All patients reported an improvement as a result of the midface lift. Statistically significant differences in judgement criteria were found for malar eminence and nasojugal groove. Almost all of the patients turned out to be completely satisfied with their appearance with the new look. Conclusions: Patients were extremely satisfied with their decision to undergo a midface lift and with the outcomes and quality of life following the procedure.

Objectives: The current article is aimed to test the effectiveness of direct and indirect brow lifting to correct brows asymmetry. Methods: Fifty patients treated with direct brow lift between January of 2011 and January of 2013 were investigated. All patients were men and treated under local anesthesia. In all patients, the brow lifting was associated with an upper blepharoplasty. The amount of brow elevation produced was assessed by comparison of the preoperative and at 1-year postoperative vertical distances between the superior eyebrow hairline and the interpupillary line at midpupil and at lateral and medial canthus. Paired sample t-test was used to investigate brow lifting amelioration after 1 year. The differences in measurements between the 2 sides were plotted to evaluate the degree of symmetry between 2 sides. In addition, a comparison was performed; a series of 45 patients treated with temporal (ie, indirect) approach. Results and Conclusions: The paired sample test demonstrated that direct brow lifting is a proper surgical technique to correct brow asymmetry. Also temporal (ie, indirect) approach is able to ameliorate brow asymmetry but direct technique provide better results. The direct brow lifting is a reliable, reproducible and safe surgical procedure, provides excellent and long-lasting results, and is very efficacious in brows asymmetry correction.

The ideal perioral and lip rejuvenation technique provides the longest period of efficacy, lowest complication rate, and best esthetic results. Genetics, intrinsic aging, sun exposure, and repetitive muscle twitching of the orbicularis oris produce angular, radial, and vertical lines of the perioral lines and, for this reason, the needs of patients in the treatment of this anatomical area can range from simple lip enhancement to a broader and more comprehensive treatment with simultaneous correction of perioral wrinkles. A myriad of materials have been described for rejuvenation of this area. At present, the most popular and commonly used lip enhancers are dermal fillers, but there is still no agreement on what the best material for filling soft tissue of the face and in particular of the perioral region is. This systematic review will focus on the various dermal fillers, of different materials approved by the US Food and Drug Administration (FDA) namely poly-L-lactic acid, calcium hydroxylapatite, and hyaluronic acid and also different grafts, for perioral rejuvenation, with the goal of determining the optimal approach. A systematic search for English studies involving perioral rejuvenation was performed using these databases: PubMed, Google Scholar, and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 17 relevant publications were included. For each study, year of publication, type of material used for filling, number of patients, subject of study assessment, and efficacy of the filler procedure for lip rejuvenation were analyzed.

Bio-revitalization is a commonly used technique in aesthetic medicine for improving skin quality and appearance by intra-dermal injection of hyaluronic acid (HA)-containing compounds. The present study compares different HA-containing injectables regarding their effects on cultured skin fibroblasts over time (24, 48, and 72 hr) by using RT-PCR and a panel of genes involved in dermal integrity. Human dermal fibroblasts were seeded on a layer of five different commercial medical devices containing 6.2 mg/mL 10 mg/mL 10%, 13 mg/mL and 20 mg/mL, respectively, of HA. The products differ not only in HA concentration but also in the content and quality of other ingredients; moreover, one of these products contained cross-linked HA. Differences among medical devices were found. In particular, HA concentration seems to be inversely correlated to elastin gene activation. Regarding the neutrophil elastase gene, the two medical devices with the higher concentration of HA displayed the greater effect. Genes encoding for hyaluronan synthase 1, hyaluronidase 1, and desmoplakin were enhanced, but the HA content of the different products did not seem to be directly related to gene activation. Therefore, the explanation for the differences must be studied further with respect to elements that are distinctive for each device. For the physician, it is important to choose which drugs or medical devices can be used and in what protocols. The present study performed a comparison that can be useful in better addressing the skin improvement therapies for aging and in its prevention.

