Nonexcisional, minimally invasive rejuvenation of the neck

A Retrospective Analysis of Upper Arm Rejuvenation Surgery in 50 Patients

BACKGROUND

Upper arm aesthetics often suffer from aging effects such as skin laxity and sagging due to collagen and elastin depletion. Fat loss, obesity, and weight fluctuations further exacerbate these issues. Existing classification systems for upper arm excess are complex and have practical limitations.

OBJECTIVES

The aim of this study was to develop a more concise and clearer classification of upper arm excess that can guide surgical interventions effectively and assess clinical outcomes.

METHODS

Patients undergoing upper arm rejuvenation surgery from January 2020 to January 2023 were categorized as mild, moderate, or severe. Mild cases underwent suction-assisted liposuction (SAL), moderate cases underwent radiofrequency-assisted liposuction combined with SAL, and severe cases underwent brachioplasty combined with SAL. Arm circumferences and BODY-Q questionnaires were collected pre- and postoperatively.

RESULTS

The study included 50 female patients, aged 21 to 49 years. The average follow-up time was 7.5 [2.2] months. Arm circumference reduction rates were 6.8% in mild cases, 15.1% in moderate cases, and 17.3% in severe cases. Regarding the BODY-Q questionnaire for upper arms, the average score increased by 0.9 for mild, 2.1 for moderate, and 2.9 for severe cases. Complications were minimal, including 1 seroma and 2 cases of scar widening.

CONCLUSIONS

The revised classification system for upper arm excess proved effective in guiding surgical decisions. Selecting the surgical approach based on severity resulted in satisfactory outcomes based on BODY-Q scores. This system offers a concise, objective, and practical tool for plastic surgeons.

LEVEL OF EVIDENCE: 3

Nonsurgical Rejuvenation of the Neck

Nonsurgical skin tightening in the neck is an area of significant growth with seemingly countless devices. Optimal treatment choice depends on the patient's concerns, anatomy, and lifestyle. Patients with minimal skin laxity, but dynamic platysmal bands may benefit from botulinum toxin injections. Mild to moderately lax skin can be addressed with microfocused ultrasound or radiofrequency with microneedling. Significant sun damage and laxity can both be addressed with fractional ablative lasers. Options for submental preplatysmal fat include percutaneous radiofrequency, radiofrequency-helium plasma, deoxycholic acid injections, and cryolipolysis. Of these, percutaneous radiofrequency has the highest patient satisfaction and lowest complication rate.

Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck

Background

Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited.

Objective

Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment.

Methods

Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference.

Results

Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach.

Conclusion

The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Assessment of Laser Parameters to Improve Lid Tension-A Proof of Concept towards Lasercanthoplasty

BACKGROUND

Preliminary clinical work indicates that increasing eyelid tension improves the function of the meibomian glands. The aim of this study was to optimize laser parameters for a minimally invasive laser treatment to increase eyelid tension by coagulation of the lateral tarsal plate and canthus.

METHODS

Experiments were performed on a total of 24 porcine lower lids post mortem, with six lids in each group. Three groups were irradiated with an infrared B radiation laser. Laser-induced lower eyelid shortening was measured and the increase in eyelid tension was assessed with a force sensor. A histology was performed to evaluate coagulation size and laser-induced tissue damage.

RESULTS

In all three groups, a significant shortening of the eyelids after irradiation was noticed (p < 0.0001). The strongest effect was seen with 1940 nm/1 W/5 s, showing -15.1 ± 3.7% and -2.5 ± 0.6 mm lid shortening. The largest significant increase in eyelid tension was seen after placing the third coagulation.

CONCLUSION

Laser coagulation leads to lower eyelid shortening and an increase in lower eyelid tension. The strongest effect with the least tissue damage was shown for laser parameters of 1470 nm/2.5 W/2 s. In vivo studies of this effect have to confirm the efficacy of this concept prior to clinical application.

