Reconstruction of Large Composite Defects Extending Beyond the Nose

Nasal reconstruction remains one of the most challenging surgeries for facial plastic and reconstructive surgeons. The addition of defects extending beyond the nose adds a layer of complexity to an already technically demanding surgery. This article will focus on the management of composite defects extending beyond the boundaries of the nose. Surgeons need to have a variety of techniques at their disposal. These complex defects often require multiple local flaps, multiple stages, and, in select cases, free tissue transfer.

Facial Feminization: Middle Third of the Face

Facial feminization surgery (FFS) as applied to the midfacial region targets modifications to the nasal and malar esthetic complexes. Although a global assessment is paramount in achieving desired functional results, most patients benefit from malar feminization in the form of bony and soft tissue augmentation, and nasal feminization in the form of reductive rhinoplasty. For patients with signs of aging, additional interventions in the form of rhytidectomy are powerful adjuncts to feminization. As with FFS techniques directed toward the upper and lower thirds, the overarching goal is to obtain complementary outcomes that enhance facial harmony and beauty.

Facial Gender-Affirming Surgery: Pitfalls, Complications, and How to Avoid Them

Facial feminization is a complex undertaking requiring skill in both craniofacial and aesthetic plastic surgery. As in aesthetic procedures, understanding the patient's goals and setting realistic expectations in light of an individual's anatomy is critical. Both soft tissue and bone must be addressed to adequately soften masculine facial features. This article delves into specific anatomic areas and delineates some of the pathways to successful outcomes.

Gender Affirming Facial Surgery-Anatomy and Procedures for Facial Masculinization

For some patients, feminine facial features may cause significant gender dysphoria. Multiple nonsurgical and surgical techniques exist to masculinize facial features. Nonsurgical techniques include testosterone supplementation and dermal fillers. Surgical techniques include soft tissue manipulation, synthetic implants, regenerative scaffolding, or bony reconstruction. Many techniques are derived from experience with cisgender patients, but are adapted with special considerations to differing anatomy between cisgender and transgender men and women. Currently, facial masculinization is less commonly sought than feminization, but demand is likely to increase as techniques are refined and made available.

Perceived change in age after functional upper blepharoplasty

PURPOSE

To evaluate the perceived age of patients before and after functional upper blepharoplasty.

METHODS

Retrospective chart review of patients who underwent upper blepharoplasty by a single surgeon at an academic center. The inclusion criterion was having external photographs before and after blepharoplasty. Exclusion criteria included any other concurrent eyelid or facial surgery. Primary endpoint: perceived change in age after surgery as judged by the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) surgeons.

RESULTS

Sixty-seven patients (14 men, 53 women) were included. Mean pre-operative age was 66.9 years (range 37.8-89.4) and mean post-operative age was 67.4 years (range 38.6-89). The mean perceived age pre-operatively was 68.9 years, and the mean perceived age post-operatively was 67.1 years, a change of 1.8 years (p = 0.0001 by two-tailed paired T-test). Inter-rater reliability of the observers was measured by intraclass correlation coefficient of 0.77 for pre-operative and 0.75 for post-operative photos. The decreased perceived age was 1.9 years for women, 1.4 years for men, 0.3 years for Asians, 1.2 years for Hispanics, and 2.1 years for whites.

DISCUSSION

Functional upper blepharoplasty by an experienced ASOPRS surgeon was shown to reduce the perceived age of a patient by an average of 1.8 years.

Angular Photogrammetric Analysis of Facial Soft Tissue by Image Processing Algorithms

BACKGROUND

The main aim of this study was to present an automatic method based on image processing algorithms for facial anatomical landmark localization and angular photogrammetric analysis applicable for rhinoplasty surgery. We studied and measured color profile photographs of 100 patients before and after rhinoplasty surgery.