Background Although "traditional" face-lifting techniques can achieve excellent improvement along the jawline and neck, they often have little impact on the midface area. Thus, many different types of procedures have been developed to provide rejuvenation in this region, usually contemplating various dissection planes, incisions, and suspension vectors. Methods A 7-year observational study of 350 patients undergoing midface lift was analyzed. The authors suspended the midface flap, anchoring to the deep temporal aponeurosis with a suspender-like suture (superolateral vector), or directly to the lower orbital rim with a belt-like suture (superomedial vector). Subjective and objective methods were used to evaluate the results. The subjective methods included a questionnaire completed by the patients. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury instructed to compare the "critical" anatomical areas of the midface region: malar eminence, nasojugal groove, nasolabial fold, and jowls in the lower portion of the cheeks. The average follow-up period was 24 months. Results High satisfaction was noticeable from the perceptions of both the jury and the patients. Objective evaluation evidenced that midface lift with temporal anchoring was more efficient for the treatment of malar eminence, whereas midface lift with transosseous periorbital anchoring was more efficient for the treatment of nasojugal groove. Conclusions The most satisfying aspect of the adopted techniques is a dramatic facial rejuvenation and preservation of the patient's original youthful identity. Furthermore, choosing the most suitable technique respects the patient's needs and enables correction of the specific defects. Clinical question/level of evidence Therapeutic, IV.

Introduction The eyebrow lifting with temporal approach is an increasing widespread technique. Many surgical procedures are described, but the long-term stability is dependent on the effectiveness in the fixation of elevated tissues. The authors compared 3 different fixation techniques in temporal brow lift. Methods Forty-five consecutive patients aged between 33 and 70 underwent brow lift surgery with temporal approach. Patients were divided into 3 groups; in group 1, anchorage was performed with Endotine Ribbon, group 2 with a Mersilene mesh, and group 3 with a Prolene suture. The amount of brow elevation was assessed comparing the distance between interpupillar line and superior eyebrow hairline, measured at the midpupil and at the lateral and medial canthal angle. The follow-up was 1 year. Results All patients had a pleasant improvement in brow shape. The average initial brow position was 19.84 mm near the head of the eyebrow area, 20.74 mm at the body, and 19.57 mm in the region of the tail. A progressive recovery and a partial relapse regarding the eyebrow body (23.88 mm at 6 months and 23.02 mm at 1 year) occurred, but overall for the lateral region, it passed from 27.53 mm at 6 months to 25.80 mm after a 12-month follow-up. Final brow position was dependent upon surgical technique used in fixation. Discussion Different options in brow elevation and stabilization affect the final shape and position of the brows. From the statistical analysis, mesh suspension provided the best results in terms of long-lasting stability. Level of evidence Therapeutic III.

Reactive oxygen species production is the final step in skin aging. These unstable molecules can damage and destroy DNA, proteins, and membrane phospholipids. The aim of this study was to test the in vitro effect of an antioxidant precursor, N-acetylcysteine (NAC), on human dermal fibroblasts. NAC alone and a solution of NAC and amino acids together, used in aesthetic medicine as intradermal injection treatment, were tested. The expression levels of some connective related genes (HAS1, HYAL1, ELN, ELANE, DSP, GDF6, and IGF1) were analyzed on cultures of dermal fibroblasts using real-time reverse-transcription polymerase chain reaction (real time RT-PCR). All genes were upregulated after 24 h of treatment. An interesting effect of gene induction by administration of NAC and amino acids in vitro was demonstrated. Upregulation of elastin-, hyaluronic acid-, and GDF6-encoding genes supports the evidence of clinical improvement induced by NAC biostimulation in the prevention and correction of skin aging. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Perfection is sometimes approached in treatment of the crooked nose today but not fully achieved due to the continued existence of flaws. While the traditional surgical algorithm envisages the use of 2 series of procedures to straighten the nasal bones and cartilaginous septum, the addition of a third appears very useful with a view to obtaining truly excellent results, above all in the case of marked deviation. The authors present their experience in the use of certain procedures designed to correct asymmetry of the upper lateral and lower lateral cartilages, as well as the soft covering tissues where necessary.A retrospective study was carried out on 105 patients treated for crooked nose over a 3-year period, 90% of the patients being due to trauma and the remaining 10% to congenital malformation. All the patients involved severe deviation of the nasal pyramid.The mean follow-up period was 18 months (range: 8-36 months). The use of these additional surgical procedures made it possible to obtain excellent final results in 83 (97.6%) patients with crooked nose of traumatic origin and in 17 (85%) patients with crooked nose due to congenital malformation. No major complication was registered, although 3 patients did present minor complications not connected with the nasal deviation.In conclusion, more modern approach to correction of the crooked nose should involve not only realignment of the osteocartilaginous axis but also treatment of the neighboring structures.

