Facelift

Neuregulin-1, a member of the epidermal growth factor family, mitigates STING-mediated pyroptosis and necroptosis in ischaemic flaps

Background

Ensuring the survival of the distal end of a random flap during hypoperfusion (ischaemia) is difficult in clinical practice. Effective prevention of programmed cell death is a potential strategy for inhibiting ischaemic flap necrosis. The activation of stimulator of interferon genes (STING) pathway promotes inflammation and leads to cell death. The epidermal growth factor family member neuregulin-1 (NRG1) reduces cell death by activating the protein kinase B (AKT) signalling pathway. Moreover, AKT signalling negatively regulates STING activity. We aimed to verify the efficacy of NRG1 injection in protecting against flap necrosis. Additionally, we investigated whether NRG1 effectively enhances ischemic flap survival by inhibiting pyroptosis and necroptosis through STING suppression.

Methods

A random-pattern skin flap model was generated on the backs of C57BL/6 mice. The skin flap survival area was determined. The blood supply and vascular network of the flap was assessed by laser Doppler blood flow analysis. Cluster of differentiation 34 immunohistochemistry (IHC) and haematoxylin and eosin (H&E) staining of the flap sections revealed microvessels. Transcriptome sequencing analysis revealed the mechanism by which NRG1 promotes the survival of ischaemic flaps. The levels of angiogenesis, oxidative stress, necroptosis, pyroptosis and indicators associated with signalling pathways in flaps were examined by IHC, immunofluorescence and Western blotting. Packaging adeno-associated virus (AAV) was used to activate STING in flaps.

Results

NRG1 promoted the survival of ischaemic flaps. An increased subcutaneous vascular network and neovascularization were found in ischaemic flaps after the application of NRG1. Transcriptomic gene ontology enrichment analysis and protein level detection indicated that necroptosis, pyroptosis and STING activity were reduced in the NRG1 group. The phosphorylation of AKT and forkhead box O3a (FOXO3a) were increased after NRG1 treatment. The increased expression of STING in flaps induced by AAV reversed the therapeutic effect of NRG1. The ability of NRG1 to phosphorylate AKT-FOXO3a, inhibit STING and promote flap survival was abolished after the application of the AKT inhibitor MK2206.

Conclusions

NRG1 inhibits pyroptosis and necroptosis by activating the AKT-FOXO3a signalling pathway to suppress STING activation and promote ischaemic flap survival.

Modified Deep-Plane Face Lift and Lower Midface Lifting Using Deep Fat Compartment Mobilization and Zygomaticus Major Muscle Plication

BACKGROUND

Most face-lift techniques greatly improve the lower face; however, techniques for lifting the midface are limited and difficult. Original deep-plane face lift is a way to lift the superficial musculoaponeurotic system and skin as a compound unit. Although it minimizes tear of the superficial musculoaponeurotic system during dissection, damage to the vascular system, and the incidence of skin necrosis, and can be easily used in secondary cases, the deep-plane face lift does not adequately improve nasolabial fold. The authors perform a modified and enhanced deep-plane face lift to improve the midface. In this article, the authors explain the effects and procedures of the method.

METHODS

This retrospective study included patients ( n = 632) on whom deep-plane face lift (DPF group; n = 299) and modified deep-plane face lift (M-DPF group; n = 333) was performed by a single surgeon from January of 2014 to January of 2017, and from February of 2017 to December of 2020, respectively, at a local clinic. The degree of improvement in wrinkles in the patients' nasolabial fold was assessed using the five-grade Wrinkle Severity Rating Scale (WSRS).

RESULTS

The preoperative WSRS score was 2.95 ± 0.89 in the DPF group and 2.89 ± 0.92 in the M-DPF group. There was no significant difference in the preoperative WSRS score between the two groups ( P = 0.058). The postoperative WSRS score was 1.81 ± 0.68 in the DPF group, which was significantly greater than the 1.65 ± 0.66 found in the M-DPF group.

CONCLUSION

This method developed by the authors that combines deep-plane face lift with deep fat compartment mobilization and zygomaticus major muscle plication is safe and directly improves the nasolabial fold and promotes a smiling expression for rejuvenation effects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Defining Standard Values for FaceReader Facial Expression Software Output

BACKGROUND

FaceReader is a validated software package that uses computer vision technology for facial expression recognition which has become increasingly popular in academic research to expedite, scale, and decrease the cost of facial emotion analysis. In this study, we compare FaceReader analysis to human evaluator interpretation in order to define standard values for the software output.