METHODS

In facial anthropometry analysis, anatomical landmarks are often defined by specialists, manually. This process is time-consuming and requires training and skill. The Cascade Regression Method (CRM) was utilized for facial landmark detection to overcome the mentioned problem. In this study, 11 anatomical landmarks were used to measure 9 facial angular metrics. Finally, a t-test (with the significance level set at a p-value of 0.05) was applied to analyze before surgery versus after surgery comparisons.

RESULTS

Experimental results dedicated that there is a significance difference (p < 0.001) in nasofrontal, nasolabial, mentolabial, nasomental, facial convexity including nose, facial convexity excluding nose, projection of the upper lip to chin, and H angles before and after surgery. Also, results showed that there is not a significance difference in nose tip angle.

CONCLUSION

We believe that the presented system can aim to reduce the personal errors made by manual measurement and to facilitate facial anthropometry analysis before and after surgery with high accuracy. Also, the normative data for Iranian women can be used as a guide for the diagnosis and planning of oral and maxillofacial, ENT, and plastic surgeries.

LEVEL OF EVIDENCE II

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 .

Open-Source 3D Morphing Software for Facial Plastic Surgery and Facial Landmark Detection Research and Open Access Face Data Set Based on Deep Learning (Artificial Intelligence) Generated Synthetic 3D Models

Background: The scarcity of 3D facial models presents a significant hurdle for researchers and educators. Gathering such data demands substantial resources. Objective: To introduce an open-source 3D morphing software to generate 3D facial data sets for research and to provide a large sample data set that is based on synthetically generated 3D models. Methods: Software is developed to morph 3D facial models in bulk by altering landmark locations. Twenty synthetic 3D facial models are generated utilizing deep learning tools and 28 landmarks located on each. The measurements of synthetic models are confirmed to be realistic by comparing them with facial statistics. Several facial deformities and types are simulated at various magnitudes on 3D models to generate a large data set. Results: An open-source software and an open-access data set of 980 3D facial models, each with 28 landmark locations, are provided. Since the data set is based on synthetically generated 3D models, no institutional review board approval is required. Conclusion: The 3D morphing software and the large 3D data set are expected to benefit researchers and educators in the field of facial surgery and facial landmark detection.

Early outcomes and risk factors for complications after facial alloplastic implant surgery: An ACS-NSQIP study

BACKGROUND

Facial implantology (FI) is a growing field in facial surgery that focuses on harmonizing and balancing facial features. Despite its increasing popularity, larger-scale studies on FI outcomes and risks are scarce.

METHODS

The ACS-NSQIP (2008-2021) was queried to identify patients who underwent combined/isolated alloplastic FI surgery of the malar/mandibular region. Based on CPT codes (21125; 21270), procedures were subdivided into combined or isolated FI surgery of the malar or the mandibular region.

RESULTS

The study population included 84 patients, of which n = 19 (23%), n = 10 (12%), n = 33 (39%), and n = 22 (26%) underwent combined malar, isolated malar, combined mandibular, and isolated mandibular FI surgery, respectively. Isolated malar (total n = 10) and mandibular FI surgery (total n = 22) patients had relatively high comorbidity rates with up to n = 6 (60%) active smokers and n = 9 (41%) with hypertension, respectively. Combined malar (n = 19) and mandibular FI surgeries (n = 33) had the highest complication rates with n = 3 (16%) and n = 5 (15%) patients experiencing any complications. For both isolated malar and mandibular FI procedures, n = 1 (10% and 4.5%) patient reported any complications.

CONCLUSION

In this study, we accessed the ACS-NSQIP database and found alloplastic augmentation for zygoma and mandible to be safe. Patients who underwent combined procedures and mandibular augmentation were more likely to show complications or require inpatient stay. Most alloplastic augmentations of mandible or zygoma were combined with other procedures (62%) which suggests that alloplastic facial implants (in the academic setting) are often used as an adjunct in the treatment of complex craniofacial disorders.