Two surgical procedures for ectropion correction are compared: the widespread "lateral tarsal strip" and the more recently introduced "tarsal belt" techniques. A retrospective interventional patient series of 40 patients with mono or bilateral ectropion are investigated.Distances of lower lid margin from interpupillary line before surgery and after 1, 6, 12, and 24 months in tarsal belt and lateral tarsal strip surgical procedure are compared. The postoperative distance is reduced in both the groups of patients, but as regard the tarsal belt the amount of correction is greater and more stable over time and this difference is statistically significant.The ideal surgical technique for ectropion's correction must be focused simultaneously on the lid and on the canthal region because it is mandatory to tight and elevate the lower lid, rotate the tarsal plate, lift the lateral canthal ligament fixing it in a sure fashion. The tarsal strip technique can result in a more vulnerability to relapse. In fact, all the lower eyelid is maintained through the little strip that is assured with a single stitch to the orbital rim periosteum.The tarsal belt technique allows a more uniform distribution of the tissue excess. The suture, with its multiple intratarsal stitches, produces a real reinforcement of the eyelid. The double passage is an added value because it is the element that assures a precise regulation of the tarsal plate rotation. Thus, the tarsal belt technique guarantees a better result over time.

Background: The importance of analysis of the nasal spine should not be underestimated in the correct planning of rhinoplasty. Deformations in position with respect to the midline and/or in size are often present, and their correction to ensure harmony between the spine and the other components of the nasal pyramid constitutes a key step in rhinoplasty that can lead to excellent results. Methods: The study includes 160 patients who underwent surgical treatment of the anterior nasal spine with or without other techniques of nasal reshaping. Eighty-seven of these patients presented with hyperplasia of the nasal spine, 43 with hypoplasia, and 30 with deviation. A combination of deviation and hyperplasia was present in 15 cases. Results: No patients developed postoperative complications. Five patients who underwent anterior nasal spine reduction reported postoperative numbness in the premaxillary area, but sensitivity was fully regained within 4 months after surgery in these patients. All the patients reported postoperative improvement of nasal airflow. A total of 142 patients considered their postoperative aesthetic result as excellent and 18 as good. Conclusion: The simplicity of the surgical procedures performed on the nasal spine and the marked aesthetic improvements thus achieved suggest that greater attention should be paid to this anatomical region.

Platelet-rich plasma (PRP) is a platelet concentrate that has widely been used to accelerate the healing of soft and hard tissues. The preparation of PRP has been described by several authors. Preparation protocols vary from system to system, depending on the concentration of different integrating proteins. The objective of this article is to describe the principal use of PRP mixed with fat grafts in aesthetic plastic surgery.

