A Meta-Analysis of Complication Rates Among Different SMAS Facelift Techniques

Suture Net Technique for Mid-face Superficial Fat Compartments Restoration

BACKGROUND

Facial fold and groove formation is influenced by the ptosis of the superficial fat compartments in the mid-face region.

OBJECTIVE

This study aimed to design a facial rejuvenation technique that targets sagging of the mid-face fat compartments and achieves a youthful facial configuration.

MATERIALS AND METHODS

A total of 102 patients underwent suture net restoration. Each specific ptosis fat compartment was carefully lifted and held at the regional facial ligaments to effectively restore volume distribution. Patient outcomes were evaluated through preoperative and postoperative photography comparison, 3-D photographic analysis, and postoperative evaluations.

RESULTS

Significant mid-cheek rejuvenation was observed. The procedure resulted in a remarkable, 10.89% increase in malar projection. The nasolabial fold improved by at least 1 grade in 61.43% of the patients and by at least 2 grades in 37.14%. A total of 87.65% of the patients expressed high satisfaction or satisfaction with the outcomes of the procedure.

CONCLUSION

By specifically targeting the mid-face ptosis fat compartments, the technique demonstrated significant enhancements of both the nasolabial fold and the malar projection. The results indicate that this novel technique holds promise as an efficient approach for satisfactorily addressing facial aging concerns.

Medial Ligament Release: Is It a Proportional Standard?

Assessing the proportionality of extended facelift surgery across surgeons is not an easy task. Risks and assumed benefits need to be weighted, yet, especially the latter is difficult to objectify. Reverse engineering the pathway of two leading facelift surgeons suggest that excellent training and focused high-volume facelift surgery preceded their leadership. Yet these conditions are not available to all surgeons. Hence defining extended facelift techniques as the professional standard, could promote novice surgeons into a path that may not correspond to safe practice.

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process.

METHODS

Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021.

RESULTS

Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001).

CONCLUSIONS

A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time.

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 .

Evolution of Superficial Muscular Aponeurotic System Facelift Techniques: A Comprehensive Systematic Review of Complications and Outcomes

Background

Facelift procedures are a popular method of facial rejuvenation. The most common technique is superficial muscular aponeurotic system (SMAS) plication, with several variations. However, the optimal approach remains unclear. This review analyzed previous studies to compare SMAS facelift techniques, their outcomes, and complication rates.

Methods

A systematic search was conducted using the MEDLINE, Cochrane, Embase, and Google Scholar electronic databases in September 2022. The search included studies published from January 2000 to September 2022 using keywords such as "facelift," "complications," and "outcomes."

Results

This review examined 27 selected studies that evaluated 6 SMAS facelift techniques. The studies involved 6086 patients in total, over 85% of who were satisfied with the outcome of their surgery. The complication rates varied depending on the technique used, with the SMAS flap and composite SMAS technique having the highest (5.75%) and lowest (0.05%) complication rates, respectively. The most common complications were temporary facial nerve injury (0.85%) and skin necrosis (0.41%). To date, only one case of permanent facial nerve injury has been reported.

Conclusions

On the basis of our findings, SMAS facelift techniques achieve high patient satisfaction rates, with complication rates that vary by technique. The composite SMAS technique showed the lowest complication rates, whereas the SMAS flap showed the highest rate. However, some studies have not reported all complications, making it difficult to determine the best approach. Therefore, future studies are required to identify the most aesthetically pleasing technique with the lowest complication risk.

Trials, Tribulations, and Techniques for Transitioning to an Extended Deep Plane Facelift for All Patients: Insight from a Very Experienced Surgeon's Perspective

The extended deep plane facelift is a powerful technique to correct aging of the midface and neck. After many years of superficial muscular aponeurotic system lift techniques, the senior author transitioned to an extended deep plane facelift for all patients. The primary catalyst for this shift in practice was the pursuit of superior rejuvenation of the midface. Consistent uniform elevation of the deep plane with complete ligament release and management of the soft tissue flap were the most significant challenges in the early adoption period. Navigating the transition was facilitated by consultation with experienced colleagues and frequent cadaver dissections. This manuscript details the authors' current technique. Complications and recovery from this technique are similar to those reported with historical techniques and are minimized with proper preparation, precision, and perioperative management. In our experience the results from this procedure are extremely reproducible, durable, and natural, and patients are overwhelmingly extremely satisfied.