Adipose Component Transplantation: An Advanced Fat-Grafting Strategy for Facial Rejuvenation

BACKGROUND

Autologous fat grafting is frequently used for volume augmentation and tissue regeneration. The uniform physical and biological characteristics of fat grafts, however, limit their optimal effects in various situations. Subjecting fat tissue to different mechanical processes results in adipose-derived products with distinct biological components and physical features. The present study describes a novel facial fat-grafting strategy, adipose component transplantation (ACT), that yields different adipose products that can be applied to specific injection sites.

METHODS

All patients who underwent ACT were evaluated retrospectively. Fat tissue samples were fractionated into high-density fat, adipose matrix complex, stromal vascular fraction gel, and adipose collagen fragment, as described. Each of these fractions was processed and injected into indicated recipient sites. Additional SVF gel was cryopreserved and, if necessary, injected during the following 3 months. Patients were followed up after 1, 2, 3, and 6 months, and annually thereafter.

RESULTS

From March of 2020 to September of 2021, 78 patients underwent whole face fat grafting using the ACT strategy. All operations and secondary injections of cryopreserved SVF gel were uneventful. There were no major complications, and final aesthetic results were satisfactory in 91% of patients.

CONCLUSIONS

The ACT strategy allows specific adipose products to be applied to specific injection sites, as warranted. Adipose matrix complex is indicated for sufficient rigid support, high-density fat when large volumes are required, SVF gel for precise injection and cryopreservation, and ACF as mesotherapy for skin rejuvenation. The ACT strategy optimizes the biological functions and physical features of different adipose-derived products.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Updated Filler Emergency Kit: Next-Generation Emergency Solution

INTRODUCTION

The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK).

METHODS

The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed.

RESULTS

The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions.

CONCLUSION

The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. 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 .

The Buried Guide Suture Method: A Novel Technique to Correct Traumatic Facial Dimples

SUMMARY

Facial dimpling, frequently occurring after blunt trauma, presents as soft-tissue depression, which is particularly apparent during facial expression. The displacement of subcutaneous tissue can be detected and measured by high-frequency ultrasound. Limited surgical methods have been applied in these closed-injury cases. Repositioning the subcutaneous tissue without incisions on unscarred skin is challenging. The authors propose a novel three-dimensional technique to suture and fix the subcutaneous tissue at a distance through a concealed incision. The buried guide suture method was used in the treatment of 22 patients with traumatic facial dimples on the cheek. All patients showed great improvement in their depressed deformity with minor complications. This technique provides an option to correct soft-tissue depression without leaving a visible scar, especially for mimetic rupture caused by blunt trauma.

Nonsurgical Rhinoplasty with Hyaluronic Acid

The history of nonsurgical rhinoplasty with hyaluronic acid fillers dates back to the early 2000s when medical advancements in cosmetic dermatology began exploring less-invasive alternatives to traditional surgical procedures. Hyaluronic acid, a naturally occurring substance in the body known for its hydrating and volumizing properties, was being used successfully in other facial augmentation treatments. Around the mid-2000s, the use of hyaluronic acid fillers for nonsurgical rhinoplasty gained momentum. By injecting hyaluronic acid fillers into precise areas of the nose, cosmetic practitioners could effectively smooth out irregularities, correct minor asymmetry, augment the nasal bridge and even enhances nasal tip projection and definition.

Geographic Distribution of Facial Plastic and Reconstructive Surgeons

Background: Distribution of the general otolaryngology workforce has been described, but not specifically for the facial plastic and reconstructive surgeon (FPRS) workforce. Objective: To describe the distribution of FPRS within the United States. Methods: The 2022 American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) registry was used to identify active FPRSs. Member addresses were converted into coordinates and overlayed onto a geographic representation of 2020 census data within ArcGIS software. A centroid model of U.S. counties was constructed to determine the average distances residents were from the nearest FPRS. Results: In total, 1312 AAFPRS active members practiced in 373 counties. Thirty-three percent of all residents (115 million) resided in counties without an FPRS and 15.3% of FPRSs practiced in New York City or the Greater Los Angeles Area, which accounted for 8% of the total U.S. population. The mean and median distances a resident in a county without an FPRS was from the nearest FPRS are 63 and 49 miles (101 and 79 kilometers), respectively. Conclusions: Metropolitan areas have greater concentrations of FPRSs than the national average and the distances U.S. residents are from FPRS services are quantifiable.