Lower blepharoplasty is a cornerstone in facial rejuvenation and improvement. Despite its popularity, several adverse effects have been described; of these, postsurgical eyelid displacement, with its aesthetic and functional consequences, is one of the more frequent complications. The tarsal sling procedure is a simplified canthopexy consisting in the fixation of the lateral portion of the septum--the canthal ligament--to the orbital wall periosteum. The aim of the current research is to demonstrate how the tarsal sling technique is effective in the prevention of lower lid malpositioning. A retrospective analysis of 40 consecutive healthy individuals was carried out. In group 1, 20 patients underwent standard blepharoplasty; in group 2, blepharoplasty was associated to the tarsal sling canthopexy. Pre- and postsurgical position of the lower eyelid margin was compared through photographic measurements at 5 time points and statistical analysis performed. Group 1 patients evidenced an increased distance between the interpupillary line and the lateral aspect of the lower lid margin. A progressive spontaneous improvement (reduction in scleral exposition) was detected. Patients who underwent the tarsal sling procedure (group 2) reported a postoperative overcorrection of scleral appearance. Two years postsurgery, progressive relapse occurred, but the lower eyelid did not reach presurgical values and maintained a slight degree of overcorrection. Tarsal sling is an easy, fast, and efficacious procedure to prevent eyelid displacement in lower blepharoplasty. Its routine use is a tool to assure further support to lower lids in the younger patients or when lid laxity is absent during presurgical examination.

Background: Brow elevation is one of the goals of surgical rejuvenation procedures. In this article, the authors reviewed their experience with brow lift, and they compared 4 different techniques: direct brow lift, brow lift with endotine ribbon device, brow lift with temporoparietalis imbrication, and brow lift with Mersilene mesh to provide long-lasting results. Methods: This is a retrospective study of 80 patients (20 for each group), aged between 48 and 75 years undergoing brow lift surgery, between January 2011 and January 2013. In all cases, the brow lift was associated with an upper blepharoplasty. The amount of brow elevation reduced was assessed by comparison of the preoperative and postoperative vertical distances between the superior eyebrow hairline and the midpupil and lateral and medial canthal angle. The average follow-up period was 18 months. Results: No incidences of infection, alopecia, or excessive scarring were noticed. The main complication associated with direct brow lift was visibility of the scar in 2 patients. One patient treated with brow lift with suture had recurrent eyebrow ptosis. Transient frontal paresthesia was noticed in 1 case treated with endotine ribbon device and in 1 case treated with Mersilene mesh, but this sensation returned by 6–12 weeks. Conclusions: In our experience, there does not exist a technique better than the other, but the best procedure depends on eyebrow contour, sex and age of the patient, magnitude of desired correction, presence or absence of patient’s hair, and patient’s expectations.

Background Despite its popularity for facial rejuvenation, blepharoplasty has been associated with several adverse effects. One of the most common is eyelid displacement after lower transcutaneous blepharoplasty. The tarsal sling procedure affixes the external portion of the septum (the lateral canthal ligament) to the internal orbital wall periosteum with a simple suture. This simplified canthopexy decreases the risk of lower eyelid margin displacement. Objectives The authors sought to determine the effectiveness of the tarsal sling technique in preventing lower eyelid malposition. Methods A retrospective analysis of 40 consecutive patients was conducted. Twenty patients underwent standard blepharoplasty (group 1), and 20 underwent blepharoplasty plus tarsal sling support (group 2). Pre- and postsurgical positions of the lower eyelid margin were compared by quantitative analysis of measurements obtained from clinical photographs. Results Postoperatively, reduction of scleral appearance was noted for group 2. Although progressive recovery occurred in this group by 2 years postoperative, the lower eyelids did not revert to presurgical position, and a slight degree of overcorrection remained. The overcorrection was minimal, without unpleasant consequences for the patients. In contrast, group 1 patients experienced an increase in the distance between the interpupillary line and the lateral aspect of the lower eyelid margin after blepharoplasty. Although progressive resolution of scleral show occurred by 2 years postoperative, recovery was not complete. Conclusions Through quantitative analysis, the authors demonstrated the effectiveness of a simplified canthopexy procedure. Tarsal sling is an easy, quick, and efficacious procedure to prevent eyelid malposition after lower blepharoplasty. Level of Evidence: 4 ![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

