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

The surgical net technique, originally conceptualized to mitigate postoperative hematomas, has evolved into a versatile tool, transcending its initial purpose, and signaling a new era of surgical innovation. This article provides a comprehensive overview of the surgical net's journey from a targeted solution to a multifaceted surgical asset and explores its burgeoning applications, challenges, and future trajectories. Despite early reluctance due to anatomical concerns and unfamiliarity with the novel technique, the surgical net's consistent success in various surgical contexts from facial surgeries to gynecological applications has catalyzed its widespread global adoption. The technique's integration of the progressive tension method and enhanced skin redraping capabilities underscores its contribution to optimal aesthetic outcomes and improved surgical control. Noteworthy is its role in the innovative concept of gliding surgery, marked by procedures like the gliding brow lift and Glidelift, demonstrating the surgical net's adaptability and effectiveness in diverse surgical environments.Contributions from international surgeons have expanded its applications to areas like axillary space obliteration after breast implant, postmastectomy closure, and the management of postpartum hemorrhage, showcasing the surgical net's global impact and universal commitment to optimizing surgical outcomes. The article delves into the anatomical considerations essential for adapting the surgical net technique to various surgical contexts, emphasizing the need for continuous research, clinical trials, and multidisciplinary collaboration to navigate emerging challenges and ensure its sustained efficacy and safety.In conclusion, the article highlights the surgical net technique's unwavering potential for further advancements, greater procedural efficiency, and the continued elevation of patient care standards. The consistent evolution of its applications, paired with a dedicated approach to addressing emergent challenges, reinforces the surgical net's enduring contribution to surgical innovation and global patient welfare., Competing Interests: None declared., (Thieme. All rights reserved.)

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

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

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

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

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

Background: Creating the ideal aesthetic eyebrow shape and position is an important goal in facial rejuvenation. One challenge of an eyebrow lift is to find a predictable procedure that balances the advantages and disadvantages of the available strategies. The gliding brow lifting (GBL) is a technique that provides minimal incisions, an effective and stable eyebrow lift, and offers the advantage of precise reshaping of the eyebrow., Methods: In a retrospective review, 124 patients, who underwent GBL technique from November 2015 through April 2016, were evaluated. With minimal incisions and tumescent infiltration, the subcutaneous plane of the forehead, eyebrows and temporal face is undermined releasing the skin from the underlying frontalis muscle, orbicularis oculi muscle, corrugator muscle and temporal parietal fascia. Fixation of the repositioned and reshaped eyebrow is achieved with the use of a hemostatic net for temporary cutaneous fixation., Results: The average follow-up period was 17 months. Adequate brow repositioning and/or reshaping was achieved in 118 patients. Six patients had bilateral or unilateral recurrence of ptosis. Of these patients with recurrence, four patients had the same procedure re-performed within 1 month postoperatively with successful repositioning and/or reshaping of their brow. There was no incidence of hematoma, seroma, infection, permanent sensory changes, motor dysfunction, skin flap necrosis or alopecia., Conclusion: The "gliding brow lifting" (GBL), which combines subcutaneous frontal undermining with minimal incisions, elevation and reshaping of eyebrow and use of a temporary cutaneous fixation with hemostatic net (Net), allows effective, long-lasting results with low rates of complications and satisfactory results., Level of Evidence Iv: 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 facial plastic surgeons with the insight to avoid and address common pitfalls in neck procedures. Many aesthetic issues are created from overtreatment or undertreatment of components of the neck. Using the platysma muscle as the divide, ease of access to superficial anatomy leads to overtreatment problems, whereas difficulty of access to deeper structures leads to undertreatment problems and to overall imbalances. Strategies to accurately assess and treat all structures of the neck proportionally can be used to both avoid and treat any neck aesthetic issues. The advent of minimally invasive techniques has resulted in new complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In deep central necklift surgery, the first step to safely and effectively modify all of the relevant components is a thorough understanding of the nuances of the complex anatomic relationships and variations within the confined space of the deep central neck. There are anatomic variations that defy our traditional approaches to create the ideal neck in the aging patient as well as the young patient. This article concentrates on the surgically relevant anatomy of the deep central neck., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Poly-L-lactic acid (PLLA) was approved for use in Europe in 1999. In the United States, it was approved by the Food and Drug Administration in 2004 for the treatment of facial lipoatrophy associated with human immunodeficiency virus, and in 2009 for cosmetic indications in immune-competent patients. The need for consistent, effective PLLA usage recommendations is heightened by an increased consumer demand for soft tissue augmentation and a shift toward a younger demographic. Over the past 14 years, considerable experience has been gained with this agent, and we have come to better understand the clinical, technical, and mechanistic aspects of PLLA use that need to be considered to optimize patient outcomes. These consensus recommendations regarding patient selection, proper preparation and storage, optimal injection techniques, and other practical considerations reflect the body of evidence in the medical literature, as well as the collective experience of this author group.