Outcomes in Facial Feminization Surgery: A Systematic Review

Objective: Review literature on facial feminization surgery (FFS) for the transgender population and identify whether heterogeneity in reported outcomes and outcome measures exists across studies, as measured by a lack of consensus, and number of outcomes and outcome measures used. Evidence Review: A search of MEDLINE and EMBASE (database inception to January 20, 2021) was performed to retrieve FFS studies. Primary outcomes included number of reported outcomes and outcome measures; secondary outcomes included clinimetric properties of outcome measures and study characteristics. Findings: In total, 15 articles were included. Sixty-nine outcomes and 12 outcome measures were identified. Of those outcome measures, zero were found to be valid, reliable, and responsive in patients who had undergone FFS. A variety of FFS interventions were studied, with the three most common interventions being: rhinoplasty (n = 7, 46.7%), mandibuloplasty (n = 7, 46.7%), and chondrolaryngoplasty (n = 6, 40%). Conclusion and Relevance: Heterogeneity was evident in reported outcomes and outcome measures in FFS literature and there is currently no outcome measure commonly used for this patient population.

Superimposition Study to Determine the Angular Arterial Distribution and Its Clinical Application

BACKGROUND

The purpose of this study was to determine the distribution of the angular artery (AA) in the medial canthal area with the aim of defining an arterial course to prevent AA injury during facial surgery in this region.

METHODS

The authors dissected 36 hemifaces of 18 cadavers. The horizontal distance from the vertical level through the medial canthus to the AAs was measured. The AA course of each specimen was then recorded, and all of them were then superimposed to determine the AA course. The diameter and depth of the AA around the medial canthal area were also investigated using ultrasonography on living subjects.

RESULTS

The horizontal distances from the medial canthus level and 2 cm below the medial canthus were 9.0 ± 2.0 mm (mean ± SD) and 1.9 ± 2.4 mm, respectively. The superimposed image demonstrated that most of the AAs were present inside the vertical line through the medial canthus. Ultrasonography indicated that the AA was 2.3 ± 0.9 mm below the skin and 1.7 ± 0.3 mm in diameter.

CONCLUSIONS

The AA course was relatively constant along the nasojugal fold. The AAs were most often present between the middle of the medial canthus and the facial midline, but were very scarce in both the medial and lateral thirds. Knowledge of the detailed course of the AA may help surgeons to avoid arterial injury and decrease the risk of surgical morbidities around the nasal root and medial canthal area.

Rotation of a Part of the Composite Flap for Simultaneous Gonion Reduction and Malar Augmentation During Rhytidectomy in Asians

BACKGROUND

The desired facial shape that Asians aim to achieve through plastic surgery differs from that of westerners.

OBJECTIVES

The author facilitates facial volume deflation by using the rotation of a part of the composite flap to the malar area resulting in volumetric augmentation during rhytidectomy; simultaneously, a volumetric reduction was implemented in the gonion.

METHODS

Extended deep plane rhytidectomy with the rotation of a part of the composite flap was performed in 49 patients, whereas extended deep plane rhytidectomy without the rotation of a part of the composite flap was performed in 20 patients. For the results, the satisfaction survey of the surgery was conducted in all patients and by 2 surgeons during a follow-up visit 12 months later. To assess the surgical outcome objectively, the author used the Allergan photometric midface volume deficit scale to measure the midface volume. The midface contour and degree of projection were analyzed using lateral view photographs of the patients. The measurement of segment CM (distance between the lateral canthus and mouth corner) and segment MA (distance from segment CM to the most protruding malar area) was performed.