The MICRO-Lift: A Ligaments-Based Anatomic Technique for Lower Face and Neck Rejuvenation Using Bipolar Radiofrequency

BACKGROUND

The aim of this paper is to present the results of a new technique for lower face and neck rejuvenation named the MICRO-lift (Minimally Invasive, Combined Radiofrequency, Outpatient lift). This technique is based on a bipolar radiofrequency treatment applied to specific ligamentous areas.

METHODS

Inclusion criteria were patients with skin laxity of the neck and jowls, with or without fat accumulation. Patients who presented platysma sag and alteration of subplatysmal structures were excluded from the study. The distribution of the energy was adapted to the ligament anatomy, differentiating three areas based on the energy concentration. In all patients, sex, age at surgery, type of anesthesia, radiofrequency parameters and complications were registered. In all cases, standard photographs and satisfaction interviews were conducted preoperatively and postoperatively. Satisfaction evaluation was also assessed.

RESULTS

Sixty-five patients underwent MICRO-lift technique for the lower face and neck. All patients in our series were female. There were no major complications. Minor complications included transient paralysis of the marginal mandibular (4,6%), infection of the submental incision that required incisional drainage (3,1%), and deep skin burn in the neck (1,5%). Fifty-nine patients were satisfied a year after the treatment (90,8%).

CONCLUSIONS

The MICRO-lift can produce outstanding and satisfying improvements in cervicofacial appearance. This new approach offers a predictable strategy to achieve the desired aesthetic results, making this procedure more reliable and reproducible for both novel and experienced surgeons with bipolar radiofrequency.

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 .

Temperature-Controlled Monopolar Radiofrequency in the Treatment of Submental Skin Laxity: A Prospective Study

BACKGROUND

Laxity of the submental area is a common cosmetic complaint of the aging population.

OBJECTIVES

The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift.

METHODS

A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes.

RESULTS

At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as "improved" at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation).

CONCLUSIONS

Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months.

LEVEL OF EVIDENCE: 4

Development and Validation of IBSA Photographic Scale for the Assessment of Neck Laxity

Objective

To describe the development and validation of the 5-grade photographic IBSA Neck Laxity Scale.

Methods

The scale was developed from 2 real images, which led to the creation of 5 morphed images, representing different degrees of severity of laxity of the neck. For validation, a set of 50 images (25 real and 25 morphed) was created and sent for evaluation to 6 trained raters (physicians) in 2 rounds, 1 month apart. Raters had to assess each image according to the 5-image scale. Inter-rater and intra-rater reliability in both rounds was evaluated.

Results

As to intra-rater reliability, single rater kappa scores between 0.69 and 0.87, and a global kappa score of 0.78 were observed. Inter-rater agreement was measured by means of the intra-class correlation coefficient and scores higher than 0.85 were reported, indicating excellent reliability.

Conclusion

IBSA Neck Laxity Scale is a validated and reliable scale.

The Efficacy and Safety of Subcutaneous Radiofrequency After Liposuction: A New Application for Face and Neck Skin Tightening

BACKGROUND

Minimally invasive or noninvasive skin-tightening procedures have become trends in facial and neck rejuvenation. Radiofrequency-assisted liposuction (RFAL) is a new choice for the treatment of skin relaxation that is more effective than noninvasive surgery without surgical incision.

OBJECTIVES

The authors recommend a 2-step method in which radiofrequency is applied after appropriate liposuction is performed. This approach is safer and more effective than traditional RFAL, and the authors detail the safety guidelines, operative techniques, postoperative satisfaction results, and complications.

METHODS

A total of 227 patients with lower face and neck skin laxity underwent RFAL between April 2012 and June 2019. The following data were collected: age, body mass index, operative duration, volume of fat aspirated, amount of energy delivered, and number and type of complications. Patient satisfaction was surveyed postoperatively and assessed by third-party surgeons at 3 and 6 months.