Evidence of Hematoma Prevention After Facelift

Hematoma is a common complication after facelift procedures. Multiple factors have been shown to increase the risk of hematoma formation, such as male gender, anticoagulant medication use, perioperative hypertension, increased intrathoracic pressure, and operative technique. The purpose of this manuscript is to provide an overview of existing literature to provide surgeons with evidence-based recommendations on how to minimize hematoma risk during facelift surgery. A literature search for hematoma and facelift surgery was performed that identified 478 unique manuscripts. Abstracts were reviewed, excluding articles not describing facelift surgery, those written before 1970, studies with a sample size of fewer than 5 patients, non-English studies, and those that did not provide postoperative hematoma rates. Forty-five articles were included in this text, with their recommendations. Measures such as the prophylactic management of pain, nausea, and hypertension, the use of fibrin glue tissue sealants, the use of local anesthesia rather than general anesthesia, and strict blood pressure control of at least <140 mmHg were found to significantly reduce hematoma formation. Quilting sutures has shown benefit in some high-risk patients. Measures such as drains, compression dressings, perioperative use of selective serotonin reuptake inhibitors, and perioperative steroids had no significant effect on hematoma formation. In addition to appropriate patient selection and careful intraoperative hemostasis, many adjunct measures have been shown to reduce postoperative hematoma formation in facelift procedures.

LEVEL OF EVIDENCE: 3

Facial Nerve Considerations for the Deep Plane Facelift and Neck Lift

The surgical approach to facial rejuvenation has evolved significantly over the last century. As surgeons have deepened their understanding of facial anatomy over the last half century, so have their surgical approaches to the rhytidectomy, with increasingly extensive manipulation of the underlying soft tissue in the face. While these procedures have become more comprehensive and natural in their approach, the risk of temporary facial palsy also appears to be on the rise. In this text, we review the technique for deep plane facelifts and neck contouring with an emphasis on the facial nerve anatomy and methods to preserve the intricate facial nerve network during tissue dissection and modification. Careful execution of the surgical steps involved, including deep neck contouring, SMAS (superficial musculoaponeurotic system) suspension, and skin management, is essential to achieve the authentic aesthetic outcomes that patients desire while ensuring patient safety.

Occurrence and treatment of peripheral nerve injuries after cosmetic surgeries

Although non-invasive and minimally invasive aesthetic procedures increasingly dominate the cosmetic market, traditional plastic surgery remains the most effective improvement method. One of the most common complications in plastic surgery, peripheral nerve injuries, though has a low incidence but intrigued plastic surgeons globally. In this article, a narrative review was conducted using several databases (PubMed, EMBASE, Scopus, and Web of Science) to identify peripheral nerve injuries following cosmetic surgeries such as blepharoplasty, rhinoplasty, rhytidectomy, breast surgeries, and abdominoplasty. Surgery-related nerve injuries were discussed, respectively. Despite the low incidence, cosmetic plastic surgeries can cause iatrogenic peripheral nerve injuries that require special attention. The postoperative algorithm approaches can be effective, but the waiting and treatment processes can be long and painful. Preventive measures are undoubtedly more effective than postoperative remedies. The best means of preventing disease is having a good understanding of anatomy and conducting a careful dissection.

Hemostatic Net in Facelift Surgery: A 5-Year Single-Surgeon Experience

BACKGROUND

The hemostatic net has been promoted as a safe and effective method to prevent hematoma formation following facelift procedures. To date there is little published evidence to validate the replicability and effectiveness of the technique.

OBJECTIVES

This study presents 2 cohorts of facelift patients from a single surgeon's practice to assess the impact of the hemostatic net on hematoma formation.

METHODS

The records of 304 patients were reviewed on whom the hemostatic net was placed following a facelift between July 2017 and October 2022. Data were collected and assessed for complications and compared with a control group of 359 patients who underwent a facelift procedure without placement of a hemostatic net by the same surgeon between 1999 and 2004.

RESULTS

A total of 663 patients were included. In this retrospective cohort study, analysis of available data showed a significantly reduced hematoma rate of 0.6% in the intervention group compared with 3.9% in the control group (P = .006722).

CONCLUSIONS

The use of the hemostatic net is a safe, reproducible, and effective technique in reducing the risk of hematoma in facelift surgery.