Atrophic facial acne scarring is a widely prevalent condition that can have a negative impact on a patient's quality of life. The appearance of these scars is often worsened by the normal effects of aging. A number of options are available for the treatment of acne scarring, including chemical peeling, dermabrasion, ablative or nonablative laser resurfacing, dermal fillers, and surgical techniques such as subcision or punch excision. Depending on the type and extent of scarring, a multimodal approach is generally necessary to provide satisfactory results. Resurfacing techniques correct surface irregularities, long-lasting dermal fillers address the volume loss resulting from acne, and sub-superficial musculoaponeurotic system (SMAS) face-lift procedures counter the soft tissue laxity and ptosis associated with aging. This article briefly reviews the evolution of individual approaches to treating atrophic acne scarring, followed by case examples illustrating results that can be achieved using a multimodal approach. Representative cases from patients in their 30s, 40s, and 50s are presented. In the author's clinical practice, multimodal approaches incorporating fractionated laser, injectable poly-L: -lactic acid, and sub-SMAS face-lift procedures have achieved optimal aesthetic outcomes, high patient satisfaction, and durability of aesthetic effect over time.

Background: Transforming growth factor alpha (TGF-alpha) and its receptor (EGF-R) may regulate normal and malignant epithelial cell growth by an autocrine mechanism. We investigated the role of TGF-alpha in regulating head and neck SCC tumor growth., Methods: TGF-alpha and EGF-R levels were measured in 7 SCC cell lines and 14 SCC biopsies by RIA, Scatchard, and Western analysis. TGF-alpha autocrine stimulation of DNA synthesis in SCC cell lines was assessed by incubation with TGF-alpha neutralizing antibodies and tyrphostin AG 1478, a selective and potent inhibitor of EGF-R kinase., Results: All SCC cell lines synthesized TGF-alpha and expressed elevated EGF-R levels compared to normal keratinocytes. Twelve of the 14 SCC biopsies contained TGF-alpha protein and 8 had specific EGF-R. Exogenous TGF-alpha or EGF significantly increased DNA synthesis in 4 of 5 SCC cell lines. TGF-alpha neutralizing antibodies or tyrphostin AG 1478 reduced DNA synthesis in the two SCC cell lines (FaDu and SCC9) tested., Conclusions: These results indicate that SCC cell lines and tumors usually synthesize TGF-alpha, have elevated levels of EGF-R, and are mitogenically stimulated by a TGF-alpha autocrine system. Selective inhibition of the TGF-alpha system by EGF-R kinase inhibitors or TGF-alpha neutralizing antibodies may be useful strategies for treating SCC that overexpress TGF-alpha and its receptor.