RESULTS

At 6 months after operation, 78.8% of patients considered the results moderate to excellent, whereas 21.2% of the patients considered the results to be poor or thought there was no change. The photograph evaluation performed by independent plastic surgeons showed moderate to excellent results in 89.1% of patients. There were no major complications that required further medical or surgical intervention.

CONCLUSIONS

This 2-step method is a safe and effective improvement in the application of radiofrequency for face and neck skin tightening. Patients can achieve significant contour correction via minimally invasive surgery with a lower risk of side effects.

LEVEL OF EVIDENCE: 4

Radiofrequency Rejuvenation of the "Tweener" Patient: Under, Over, or Through the Skin

The demand for noninvasive facial rejuvenation continues to increase as younger, well-informed patients enter the aesthetic market. We refer to a subset of these patients as "tweeners," those who present with early signs of neck and facial aging, but who have not yet developed changes significant enough to warrant a traditional excisional surgery approach. Many of these patients are in search of a minimally invasive intervention, a bridge in between observation and surgery. The authors describe their experience with radiofrequency (RF) technology as an in-office tool to address the aging face in a select patient population. This review also attempts to comprehensively search the existing body of literature to describe the RF technologies and devices available for facial rejuvenation. The efficacy and safety profiles of the devices are discussed, and the devices are categorized by their method of RF delivery-over (contact), through (microneedle), and under (percutaneous) the skin.

Marginal Mandibular Nerve Mapping Prior to Nonablative Radiofrequency Skin Tightening

BACKGROUND

Aging skin and increased skin laxity is a prevalent concern of patients. Nonsurgical treatments, such as radiofrequency, are increasing in popularity due to decreased pain, downtime, and scarring. ThermiRF (Thermi, Irving, TX) is a subdermal radiofrequency treatment for tightening skin. When applying radiofrequency treatments to the neck, it is important to avoid ablating the marginal mandibular nerve and causing nerve trauma.

OBJECTIVES

The purpose of this study was to locate and record the position of the marginal mandibular nerve in 72 patients undergoing subdermal radiofrequency skin tightening, to determine how often the nerve correlates to its textbook anatomic position.

METHODS

Marginal mandibular nerves were located with a nerve stimulator and marked with the subject in both upright and recumbent positions. Photographs were taken and the nerve position in relation to the mandible was recorded.

RESULTS

The marginal mandibular nerve was in its correct anatomic position above the mandible in 18% of patients. Nerve position did not shift between the upright and recumbent positions. Only 10% of patients had left-right nerve symmetry.

CONCLUSIONS

To avoid nerve injuries, nerve mapping prior to nonablative radiofrequency treatment is recommended. The marginal mandibular nerve is not always in its correct anatomic position or symmetric to the opposing side. Its location cannot be assumed from the textbook anatomic position or from a single-side mapping.

LEVEL OF EVIDENCE: 4

Thermal effects of percutaneous application of plasma/radiofrequency energy on porcine dermis and fibroseptal network

Background

Skin laxity is one of the defining characteristics of aging and can be the result of various factors including intrinsic aging, genetics, diet, stress, lifestyle, sun exposure, weight fluctuations, and smoking. Recent reports suggest the ability of subdermal energy application to reduce skin laxity. Thermal energy can be delivered using different devices including lasers, radiofrequency (RF) monopolar and bipolar devices, and plasma/RF devices. Plasma‐based energy platforms generate a plasma gas, allowing heat to be applied to the tissue. This study focused on the evaluation of thermal effect of plasma/RF compared to a monopolar RF device applied percutaneously to the subdermis and connective fibroseptal network in a porcine model.

Methods

The subdermal application of energy was conducted using a plasma/RF system and a monopolar RF system. Both low and high energy/temperature settings were evaluated in dynamic and stationary modes. Histomorphometry was used to determine the depth of thermal effect associated with each treatment setting.