The “non-animal stabilized hyaluronic acid” (NASHA) is a widely used product in bio-revitalization injective procedures in esthetic medicine. The present research aimed to quantitatively evaluate the therapeutic effect of one of the more used bio-revitalization products on cultured dermal fibroblasts. RT-PCR was used for gene expression profiling of some proteins known to be relevant in skin homeostasis. Human dermal fibroblasts were seeded on a culture medium enriched with a product for dermal bio-revitalization, consisting of stabilized hyaluronic acid gel 20 mg/ml. After 24, 48, and 72 h of exposure, the cDNA was amplified by real-time PCR. Gene expression was quantified with the delta/delta calculation method. In this study, the gene of metalloproteinase (MMP)-13 is strongly expressed after NASHA incubation. The MMP-2 encoding gene instead is less expressed, but both evidence the same temporal trend, being progressively up-regulated after 24 and 48 h, thereafter the expression decreases, whereas MMP-3 maintains the same up-regulation at 72 h. Hyaluronan synthase 1 and desmoplakin are progressively up-regulated and increase at 24, 48, and 72 h. Hyaluronidase 1 and neutrophil elastase genes are overexpressed, but at 72 h they both exhibit the same behavior as the other degradative enzymes MMP-13 and MMP-2. Skin bio-revitalization by injecting the tested NASHA gel produces an enhancement in the expression of some genes involved in extracellular matrix degradation and organization. In this study, a time-dependent behavior, different for genes encoding degradative compared to synthesis proteins, was demonstrated. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Background/aims Ectropion correction is a challenge in plastic surgery. Correction of the lower lid area, including restoration of the shape and position of lid margin, is the surgical goal. In this study, we describe a new surgical technique, the tarsal belt , for the correction of ectropion and evaluation of the effective outcome and complications of this procedure. Methods Between January 2008 and January 2012, a total of 42 patients aged between 48 and 75 years (average age 61.5 years) were treated with this technique. This procedure consists in a trans-tarsal mattress non-absorbable suture anchored to the periosteum of the lateral orbital rim, combined with a small wedge excision of a lateral portion of the tarsus close to the lateral canthal tendon. During the same period, 66 patients were treated with the standard lateral tarsal strip technique. Preoperative and postoperative Ectropion Grading Scale (EGS) was recorded to evaluate anatomical improvement. The average follow-up period was 24 months. Results Rate of success was 100% for involutional and cicatricial ectropions, 90% for lid retraction and 87.5% for paralytic ectropions. Anatomical success according to EGS scale was obtained in 41 patients. Recurrence of ectropion occurred in only one patient 6 months after the first surgery and required a further operation with a larger posterior lamella resection and new tarsal belt suture. Conclusions The tarsal belt seems to be effective to correct the horizontal and vertical instability of the lid. The suture supports the lower eyelid along the entire tarsal plate length and corrects the outward buckling of the tarsal plate.

While a large number of studies have been published on the surgical techniques used to obtain optimal functional and esthetic results in the field of septorhinoplasty, less attention has been devoted to techniques for minimizing postoperative trauma. In this connection, the authors highlight a number of intraoperative methods, such as microosteotomy, extramucosal approach, hemostasis, careful suture placement, and endonasal splints, the use of which has led to an overall improvement in postoperative recovery and swifter attainment of esthetic objectives.

Actually, autologous fat grafts have many clinical applications in breast surgery, facial rejuvenation, buttock augmentation, and Romberg syndrome as well as a treatment of liposuction sequelae.The aim of this article was to describe the preparation and isolation procedures for stromal vascular fraction (SVF), the preparation of platelet-rich plasma (PRP), and the clinical application in the treatment of the scar on the face.Ten patients with burns sequelae (n = 6) and post-traumatic scars (n = 4) were treated with SVF-enhanced autologous fat grafts obtained by the Celution System. Another 10 patients with burns sequelae (n = 5) and post-traumatic scars (n = 5) were treated with fat grafting based on the Coleman technique mixed with 0.5 mL of PRP.To assess the effects of their treatment, the authors compared their results with those of a control group consisting of 10 patients treated with centrifuged fat.In the patients treated with SVF-enhanced autologous fat grafts, we observed a 63% maintenance of contour restoring after 1 year compared with only 39% of the control group (n = 10) treated with centrifuged fat graft (P0.0001). In the patients treated with fat grafting and PRP, we observed a 69% maintenance of contour restoring after 1 year compared with that of the control group (n = 10).Autologous fat grafting is a good method for the correction of scars on the face instead of the traditional scar surgical excision.