RESULTS

The patients who underwent extended deep plane rhytidectomy with the rotation of a part of the composite flap reported higher overall satisfaction and achieved more favorable results, as evaluated by the 2 aesthetic surgeons (P < 0.05). The scores on the Allergan photometric midface volume deficit scale showed a significant increase before and after the surgery in both groups (P < 0.05), also as evaluated by the 2 aesthetic surgeons. However, the change in scores was found to be higher in the extended deep plane rhytidectomy with the rotation of a part of the composite flap group. The midface contour and degree of projection showed an increase of 20.6% on the right face and 22.7% on the left face, respectively (P < 0.001).

CONCLUSION

Using the rotation of a part of the composite flap during rhytidectomy resulted in overall satisfactory outcomes for all patients. Based on these findings, it can be concluded that the use of this surgical method is beneficial and effective.

Complete Hemifacial Paralysis Post-facelift: Making Sense of a Plastic Surgeon's Worst Nightmare

BACKGROUND

Postrhytidectomy hemifacial paralysis is a frightening clinical condition affecting the proximal facial nerve and most often associated with Bell's palsy. Associated symptoms are common and include auditory, salivary, vestibular, and gustatory complaints.

OBJECTIVES

The aim of the study was to provide increased awareness of postrhytidectomy hemifacial paralysis secondary to Bell's palsy in the plastic surgery community.

METHODS

Following a roundtable discussion with the senior author's (J.C.G.) plastic surgery colleagues located all over the world, 8 surgeons reported having had firsthand experience with hemifacial paralysis in patients following facelift. Descriptions of their cases, including preoperative, intraoperative, and postoperative courses were collected and reported.

RESULTS

A total of 10 cases of postrhytidectomy hemifacial paralysis were analyzed based on results of a clinical questionnaire. Eight of the 10 cases involved all facial nerve branches, with 2 cases sparing the marginal mandibular branch. The vast majority of cases were referred to a neurologist and steroids initiated. Two patients were returned to the operating room for exploration. Associated symptoms reported included pain in the ear, hearing loss, ocular symptoms such as tearing or dryness, vestibular symptoms such as vertigo, changes in taste, and in 1 patient an electric-shock type sensation to the face.

CONCLUSIONS

Hemifacial paralysis associated with Bell's palsy following rhytidectomy is a rare but known clinical entity that should be included in the preoperative informed consent process before facelift. Current management trends are neurology referral and steroid initiation.

LEVEL OF EVIDENCE: 4

Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Single-Step Full-Face Surgical Treatment of the Facial Profile

The present study was performed to describe how much affordable, feasible, and straightforward is the approach the authors called "single-stage full-face surgical profileplasty," tailored to greatly improve the surgery of the facial profiling setting and achieve complete profile correction at the same time. From January 2010 to May 2019, 113 patients (95 females and 18 males; aged 19 - 63 years) were surgically treated for full-face profile amelioration. Profile correction was performed by using a combination of five procedures out of other various previously experienced: forehead fat grafting, rhinoplasty, lip fat grafting, genioplasty, and submental liposuction. All patients were assessed at 1, 3, 6, and 12 months following surgery for assessing the surgical profile treatment (SPT) outcome and any possible side effects of the combined treatment. Facial profile stability at 1 year was taken as the completion point of this treatment. Arnett et al's "Soft Tissue Cephalometric Analysis" (1999) was used to clinically evaluate the soft tissues before and after the SPT. Patients' satisfaction was measured with the Client Satisfaction Questionnaire-8" at 3 and 12 months after surgery. Statistics were used for Arnett et al's evaluation. Almost all the values were consistent and reached the normal ranges indicated by Arnett et al (p < 0.001), confirming that the desired results of the surgical profileplasty have been achieved. Single-stage full-face surgical profile treatment helps in correcting faults of the global facial deformity, in every single treated area, providing an overall improvement in facial aesthetics and harmony. Obtaining the simultaneous correction in the whole face has also the advantage of avoiding multiple surgical procedures, reducing postoperative discomfort, and the overall risks for the patient due to multiple surgical and anesthetic procedures.