LEVEL OF EVIDENCE: 4

State of the Evidence for Facial Skin Cancer Reconstruction

This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

Evidence-Based Medicine for Lower Facial Rejuvenation

Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine.

A Systematic Review and Meta-Analysis of Early Relapse After Facelift

BACKGROUND

Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure.

METHODS

The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria.

RESULTS

RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis.

CONCLUSIONS

Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress.

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 .

Facelift Techniques: An Overview

Facelift techniques can be classified according to the depth and extent of the dissection applied. Imbrication and plication of the superficial musculoaponeurotic system (SMAS) referred to as "SMAS lifts" or "classical facelifts" are the most commonly used techniques. Plication techniques involve in-folding of the SMAS and suture suspension without any SMAS incision whereas imbrication techniques involve a SMAS incision with a portion of the SMAS either removed or transposed with or without limited sub-SMAS dissection. Aging changes in the lower face and neck can be successfully treated with SMAS lift techniques. However, there is no lifting effect at midface level or improvement in the nasolabial folds since the retaining (zygomatic cutaneous and masseteric cutaneous) ligaments that prevent the transmission of traction to the malar portion of the facelift dissection are not released. Extended facelift techniques involve surgical release of these ligaments, and produce combined, balanced, and harmonious rejuvenation of the midface, cheek, and lower face without requiring a separate midface lift procedure. There are different techniques having similar extended midface dissections with some variations: The extended SMAS technique involves a long skin flap and a distinct SMAS flap dissected and pulled separately. The high SMAS technique has a similar dissection but involves a higher SMAS flap along the superior border of the zygomatic arch. The deep plane facelift involves undermining of skin-SMAS flap as a single unit following a more limited subcutaneous dissection. In the composite plane facelift, in addition to deep plane facelift dissection, the lower part of the orbicularis oculi muscle is also dissected and included in the flap. As they have a single unit, deep and composite flap facelifts allow excellent blood supply to the overlying skin. In this article, various facelift techniques are discussed in detail in line with the relevant surgical anatomy.

Modified Composite Plane Facelift with Extended Neck Dissection

The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low superficial muscular aponeurotic system (SMAS) facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, high SMAS, deep plane facelift, and composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less-invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the sub-SMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improve the cervical contouring and enhances the jawline rejuvenation. This study explains modified composite-flap facelift with extended neck dissection in a step-by-step manner and highlights anatomical details to perform a safe, effective, and successful extended face and neck lift surgery.

Sub-SMAS Reconstruction of Retaining Ligaments

BACKGROUND

Retaining ligaments must be fully released for effective soft-tissue mobilization during sub-superficial musculoaponeurotic system (SMAS) facelifts. Standard deep temporal fascia and lateral SMAS fixation techniques may fail earlier than anticipated, which may cause a relapse of facial aging signs. Reconstruction of retaining ligaments was previously proposed to enhance facelift fixation.

OBJECTIVES

The author sought to assess the effect of their ligament reconstruction technique on early relapse rates and complication rates.

METHODS

This study was a comparative analysis of 188 consecutive facelift cases where retaining ligaments were reconstructed employing the described techniques. A total 104 patients with standard fixation were analyzed in the control group. A novel set of criteria was established for the diagnosis of early relapse after facelift surgery based on the validated Merz scale.

RESULTS

Early relapse rate was significantly lower (0.53% vs 5.76%) in the ligament reconstruction group compared with the control group. Ligament reconstruction was associated with an increased rate of temporary nerve paralysis (8.5%).

CONCLUSIONS

Sub-SMAS reconstruction of retaining ligaments enhances facelift fixation and reduces the rate of early relapse. Increased risk of temporary neuropraxia is a reasonable trade-off.

LEVEL OF EVIDENCE: 4

Analysis of the Outcome of Reoperative Face Lifts Using Sub-SMAS Techniques

BACKGROUND

Reoperative face lift can be technically more demanding than primary face lift because of altered anatomy and scarred tissue plane. This study was carried out to analyze the outcome of reoperative face lift using sub-superficial musculoaponeurotic system (SMAS) techniques, including facial nerve injury.

METHODS

Seventy reoperative face lifts using sub-SMAS techniques were studied. Data analysis includes the patients' demographic information, the interval between the previous face lift and the reoperative face lift, intraoperative findings of the SMAS-platysma anatomy, complications, and rate of revision. A separate group of 180 primary face lifts using sub-SMAS techniques during the same period was analyzed for the incidence of facial nerve injury only.