Giovanni Botti,1 Michele Pascali,2 Chiara Botti,1 Florian Bodog,3 Pietro Gentile,2 Valerio Cervelli2 1Villa Bella Clinic, Salò, 2Department of Plastic and Reconstructive Surgery, University of Rome Tor Vergata, Italy; 3University of Oradea, Oradea, Romania Background: The aim of this study was to compare the effects of two types of fibrin glue in patients undergoing facelift surgery. Methods: A prospective, controlled "right-left side" study was carried out in 20 patients. The two fibrin sealants used were Quixil® and Tissucol®. The two sealants were used at the same time, ie, one on one side of the face and the other on the contralateral side. Comparisons were made with regard to rates of hematoma and seroma, degree of induration, edema, ecchymosis, pain levels, and patient satisfaction. Results: The results were almost equivalent. The only exception was a significant (40 mL) hematoma in a patient treated with Quixil. Bleeding was most likely due to a sudden rise in blood pressure during the immediate postoperative period. However, it must be emphasized that, while Tissucol actually seals the undermined area, thus virtually eliminating the dead space, Quixil acts differently, in that its effectiveness in preventing hematoma is linked mainly to its hemostatic effect. Conclusion: The two fibrin sealants used were nearly identical with regard to patient safety and quality of the result. Nevertheless, it is noted that, while Tissucol has both hemostatic and "gluing" effects, Quixil is mainly effective in securing hemostasis. Keywords: facelift surgery, rhytidectomy, fibrin sealants, hematoma

Background: Correction of brow ptosis and lateral temporal laxity is one of the goals of surgical rejuvenation of the aging face. The Endotine Forehead (Coapt Systems, Inc., Palo Alto, Calif.) device is an effective bioabsorbable fixation tool for forehead and brow-lift procedures. However, the Endotine Forehead device alone is not able to correct lateral brow ptosis and temporal laxity. In this article, the authors propose an innovative use of another special device, the Endotine Ribbon (Coapt Systems), to provide long-lasting results in lateral brow-lift surgery and temporal lateral laxity correction. Methods: Between February of 2006 and April of 2007, a total of 30 patients, aged between 38 and 70 years (average, 50 years), underwent brow-lift surgery. With this technique, the Endotine Ribbon is cut in halves and each portion of it is anchored to the deep temporal fascia with sutures, and its multiple tines facing outward grasp the superficial temporal fascia. The amount of brow elevation produced was assessed by comparison of the preoperative and postoperative vertical distances between the superior eyebrow hairline and the midpupil and lateral and medial canthal angle. The average follow-up period was 18 months. Results: Using this technique, perfectly symmetric lateral eyebrows and temporal laxity correction were obtained in all patients. A lasting result was observed, and no significant adverse events were encountered. Conclusions: The application of the Endotine Ribbon for brow-lift procedures provides significant and reproducible lateral brow elevation and temporal laxity correction. This fixation method is effective, safe, and easy to use, and leads to high patient satisfaction.

The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results.From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months.The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed.The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.

Some candidates for primary rhinoplasty are at greater risk of postoperative complications due to the presence of certain very specific anatomic characteristics. The authors describe their experience with spreader grafts in primary rhinoplasty and provide an analytic method of identifying the types of patient needing such grafts who present a high risk of complications. Sixty patients were treated with spreader grafts during primary rhinoplasty. Bilateral spreader grafts were used in cases of "narrow nose syndrome" (short nasal bones, long and weak upper lateral cartilages, thin skin) and in cases of disproportionate nose with narrow middle vault and bulbous tip. Unilateral spreader grafts were placed on the concave side in cases of crooked nose. After an average follow-up of 17 months, all the patients reported improvement in functional and esthetic problems, with no complications related to the preoperative features.