METHODS

Randomly generated facial images produced by generative adversarial networks were analyzed using FaceReader and by survey participants (n=496). The age, facial emotion, and intensity of emotion as determined by the software and survey participants were recorded. Results were analyzed and compared.

RESULTS

80 randomly generated images (20 children, 20 young adult, 20 middle aged, and 20 elderly; 38 male and 42 female) were included. Analysis of correlation between most common expression identified by FaceReader and the primary emotion detected by surveyors showed strong correlation (κ = 0.77, 95% CI = 0.64-0.91). On analyzing this correlation by age group, there was fair correlation in children (κ = 0.40, 95% CI = 0.078-0.72), perfect correlation in young adults (κ = 1.0, 95% CI = 1.0-1.0), strong correlation in middle aged adults (κ = 0.79, 95% CI = 0.53-1) and near perfect in elderly adults(κ = 0.9 , 95% CI = 0.7-1.0).

CONCLUSIONS

We provided the first study defining the expected average values generated by FaceReader in generally smiling images. This can be used as a standard in future studies.

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 .

Top 50 Highly Cited Publications in Facelift Surgery: A 50-Year Bibliometric Analysis Review

INTRODUCTION

Facelift surgery, also known as rhytidectomy, is a commonly performed procedure to address aging-related changes in the face and neck. Over the years, its techniques and methodologies have evolved. This study aimed to provide a bibliometric analysis of the top 50 most cited publications related to facelift surgery over a fifty-year period (1973-2023).

METHODS

The authors obtained data from the Web of Science Core Collection on July 15, 2023. Using a predefined search strategy, the most cited articles from 1973 to 2023 on facelift surgery were identified. The publications were analyzed for their type of study, journal of publication, geographic origin, and primary outcomes. Furthermore, the authorship gender distribution was assessed.

RESULTS

The majority of the publications (34 out of 50) were published in the "Plastic and Reconstructive Surgery" journal. The USA contributed to 72% of the research, followed by the UK, Mexico, Australia, and Germany. The primary outcomes varied from surgical techniques, anatomical studies, risk factors, patient-specific outcomes, and facial rejuvenation techniques, to comparative and historical progression of techniques. Notably, male authors dominated the field with 47 out of 50 papers having both a first and senior male author.

CONCLUSION

Facelift surgery has seen substantial research development over the past fifty years. The USA has been at the forefront of this research, with a predominant focus on surgical techniques and anatomical studies. Male dominance in authorship indicates potential scope for increased gender diversity in this specialty. Annual updates are recommended for continued insights.

LEVEL OF EVIDENCE III

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 .

Focused Ultrasound for Dermal Applications

Focused ultrasound (FUS) is emerging as one of the most promising, non-invasive treatment techniques. The advancement of transducer technology has paved the way for dermatological applications. A comprehensive review is presented for healthcare practitioners and researchers, summarizing the effect of various operational parameters on the injury zone produced by ultrasound beams for various dermatological applications, which include skin tightening, fat reduction, hyperpigmentation and cancer treatment. In this article, we aim to highlight the efficient operational parameters of FUS to enhance pain relief during surgery and its affordability for skin treatment. Finally, a prospective future technique for efficient FUS is discussed.

Imaging Features and Complications of Facial Cosmetic Procedures

Facial aesthetic procedures have become increasingly popular and complex, making knowledge of facial anatomy crucial for achieving desired outcomes without complications. Some of the most common procedures include blepharoplasty, bichectomy, face-lifts, facial implants, thread lifting, and fillers. Blepharoplasty and bichectomy are surgical procedures that respectively aim to restore youthful contours to the periorbita and create a slimmer lower face by removing Bichat fat from the maxillofacial region. Facial implants are used for aesthetic augmentation of the skeletal structure and restoration of facial contour by using biomaterials or autogenous bone grafts. Face-lift surgeries involve incisions and removal of excess skin, and thread lifts involve less invasive procedures performed by inserting threads beneath the skin, with the aim to lift the skin and thus reduce wrinkles and sagging. Fillers improve wrinkles and loss of facial volume, with biologic types made from animal, human, or bacterial sources (such as hyaluronic acid), while synthetic fillers include substances such as paraffin, silicone, calcium hydroxyapatite, polymethylmethacrylate microspheres, polyacrylamide hydrogel, hydroxyethyl-ethyl methacrylate, and poly-l-lactic acid. Synthetic fillers can be classified as rapidly resorbable (<12 months), slowly resorbable (<24 months), or permanent. Imaging modalities such as US, CT, and MRI can help identify and analyze each type of facial aesthetic procedure or filler, as well as their possible complications such as foreign-body granuloma, noninflammatory nodule, late intermittent persistent edema, filler migration, infection, or complications after removal of the buccal fat pad. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center The online slide presentation from the RSNA Annual Meeting is available for this article.