RESULTS

Intraoperative findings in the reoperative group consist of anatomical changes in the SMAS-platysma in 82.9 percent of the cases, including increased fibrosis, changes in thickness, limited movement, and increased adhesion on the undersurface. Sub-SMAS dissection was completed in 137 hemifaces. Complication consists of seroma (1.4 percent), delayed healing (1.4 percent), and temporary facial nerve injury (7.1 percent), which was not correlated with increased fibrosis or adhesion under the SMAS-platysma. The rate of revision within 18 months was 11.4 percent. There was a 2.2 percent incidence of temporary facial nerve injury in the primary face-lift group.

CONCLUSIONS

Sub-SMAS techniques, with few exceptions, were successfully used in a series of reoperative face lifts. Temporary facial nerve injury was the most frequent complication. Satisfactory outcome was obtained in all the cases. The incidence of facial nerve injury was higher than in primary face lift using sub-SMAS techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facelift Patients Receiving Intraoperative Administration of a Self-assembling Hemostat Agent Experienced Minimal Bruising and No Acute Hematomas: A Pilot Study

Background

Hematomas are consistently cited as the most common complication of facelift surgery, with reported incidence rates ranging from 1% to 9% despite preventative measures. A self-assembling RADA16 peptide solution (PuraSinus, 3-D Matrix, Newton, MA) designed to aid in wound healing, adhesion prevention, and bleeding control has demonstrated hemostatic control of intra- and postoperative bleeding associated with various surgical procedures, including nasal and sinus surgery.

Objectives

To report surgical experience using novel application of RADA16 hemostatic agent in facelift procedures.

Methods

Through exploring incorporation of RADA16 hemostatic agent into standard of care, 15 higher-risk facelift patients were treated intraoperatively between December 2020 and July 2021. Postoperative follow-up was on post-procedure day 1 and 3 and at approximately one week. During follow-up, potential complications were assessed subjectively, including hematoma, swelling, and bruising; postoperative observations recorded; and photographs taken.

Results

Among facelift patients receiving intraoperative RADA16 hemostatic agent there were no hematomas or protracted ecchymosis events. The only significant complication was one patient admitted for intravenous hydration due to post-operative nausea and vomiting. All patients had minimal bruising or a dramatic absence of bruising and experienced no hemorrhage or hematoma. Through surgical experience, technique for RADA16 hemostatic agent placement was optimized and procedural details are provided.

Conclusions

Intraoperative administration of topical RADA16 hemostatic agent appears to deter acute hematoma and hemorrhage formation and early experience suggests that RADA16 hemostatic agent may also attenuate post-operative bruising in facelift patients. These observations warrant further investigation in a larger randomized controlled study.

Level of Evidence: 4

Asian Face Lift with the Composite Face Lift Technique

BACKGROUND

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

METHODS

Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

RESULTS

Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

CONCLUSION

The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facelift With Power-Assisted Dissection: A Preliminary Report

BACKGROUND

Subcutaneous elevation of the skin has remained a key component in all facelift techniques.

OBJECTIVES

The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss.

METHODS

The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck.

RESULTS

Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema.

CONCLUSIONS

The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.

LEVEL OF EVIDENCE: 4

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

An outcome comparison of superficial versus deep plane dissection of cervicofacial flaps: A systematic review and meta-analysis

PURPOSE

Cervicofacial flaps represent an excellent option for coverage of cheek defects secondary to oncologic resection, trauma or infection. However, there remains clinical equipoise regarding whether superficial plane or deep plane dissection results in the lowest rates of complications and optimal outcomes.

METHODS

A systematic review and meta-analysis of proportions was conducted to assesses outcomes between cheek reconstruction superficial plane or deep plane cervicofacial flaps. Outcome measures included flap necrosis, ectropion, hematoma formation, facial nerve injury, and requirement for further operative or non-operative intervention.

RESULTS

Of 881 citations identified for review, 10 met the inclusion criteria. In total, 284 patients received superficial plane flaps while 44 patients received deep plane flaps. Overall, reported rates of complications were low for cervicofacial flaps. The proportion of necrosis, ectropion, and hematoma were 3.05% (95% CI: 0.00-10.71%), 2.03% (95% CI: 0.41-4.42%), and 0.05% (95% CI: 0.00-3.29%), respectively. No cases of permanent facial nerve injury were reported. Sub-group analysis demonstrated comparable rates of complications between superficial and deep plane dissection and no difference was found between groups. Other complications were noted with low incidence.