Surgical management of the crooked nose still constitutes a problem that is difficult to solve because of the possibility of recurrence and the risk of weakening the supporting structures. The authors propose an innovative surgical technique for the correction of this deformity that takes into account both aspects of the problem. The technique combines septoplasty by means of staggered intracartilaginous incisions with the original positioning of a unilateral spreader graft. Once realignment of the deviated cartilages is achieved, this cartilaginous stent, referred to as a "crossbar graft," makes it possible to keep the mobilized axis firmly in the correct position over time. This graft is also quite effective from a functional point of view in restoring the correct angle of the internal nasal valve. Moreover, the technique allows for the harmonization of the aesthetic line from the eyebrow to the tip-defining point on the concave side with the same line on the other side.

This study reports a patient affected by congenital frontoethmoidal encephalocele. The cause of this malformation is unknown. A preoperative selective diagnosis evaluation is necessary. The workup should include an accurate clinical examination associated with radiological study (two- and three-dimensional computed tomography, magnetic resonance imaging, etc). The aim of the surgical treatment is to restore the functional brain tissue in the cranial cavity, perform dural repair, correct bone lack and other associated facial malformations (hypertelorism, orbital dystopia, etc.). A multidisciplinary team approach is necessary to resolve the brain herniation and to correct splanchnocranium malformations frequently associated with encephalocele. Cranial flap with orbital osteotomies has been performed; this operation permits correction of the hypertelorism and of the orbital dystopia associated with this malformation. In bone reconstructions, miniplates have been used as fixation devices. In adults we generally use titanium, but resorbable devices are required in children because of growing tissues. A restoration of craniofacial malformations with good aesthetic and functional results is achieved with early surgery.

Sleep apnea syndrome (SAS) is a complex respiratory disorder that is very difficult to diagnose and to treat surgically as well as medically. SAS can affect growing patients as well as adults. SAS shows a central, an obstructive, and a mixed form. Diagnosis is based on clinical examination of the patient and instrumental examinations such as teleradiography, nuclear magnetic resonance imaging (NMR), three-dimensional computed tomography, polysomnography, rhinomanometry, and spirometry. The patient presented has an obstructive form of SAS in addition to Crouzon's disease. He underwent a Le Fort III osteotomy to obtain an advancement of the orbitomaxillary complex, allowing an increase in volume of posterior airway space at the level of the hypopharynx.

Background: The ′medial thigh lift′ was first described by Lewis in 1957, but did not receive the widespread acceptance because of the various postoperative complications, such as scar migration with vulvar deformities and early recurrence of ptosis. For this reason, Lockwood developed a technique of anchoring the dermis to the Colles′ fascia, to make the surgical outcome more stable over time and to prevent scar migration. In this article, we describe our approaches to the medial thigh lift in post-bariatric surgery patients. Materials and Methods: A total of 45 females underwent medial thigh reduction. In 15 patients with Grade 2 on Pittsburgh Scale (PS), we performed a thigh lift with a horizontal scar; in 15 patients with Grade 2 on PS, we used a technique with a vertical scar; in 15 patients with Grade 3 on PS, the above-mentioned two procedures were combined. When it was really necessary, we also did the liposuction of the medial thigh. The patients were observed every 6 months with a 60-month median follow-up (range: 12-108 months). Results: In six patients was observed scar enlargement due to poor wound healing (one patient with a horizontal scar, three patients with a vertical scar and two with the combined procedure). In two patients with a horizontal scar, minimal scar migration was observed. In three patients, the recurrence of ptosis was evident (one patient with a horizontal scar and two patients with the combined procedure). No skin necrosis was observed. Conclusion: The medial thigh lift surgery is remarkably simple and free of major complications, if the basic anatomy of this region is understood, in order to preserve important structures such as the great saphenous vein and femoral vessels. The only complication is the presence of extensive and visible scars along the thigh, in the case of vertical procedure, and along the inguinal canal, with a possible distortion of the labia major, in the case of horizontal procedure.