Posterior pharyngeal wall augmentation has been advocated for patients having velopharyngeal dysfunction with a small coronal gap. Nonautogenous augmentation has not been accepted widely because of migration or extrusion of alloplastic implants and resorption of injected materials. Autogenous posterior pharyngeal wall augmentation has been performed for decades by Italian surgeons. A retrospective study was conducted to evaluate the efficacy of this procedure. Autogenous posterior pharyngeal wall augmentation, using a rolled superiorly based pharyngeal myomucosal flap, was performed on 14 patients, between November of 1989 and June of 1992, who fulfilled two criteria: velopharyngeal dysfunction unresponsive to speech therapy and a small (< 20 percent) coronal gap on velopharyngeal nasendoscopy. Of these, 3 patients had prior prosthetic velopharyngeal management, including 2 patients with Robin sequence. All patients were evaluated preoperatively and 3 months postoperatively with recorded (audio-videotape) perceptual, nasendoscopic, and fluoroscopic standardized speech and airway evaluations. The tapes were used for construction of a randomized master tape that was presented in blinded fashion and random order to three skilled raters for independent assessment of numerous perceptual and instrumental parameters of speech. The raters were uninvolved in the care of the patients or this study, and their intraobserver and interobserver reliabilities were known. Preoperatively, the majority of patients had nasal turbulence. All patients had variable degrees of hypernasality ranging from intermittent to pervasive. Parameters rated included (1) resonance (hypernasality, hyponasality, mixed), (2) auditory nasal emission (including nasal turbulence), and (3) visual characteristics regarding velopharyngeal closure. The visual parameters consisted of questions about whether a pharyngeal bulge was present or absent, descriptions of posterior pharyngeal wall movements with speech, level of closure, completeness of velopharyngeal closure, and quantitative descriptions of the percentage of velopharyngeal closure postoperatively. Examiners were instructed to look for a static and/or dynamic projection or bulge (i.e., Passavant's ridge) and, if a bulge was present, whether the level of velopharyngeal closure was on the same plane as the neoposterior pharyngeal bulge. Results of the extramural judgments of these parameters showed that there was no statistically significant tendency for patients' speech to be rated as more normal after the augmentation procedure than before it. We conclude that (1) autogenous posterior pharyngeal wall augmentation does not result in speech improvement and (2) autogenous posterior pharyngeal wall augmentation does not impair the nasal airway.

Two hundred eighty patients underwent neck dissection over a 10-year period: 138 during the 5-year period before the institution of Diagnosis-Related Group (DRG) reimbursement and 142 during the 5 years after DRG regulations. A comparison of these two groups by site of tumor, stage of disease, histopathology, previous treatment, type of neck dissection, whether neck dissection was carried out alone or in combination with another procedure, presence of preexisting disease, postoperative complications, and mortality revealed no significant differences. A 35% reduction in the length of hospital stay from 16 to 10 days was identified in the post-DRG group with no detrimental effects on patient care. The variables found to have the greatest impact on length of hospital stay were the extent of operation and postoperative complications.

Among the most elegant of recent flap refinements are innervated composite skin-muscle-mucosal flaps that restore the oral sphincter and carry both motor and sensory nerves. These flaps are based on the orbicularis oris, depressor anguli oris, and levator anguli oris perioral muscles of facial expression. Each flap can be dissected in a manner that allows transfer of the muscle into the oral sphincteric ring while restoring lip form and preserves the motor and sensory innervation. Each flap can be designed to carry skin and mucosa as needed for cover, lining, and vermilion reconstruction. Choice is determined by the specific anatomic lip defects. The orbicularis oris flap is most useful for large central defects of either the upper or lower lip. The depressor anguli oris flap is most useful for lateral lower lip defects or total lower lip reconstruction with bilateral flaps. The levator anguli oris is most useful for upper lip lateral element defects or for total upper lip restoration with bilateral flaps and an Abbe flap philtral reconstruction. Innervated composite flaps demonstrate substantial advantages when compared with preceding methods because of the superior function conveyed by the sphincter reconstruction and preserved motor and sensory nerve innervation.

A significant percentage of tympanic membrane (TM) perforations require some form of therapy to heal. Topical application of epidermal growth factor (EGF), a potent mitogen for epidermal and mesodermal cells, promotes healing of injuries in tissues histologically similar to TM, such as cornea and skin. We evaluated TM as a target tissue for EGF action. Specific, high affinity receptors for EGF were detected in TM (Kd = 3.1 nM, 150 fmol receptor/mg protein). Autoradiography of iodine 125-EGF binding to intact TMs revealed that EGF receptors were present on cells in the stratified squamous epithelial layer and in the stromal/mucoepithelial layer. Repetitive treatment of perforated cat TMs with 20 micrograms of EGF formulated in saline induced substantial hyperplasia of epithelial and stromal layers compared to paired TMs treated with saline. A single treatment of perforated cat TMs with 50 micrograms of EGF formulated in a hydrogel or in shredded Gelfoam produced significantly (p less than .05) smaller perforations at 6 days following the operation compared to paired TMs treated with vehicles. These results demonstrate that TM is a target tissue for EGF and that topical treatment with EGF stimulates healing of TM perforations.