Results

Both dermis and fibroseptal network tissue exhibited the presence of microscopically thermally treated zones. There were no significant differences in average and maximum depths of thermal effect between the different handpieces and electrosurgical systems used for all treatment settings.

Conclusions

No significant differences in the thermal effect between plasma/RF and monopolar RF systems were observed, suggesting that plasma/RF systems can be safely used for the percutaneous application of energy in the subcutaneous space.

The use of radiofrequency-assisted lipolysis with radiofrequency microneedling in premature jowl and neck laxity following facialplasty

BACKGROUND

A subset of facelift patients have premature redevelopment of skin laxity in the lower face and neck. Many patients seek alternatives to revision facelifts to avoid high risks and costs. Radiofrequency-assisted lipolysis (RFAL) with Radiofrequency (RF) microneedling may be alternative minimally invasive options.

OBJECTIVE/AIM

To evaluate the efficacy of radiofrequency energy devices for treatment of premature jowl and neck skin laxity following facialplasty.

METHODS

This is a single-center, prospective study of patients seeking treatment for jowl and neck skin laxity 1-5 years following facialplasty. Treatment was performed with the InMode radiofrequency AccuTite^® and Morpheus8^® systems. Study duration was 12 months with 6 months of follow-up. Endpoints included improvement in skin tightening assessed by blinded investigators, and investigator and subject assessment of skin appearance. Subjects also rated satisfaction with treatment and pain levels.

RESULTS

The study protocol was completed by nine patients. Based on investigator evaluations, 33% had marked improvement at 3 months, which increased to 55% at 6-month postprocedure. Patient-reported improvement was "markedly improved" in 67%, "moderate improvement" in 11%, and "slight improvement" in 22% at 3 months. Overall patient satisfaction was rated as "very satisfied" by 33% and "satisfied" by 67% at 3 months. There were no adverse events reported.

CONCLUSION

The results of this study provide supporting evidence that RFAL technology can provide a safe, minimally invasive, and effective treatment for skin laxity in the jowls and neck in patients who desire further correction after undergoing primary facelift.

Radiofrequency-assisted Liposuction for Neck and Lower Face Adipodermal Remodeling and Contouring

Background:

The purpose of this study is to report our experience using radiofrequency-assisted liposuction (RFAL) for neck and face contouring. This article details the operative technique, selection, complications, third-party surgeon appraisal, and patient satisfaction survey.

Methods:

From November 2009 to November 2013, 55 patients who underwent RFAL treatment were enrolled in the study. Postoperative patient satisfaction surveys were conducted, and 2 independent plastic surgeons evaluated contour and skin quality with randomized preoperative and postoperative photographs at 6 months postoperatively. The different parameters recorded involved age, sex, weight, body mass index, operative time, amount of fat aspirated and energy delivered, complications, and aesthetic outcome in 1 and 4 weeks and 3 and 6 months. Our longest follow-up was 4 years. Patients were asked 6 months postoperatively to grade their satisfaction as poor, no change, moderate, good, and excellent.

Results:

The mean age was 51 years (range, 35–61 years), and the mean amount of fat aspirated was 30 mL (range, 10–200 mL). Five out of 55 patients (9.1%) developed tissue hardness that resolved with massage. All patients were followed up for a minimum of 6 months. Eighty-five percent of patients were satisfied with their contouring result and degree of skin tightening (48/55 patients). Two independent plastic surgeons considered the improvement in contouring and degree of skin tightening good to excellent in 52 of 55 cases.

Conclusions:

In appropriately selected patients, RFAL neck and face contouring represent a safe procedure to achieve significant improvement of the skin laxity and fat deposits of the cervicomental zone and jowls.