Histomorphological analysis of the superficial musculoaponeurotic system in Macaca mulatta species

INTRODUCTION

The superficial musculoaponeurotic system (SMAS) is a well described facial functional unit in humans. SMAS connects mimic musculature to the skin having many implication in facial mimic expression. One of the various morphological and physiological analogies in human and Macaca mulatta species is the facial mimic. The present study analyzed Macaca mulatta species SMAS morphology and its facial topographical differences and compared this with human SMAS tissue morphology.

MATERIAL AND METHODS

Macaca mulatta full-graft tissue blocks of skin, subcutaneous tissue and mimic muscles from five topographical different facial regions (Regio Temporalis, Regio Buccalis, Regio Infraorbitalis, Regio Angulus Oris and Regio Mandibularis) were collected postmortem from eight individuals (n = 8) at the German Primate Center, Leibniz Institute for Primate Research in Göttingen (DPZ) and studied histologically. Haematoxylin-eosin and azan stained histological serial sections of full-graft tissue blocks were analyzed and SMAS topographical differences evaluated.

RESULTS

SMAS typical tissue morphology was recognized in all Macaca mulatta histological serial sections (n = 780). Regio Infraorbitalis Macaca mulatta SMAS (MmSMAS) morphology was similar to human infraorbital SMAS morphology (type I SMAS). Suborbicularis oculi fat pad was recognized in Macaca mulatta samples. Human type I similar SMAS morphology was demonstrated over Macaca mulatta Regio Temporalis and Regio Buccalis. Regio Angulus Oris and the cranial area of the Regio Mandibularis presented human type II similar SMAS morphology. Type IV MmSMAS was closely related to the parotid gland tissue presence. The cervical area of the Regio Mandibularis presented human type V similar SMAS morphology.

CONCLUSIONS

SMAS is a complex fibro-musculo-adipose tissue network and probably an important pivot in Macaca mulatta facial system supporting mimic expression. This study provided insights into MmSMAS typology and similarity with human SMAS tissue morphology.

Artificial Intelligence in Surgical Evaluation: A Study of Facial Rejuvenation Techniques

Background

Aesthetic facial surgeries historically rely on subjective analysis in determining success; this limits objective comparison of surgical outcomes.

Objectives

This case study exemplifies the use of an artificial intelligence software on objectively analyzing facial rejuvenation techniques with the aim of reducing subjective bias.

Methods

Retrospectively, all patients who underwent facial rejuvenation surgery with concomitant procedures from 2015 to 2017 were included (n = 32). Patients were categorized into Groups A to C: Group A-10 superficial musculoaponeurotic system (SMAS) plication facelift (n = 10), Group B-SMASectomy facelift (n = 7), and Group C-high SMAS facelift (n = 15). Neutral repose images preoperatively and postoperatively (average >3 months) were analyzed using artificial intelligence for emotion and action unit alterations.

Results

Postoperatively, Group A experienced a decrease in happiness by 0.84% and a decrease in anger by 6.87% (P >> .1). Group B had an increase in happiness by 0.77% and an increase in anger by 1.91% (P >> .1). Both Group A and Group B did not show any discernable action unit patterns. In Group C, the lip corner puller AU increased in average intensity from 0% to 18.7%. This correlated with an average increase in detected happiness from 1.03% to 13.17% (P = .008). Conversely, the average detected anger decreased from 14.66% to 0.63% (P = .032).

Conclusions

This study provides the first proof of concept for the use of a machine learning software application to objectively assess various aesthetic surgical outcomes in facial rejuvenation. Due to limitations in patient heterogeneity, this study does not claim one technique's superiority but serves as a conceptual foundation for future investigation.