CONCLUSIONS

Currently published literature demonstrates that superficial and deep plane cervicofacial flaps exhibit similar rates of complications, although there is a low level of evidence overall. Overall, the rates of flap necrosis (3.05%), ectropion (2.03%), and hematoma (0.05%) are low. Notably, there were no reported cases of permanent facial nerve injury from either technique.

Complications in Facial Esthetic Surgery

Esthetic surgery continues to become increasingly popular both in the United States and globally. Facial esthetic procedures in particular account for a large proportion of procedures performed. This increase in popularity will inevitably result in the number of potential complications associated with these procedures. In this review, the authors describe common complications encountered with frequently performed cosmetic facial procedures and their associated management. This article is meant as a general overview and introduction to potential complications surgeons may encounter, interested readers are encouraged to further review comprehensive subspecialty literature for more detailed discussion.

The Male Facelift

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

Demystifying the Deep Plane Facelift: What It Means Anatomically and Why It Works

Rhytidectomy is a common procedure performed by facial plastic surgeons. On well-selected patients, rhytidectomy rejuvenates the aging face by repositioning soft tissues and improving facial shape. The fundamental goal of rhytidectomy, or facelift surgery, is to provide a more youthful facial appearance by elevating soft tissues that often descend with aging. The success and longevity of any rhytidectomy procedure are based on the individual patient's anatomy and aging and on the mobilization, elevation, and fixation of the soft tissues during the facelift procedure. Although surgeons often use many terms to describe a given facelift technique, anatomical terms are best used to name the facelift procedure, as the plane of dissection and the vector of elevation are what determines the end result. This paper attempts to simplify and demystify the deep plane facelift procedure and to describe the anatomy that makes this technique successful.

Deep-Plane Approach to the Vertical Platysma Advancement: Technical Modifications and Nuances over 25 Years

In this article, we will provide the reader with the anatomical and embryologic evidence supporting the use of the deep-plane approach in rhytidectomy and insight into the evolution of the technique into the vertical platysma advancement. The original description of the deep-plane technique only described a basic superficial muscular aponeurotic system dissection in the midface with the ability to use tension on the flap without aesthetic consequences. This plane of dissection provides additional advantages not previously described, including access to deeper anatomical structures such as the buccal fat pad, and allows in vivo assessment and treatment of jowling. We describe how extension of this dissection and selective release of facial ligaments allows us to optimize treatment outcomes and longevity, especially in cases of difficult anatomy or revisions. Further advancements include case-specific facial volume enhancement, created by complex flap design, and facial narrowing by preauricular contouring and parotid hypertrophy treatment. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented.

First Bite Syndrome Following Rhytidectomy: A Case Report

Background:

First bite syndrome (FBS) is a known complication of parotid gland resection, parapharyngeal space dissection, and cervical sympathetic chain injury. It can be described as severe cramping or spasms in the parotid region triggered by the first bite of a meal, with the pain lessening during each subsequent bite. Although dissection for a rhytidectomy is in the vicinity of the parotid parenchyma, face-lift is not typically characterized as a procedure that can lead to FBS.

Case description:

A 53-year-old female underwent a deep plane face-lift to address her goals of improving jowls, nasolabial folds, and cervicomental angle. Intraoperatively, the dissection proceeded without any complications. Initially, her postoperative course was uneventful; 3 weeks after surgery, she noticed pain at the start of mastication that would improve throughout the course of a meal. She elected to proceed with observation. At 6 months after surgery, she began to experience improvement in her symptoms, and shortly thereafter had complete resolution.

Discussion:

First bite syndrome is a complication associated with deep lobe parotid resection, first described in 1998. The innervation of the parotid gland is complex and includes contributions from the auriculotemporal nerve, the great auricular nerve, and the cervical sympathetic chain. During rhytidectomy, dissection occurs along the parotidomasseteric fascia in order to elevate a flap of the superficial musculoaponeurotic system. Inadvertent injury to the parotid parenchyma can lead to damage to the postganglionic sympathetic fibers innervating the myoepithelial cells. Ultimately, expectant management is the mainstay of treatment and symptoms typically resolve within 6 months to 1 year.