Botulinum toxin in the management of facial paralysis

PURPOSE OF REVIEW

Complete flaccid facial paralysis, as well as the synkinetic and hyperkinetic sequelae of partial recovery, has significant impact on quality of life. Patients suffer from functional deficiencies, cosmetic deformity, discomfort and social consequences leading to emotional distress. Despite an extensive and sophisticated array of available interventions for facial reanimation, most patients have persistent issues that require consistent follow-up. In long-term management, botulinum toxin (BT) injection remains a critical tool in the treatment of the facial paralysis patient, particularly in the case of synkinesis, hyperkinesis and imbalance. We review the recent scientific literature and highlight key principles and developments in the use of BT in the management of facial paralysis, including less common applications for acute facial paralysis, hyperlacrimation and pseudoptosis.

RECENT FINDINGS

We reviewed the literature for the latest advances in the use of BT in facial paralysis, including applications and technique, as well as measurement tools and adjunct exercises. We also share our experience in treating our own patient population.

SUMMARY

BT continues to be a well tolerated and effective tool in the long-term management of facial paralysis, specifically in treating synkinesis, imbalance and hyperkinesis, as well as hyperlacrimation and pseudoptosis. Consistent measurement tools and adjunct neuromuscular retraining are crucial in the successful deployment of BT. Controversy exists as to whether BT should be used to manage facial paralysis during the acute phase, and whether BT application to the nonparalyzed face can improve long-term recovery in the paralyzed side.

Radiofrequency-Assisted Liposuction Compared with Aggressive Superficial, Subdermal Liposuction of the Arms: A Bilateral Quantitative Comparison

BACKGROUND

Liposuction of the arms alone may be inadequate for aesthetic improvement because of skin laxity. Radiofrequency-assisted liposuction (RFAL) and aggressive superficial liposuction (SupL) have been described to stimulate soft tissue retraction to improve results. We compare the techniques and describe a classification scheme that factors skin laxity, skin quality, and Fitzpatrick type to provide treatment recommendations.

METHODS

Ten consecutive female patients underwent RFAL of 1 arm and SupL on the contralateral arm. All patients had Fitzpatrick skin types of III, IV, or V with an average body mass index of 26.0. Using fluorescent tattooing, key points on the arm skin were measured preoperatively and postoperatively to indicate changes in surface area.

RESULTS

There were no complications in the group, and all patients reported satisfaction with the aesthetic results. All patients showed reduction of measured skin surface areas and skin distances postoperatively. At 1 year, the measured surface area reductions on the anterior arms averaged 15.0% for RFAL and 10.9% for SupL on the anterior arm skin. Posteriorly, RFAL showed 13.1% reduction and SupL 8.1% reduction in the surface areas at 1 year. Linear reduction for RFAL averaged 22.6% and 17.8% for SupL 1 year postoperatively anteriorly.

CONCLUSION

Both RFAL and SupL of the arms showed quantifiable and sustained reductions in skin surface. Good contour and soft tissue contraction were achieved with both techniques but RFAL with its safety features presents an alternative to SupL, which has a higher complication rate, risk for contour deformities, and steeper learning curve.

Facial skin rejuvenation by combination treatment of IPL followed by continuous and fractional radiofrequency

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of combination facial treatment by 3 technologies.

MATERIALS AND METHODS

Eleven patients completed the clinical trial that consisted of alternate treatments of intense pulsed light (IPL) in 3 sessions and continuous + fractional bipolar radiofrequency (RF) in 3 alternating sessions, 3 weeks apart. Follow-up visits were made at 6 and 12 weeks following the last treatment. Lesions were evaluated by photographs taken at baseline and at follow-up time points according to predetermined scales.

RESULTS

Results showed statistically significant improvement in wrinkling (24% after 6 weeks and 33% after 12 weeks), pigmentation (38% after 6 weeks and 62% after 12 weeks), vascular lesions (29% after 6 weeks and 67% after 12 weeks), and laxity (37% after 6 weeks and 40% after 12 weeks).

CONCLUSIONS

Combination facial treatment by IPL, and continuous and fractional RF is safe and enables the treatment of a variety of facial lesions, taking advantage of accessible applicators for different clinical indications on the same device. Thus, comprehensive facial skin rejuvenation has become feasible.