Level of Evidence 4

Subcutaneous Face and Neck Lift With Prefabricated Skin Excision: A Practical Technique With Favorable Results in Young and Middle-Aged Chinese Patients

BACKGROUND

Subcutaneous face and neck lift is a popular procedure in Chinese face and neck rejuvenation. However, there are limited studies focusing on the details and evaluation of this technique.

OBJECTIVE

To introduce our subcutaneous face and neck lift technique with prefabricated skin excision, evaluating the efficacy with patient reported FACE-Q Scale. In addition, to investigate on skin excision and patient's satisfaction under different circumstances.

MATERIALS AND METHODS

One hundred forty-five consecutive patients were identified who underwent subcutaneous face and neck lift with our technique. Online FACE-Q Scale was assessed for patients' satisfaction 6 months postoperatively. The skin excision and FACE-Q Scale were compared among different subgroups.

RESULTS

Fifty-eight patients completed the FACE-Q. Patients demonstrated high satisfaction overall and felt 8.8 years younger than their actual age. Intraoperative skin excision data verified the practicality of the prefabricated technique. There was a constant trend with patients' satisfaction among different age groups. The preliminary comparison between the facial bone reduction group and the general group revealed no significant difference.

CONCLUSION

The subcutaneous face and neck lift technique with prefabricated skin excision is an effective technique with favorable results in young and middle-aged Chinese patients.

LEVEL OF EVIDENCE

IV. Evidence obtained from a retrospective cohort analytic study.

Advances in Face-Lift Surgical Techniques: 2016-2021

BACKGROUND

Face-lift surgery is the most crucial and constantly evolving technique of facial rejuvenation. Periodic reviews synthesizing the latest face-lift techniques may help surgeons sharpen their surgical procedures.

METHODS

A literature search was conducted of the PubMed databases using the search term "face lift" and "rhytidectomy." Articles reporting rhytidectomy of the forehead/brow, midface, lower face, and neck were included. Sixty-nine articles were selected after independent screening by three of the authors. The Oxford Centre for Evidence-based Medicine scale was used for evaluating evidence level.

RESULTS

Of the 69 candidate articles, 10 studies (15%) reported techniques of neck lifting; 10 studies (15%) introduced techniques of endoscopic brow lifting; 7 studies (10%) pertained to brow lifting without endoscopic techniques. The most frequently reported locations of rhytidectomy were the brow/forehead (20%), neck (19%), and face-neck (17%). Additionally, articles regarding Asian face-lifts (14%) have been increasing. The evidence level of the articles was generally low, with only 10 articles assessed as level 1-3 with 59 articles as level 4-5.

CONCLUSIONS

Face-lift articles with high-level evidence are still lacking. Prominently, forehead lifting and neck lifting have become upward trends of rhytidectomy in recent years, and the techniques of short-scar face-lift have been more valued.

LEVEL OF EVIDENCE III

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 .

Aesthetic Values of the Buccal Fat Pad Excision in Middle Aged Patients

Background

Despite buccal fat pad (BFP) excision being an effective and established surgery for the reduction of lower facial volume, there are very few reports explaining a systematic and reliable method for this surgery. The author will demonstrate one method for BFP excision surgery with some important tips and information on the procedure.

Objectives

The author performed BFP excision surgery for patients seeking facial slimming or improvement of the ptotic lower face. To know the true efficacy of this surgery, objective facial scales were compared preoperatively and postoperatively.

Methods

Preoperative and postoperative three-dimensional (3D) pictures were taken, and numerical data for cheek volume and horizontal lower facial length were obtained from 3D picture analysis. The data were statistically analyzed to reveal postoperative improvements.

Results

The average age of the patients was 54.23 ± 10.31 years old. BFP excision surgery took 60.30 ± 5.93 minutes. Preoperative and 12 months postoperative body weight was 52.3 ± 6.84 and 52.3 ± 6.75 kg, respectively. The average weights for excised BFP were 1.74 ± 0.72 g right and 1.59 ± 0.71 g left. The average of preoperative lower facial volumes was 209.36 ± 30.22 mL right and 209.03 ± 30.13 mL left. The average 12 months postoperative lower facial volumes were 205.00 ± 30.37 mL right and 204.43 ± 30.02 mL left. The results showed a significant difference in both sides (P < 0.01). The average of horizontal lower facial lengths was 238.73 ± 10.87 mm preoperatively and 235.06 ± 10.57 mm 12 months postoperatively. The results affirm that there is a significant difference (P < 0.01).