Conclusion:

First bite syndrome is a complication that can be seen with a variety of facial surgeries. In the case of rhytidectomy, FBS should be considered a potential risk, as dissection into the parenchyma of the parotid gland can result in postoperative autonomic dysfunction.

Triple-C SMAS Plication Facelift for Natural Facial Rejuvenation

Various methods are used to reposition the superficial musculoaponeurotic system (SMAS) during facelift procedures. This study presents a novel, radially oriented, layered SMAS plication: the triple-C SMAS plication. This technique utilizes customizable vectors in the pattern of a “C” to plicate the SMAS in 3 layers to lift and tighten the deep structures of the face.

Tranexamic Acid in Aesthetic Facial Plastic Surgery: A Systematic Review of Evidence, Applications, and Outcomes

Background

Tranexamic acid (TXA) is an antifibrinolytic that has become widely used in aesthetic facial plastic surgery, although its efficacy has not been well investigated.

Objectives

To evaluate the existing evidence for use of TXA in aesthetic facial plastic surgery, highlighting routes of administration, dosing, surgical applications, and clinical outcomes.

Methods

Systematic review of primary literature evaluating TXA in aesthetic facial plastic surgery.

Results

Eleven studies met inclusion criteria: 8 prospective randomized controlled trials, 2 retrospective case series/cohort studies, and 1 clinical opinion. Six studies evaluated TXA in rhinoplasty, 4 in rhytidectomy, and 1 in blepharoplasty. Significant reductions in intraoperative blood loss were found in 5 rhinoplasty studies. Three rhinoplasty and 2 rhytidectomy studies found significantly reduced postoperative edema and ecchymosis. One rhinoplasty and 1 rhytidectomy study reported reduced operative time and time to achieve hemostasis. One rhytidectomy study reported reduced postoperative drain output and faster time to drain removal. No studies reported an adverse outcome directly related to TXA.

Conclusions

Existing literature investigating TXA in aesthetic facial plastic surgery is sparse with varying levels of evidence and heterogeneous data. Literature suggests systemic TXA reduces intraoperative blood loss during rhinoplasty, although the clinical significance of this blood loss reduction is unclear. TXA may also reduce postoperative edema and/or ecchymosis in rhytidectomy and rhinoplasty, although the lack of validated grading scales yields insufficient evidence to support this claim. Topical and subcutaneously injected TXA are emerging administration routes in rhytidectomy, with evidence suggesting TXA mixed with tumescent may reduce postoperative drain output, thereby expediting drain removal.

Level of Evidence: 2

From the Deep-Plane Rhytidectomy to the Vertical Platysma Advancement

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

Clinical Evaluation of 225 Sub-SMAS Facelifts with No Temporal Incision

BACKGROUND

Despite their name, "short scar" procedures leave scars in the temples and the postauricular scar often requires extension. Redraping the orbicularis muscle for periorbital rejuvenation increases the risk of facial nerve injury. This retrospective cohort study was undertaken to clinically evaluate a surgical approach that eliminates the temporal incision.

METHODS

A sub-superficial musculoaponeurotic system (SMAS) facelift was used, incorporating a triple-vector platysmaplasty and fat injection for periorbital rejuvenation. From 2009 to 2019, 225 consecutive outpatients underwent a sub-SMAS facelift with a triple-vector (superior, lateral, medial) platysmaplasty, either alone or in combination with fat injection, laser resurfacing, blepharoplasties, endoscopic forehead lift, and other cosmetic procedures. Release of the retaining ligaments optimized SMAS mobilization. A temporal incision was not used. Fat (mean volume 32 ml) was injected into the undissected subcutaneous tissue plane. The mean follow-up time was 28 months.

RESULTS

The most frequent complication was a neuropraxia (7.6%), usually affecting a frontal nerve branch, and always temporary. Two deep venous thromboses were detected by ultrasound surveillance. No significant correlation was detected between complications and age, sex, body mass index, smoking history, or a previous facelift. Sixteen patients (7%) returned for a secondary facelift (mean interval, 3.5 years).

CONCLUSIONS

A sub-SMAS facelift and triple-vector platysmaplasty with fat injection combine effective neckline rejuvenation with facial volume restoration. Avoiding a temporal incision eliminates a telltale scar. Orbicularis preservation avoids additional dissection, possibly reducing the risk of neuropraxia. Fat injection provides a net increase in facial volume. Long-term measurement studies are recommended.