Enhanced Recovery After Surgery Protocols in Craniofacial Surgery

Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. ERAS protocols are generally substantiated on 3 phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined.

Case Reviews in Head and Neck Vascular Lesion Management

The treatment of hemangiomas and vascular malformations should be individualized, based upon the size of the lesion(s), morphology, location, presence or possibility of complications, the potential for scarring or disfigurement, the age of the patient, and the rate of growth or involution at the time of evaluation. The major challenge is the location in a head and neck can lead to unsightly scars if approached improperly, or with inadequate approaches can lead to intraoperative and postoperative morbidity with neurovascular damage and inadequate lesion excision. Facial, trigeminal, and other cranial nerve branches are of key importance in the functional outcome while accessing and approaching head and neck vascular lesions.

Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science

SUMMARY

The scientific study of facial aging has transformed modern facial rejuvenation. As people age, fat loss in specific fat compartments is a major contributor to structural aging of the face. Autologous fat grafting is safe, abundant, readily available, and completely biocompatible, which makes it the preferred soft-tissue filler in the correction of facial atrophy. The addition of volume through fat grafting gives an aging face a more youthful, healthy, and aesthetic appearance. Harvesting and preparation with different cannula sizes and filter-cartridge techniques have allowed for fat grafts to be divided based on parcel size and cell type into three major subtypes: macrofat, microfat, and nanofat. Macrofat and microfat have the benefit of providing volume to restore areas of facial deflation and atrophy in addition to improving skin quality; nanofat has been shown to improve skin texture and pigmentation. In this article, the authors discuss the current opinions regarding fat grafting and how the evolving science of fat grafting has led to the clinical utility of each type of fat to optimize facial rejuvenation. The opportunity exists to individualize the use of autologous fat grafting with the various subtypes of fat for the targeted correction of aging in different anatomic areas of the face. Fat grafting has become a powerful tool that has revolutionized facial rejuvenation, and developing precise, individualized plans for autologous fat grafting for each patient is an important advancement in the evolution of facial rejuvenation.

Assessing Preferences of Facial Appearance in Transgender and Gender Nonbinary Patients

BACKGROUND

We designed a survey to evaluate preferences of facial appearance in transgender male (TM), transgender female (TF) and gender nonbinary patients to better inform goals of facial gender affirming surgery (FGAS) in gender nonbinary patients.

METHODS

TM/TF and nonbinary patients > 18 years old were identified via retrospective chart review and distributed an anonymized survey via email from October 3 to December 31, 2022. To assess facial preferences, AI-generated and open-source portraits were edited to create five image sets with a range of features from masculine to feminine for the forehead, mandible/chin and hairline. Data were analyzed using Fisher's exact tests and ANOVA in R-Studio.

RESULTS

Survey response rate was 32% (180 patients identified via chart review, 58 respondents; TM = 5, TF = 39, nonbinary = 14). TM and TF patients as well as TF and nonbinary patients had significantly different preferences for all regions (p < 0.005; all series), while TM and nonbinary patients did not (p => 0.05; all series). TF patients consistently selected 4s with neutral or more feminine features. TM and nonbinary patients, however, demonstrated no consistent preference for either male or female features but rather a range of responses spanning extremes of both masculine and feminine options. When stratified by sex assigned at birth, nonbinary patients consistently identified preferences opposite to their assigned gender.

CONCLUSION

Gender nonbinary and TM patients appear to have uniquely individual preferences regarding facial appearance that do not fit into classically masculine or feminine patterns/phenotypes. As a result, we recommend individualized preoperative planning for FGAS to achieve the optimal result in these patient populations.