Conclusions

A properly executed BFP excision can achieve distinct facial slimming for the capacious face and can also contribute to improving lower face sagging due to BFP ptosis in middle-aged patients.

Level of Evidence: 4

Total Neck Rejuvenation, Harnessing the Platysma in the Lower Neck and Décolletage

BACKGROUND

Efforts to rejuvenate the lower neck and décolletage have not been adequately addressed by neck lift techniques which predominantly focus on improving the cervicomental angle and correcting fullness in the submental and submandibular region. Disappointment with a lack of initial result in the lower neck and early relapse of laxity led the author (DJH) to adopt the Fogli/Labbé vertical neck lift with a fixation of the platysma muscles to Loré's fascia Fogli (Aesthet Plast Surg 32:531-541, 2008), Labbé et al. (Plast Reconstr Surg 117:2001-2007, 2006). Over the past 8 years, since the original "modified" Fogli description was published by Hodgkinson (Aesthet Plast Surg 36:28-40, 2012), the technique has evolved with a specific aim to improve the initial results of the neck lift in the lower half of the neck and have the result maintained in follow-up.

METHODS

The clinical photographs of female patients who underwent face and neck rejuvenation utilising a modified Fogli vertical platysma advancement technique were evaluated as to the improvement of the rejuvenation in the lower neck and décolletage and compared with the photographs obtained by the original pexy technique. The review was restricted to patients operated on in the prior extant three-year period and compared with the results of patients having surgery in that preceding five years prior to the review period.

RESULTS

The results of the recent technical modifications of the vertical lift by the platysma flap advancement were superior to the previous pexy technique and attributable to the advent of the surgical auricular-platysmal flap advancement. This flap, which in continuity with the distal platysma was affixed with permanent sutures to Loré's fascia after definitive release of the cervical retaining ligaments of the platysma.

CONCLUSION

The modifications of the vertical platysma fixation to Loré's fascia after mobilisation of the distal platysma by detachment of the cervical retaining ligaments utilising an advancement of the platysma led to improvement in the rejuvenation of the lower neck and décolletage when compared to the pexy technique of the original Fogli/Labbé description.

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.

Conservative Neck Rejuvenation

In the field of facial rejuvenation, among the recurrent topics, one of the most discussed is the return to less invasive techniques. Lower face rejuvenation is best achieved acting on the platysma muscle. Many techniques are used and usually include platysma section, redundancy reduction, and redraping. Platysma plication is also used especially in secondary cases because of the increased risk of nerve injury due to possible anatomical damage caused by previous operations. A technique that preserves the deep planes based on a new plication method is proposed (conservative neck rejuvenation). In this technique, the dissection plane is only subcutaneous to reduce the risk of nerve injuries. An effective neck contouring is possible using a simpler technique with very good results and a lower rate of morbidity.

The Anatomy of the Temporal and Zygomatic Branches of the Facial Nerve: Application to Crow's Feet Wrinkles

BACKGROUND

Advances in the understanding of wrinkling crow's feet while improving the safety and efficacy of botulinum toxin type A injection has pointed to drug dispersion in the lateral orbital wrinkles as a cause of adverse events of botulinum toxin type A injection. The purpose of this study is to identify the distribution of temporal and zygomatic branches of facial nerve in the orbicularis oculi muscles.

METHODS

Anatomical dissection of cadavers was performed in 31 cadavers, 13 females and 18 males, with ages ranging from 20 to 60 years, which of all had been embalmed by 10% formalin solution. The facial nerve was identified within subcutaneous tissue close periorbital region and both traced proximal and distal. Its temporal branch, zygomatic branch, facial and muscular entrance were located and accurately measured relative to established surface landmarks.

RESULTS

Dissection of the facial nerve revealed 2 to 6 entrances of the temporal branch into the orbicularis oculi and 1 to 5 entrances of the zygomatic branch into the orbicularis oculi. Concerning the measurements of neural entering points, distance and angle from orbicularis oculi muscle to lateral ocular angle, a distribution map of its muscular entrance and their patterns of distribution were constructed. According to the dense area of the coordinate map, there were 3 points determined as the muscular entrance points to established surface landmarks.

CONCLUSIONS

An anatomical dissection of cadavers was performed to identify the distribution of temporal and zygomatic branches of the facial nerve in the orbicularis oculi. According to the dense area of the coordinate map, the surface landmarks of 3 points were established as the muscular entrance of the facial nerve (MEF).