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 .

Buccal Fat Pad Augmentation for Midfacial Rejuvenation: Modified Fat Grafting Technique and Ogee Line Remodeling

BACKGROUND

The volume and position of the buccal fat pad (BFP) change with age, which manifests as a hollow midface. Previous studies showed that autologous fat grafting for BFP augmentation could effectively ameliorate midfacial hollowing.

OBJECTIVES

The aim of this study was to introduce a modified fat grafting technique for female patients with midfacial hollowing to restore the volume of BFP, and to evaluate the safety and effectiveness of this approach.

METHODS

Two cadavers were used for the dissection of the BFP and to demonstrate the surgical procedures. Forty-eight patients were treated for midfacial hollowing with the modified grafting strategy. The BFP was filled through a percutaneous zygomatic incision and an immediate amelioration in the hollow area was observed. Improvements were evaluated from measurements of the ogee line and ogee angle, FACE-Q questionnaires, and 3-party satisfaction ratings. Clinical profiles were reviewed and statistically analysed.

RESULTS

The mean [standard deviation] ogee angle was 6.6° [1.9°] preoperatively and 3.9° [1.4°] postoperatively (average reduction, 2.7°). Patients' ogee lines were smoother postoperatively, with marked improvements in overall appearance, psychological well-being, and social confidence. Patients reported high satisfaction with decision-making and postoperative outcomes and felt 6.61 [2.21] years younger. Overall, 88%, 76%, and 83% of the cases were graded as good or excellent in improvement by surgeon, patient, and the third party, respectively.

CONCLUSIONS

For age-dependent midfacial hollowing in female patients, the modified percutaneous grafting technique described here was safe and efficacious in restoring BFP volume. This technique produced a smoother ogee line and a natural, younger midfacial contour.

LEVEL OF EVIDENCE: 4

Superior Vector Plication of the Mobile Anterior Midface: The Delta Facelift

BACKGROUND

Traditional plication techniques have been ineffective in addressing the anterior midface when compared to the sub-superficial musculoaponeurotic system (SMAS) "deep plane" approaches. However, by moving the plication much closer to the mobile medial fat tissues, a more effective and long-lasting plication can be accomplished without releasing the SMAS layer.

OBJECTIVES

The authors' "Delta facelift" approach combines a rotation vertical advancement of the midface fat with a dual-vector platysmaplasty and deep cervicoplasty as indicated for a harmoniously youthful neck.

METHODS

A retrospective chart review was performed on all patients who underwent facial rejuvenation with the Delta facelift technique between January 1, 2012, and May 30, 2021, for patient demographics, procedure details, outcomes, and complications.

RESULTS

A total of 283 patients underwent Delta facelift (273 females, 10 males). The average age was 60.8 years old. Primary facelift was performed in 229 patients, whereas 54 facelifts were secondary or further procedures. Adjunctive procedures included autologous fat grafting (93%), blepharoplasty (52%), and skin rejuvenating procedures (35%). There were 11 self-resolving neuropraxias, 6 minor hematomas, and 6 infections. Nine patients underwent repeat Delta facelift at an average of 9.3 years.

CONCLUSIONS

The Delta rotation vertical advancement of the anterior facial fat counters the descent and deflation associated with facial aging. Dual-vector platysmaplasty, with or without myotomy, effectively manages the jowl and delineates the jawline. Addition of deep cervicoplasty is recommended for patients with oblique necks or those with subplatysmal volume excess.

LEVEL OF EVIDENCE: 3

Feminization Surgery of the Upper Face as the Crucial Factor in Gender Confirmation-Pearls and Pitfalls

Background: Upper-face feminization is a frequently executed procedure in sexual reassignment surgery, owing to its ability to influence gender identity through adjustments to the hairline, forehead, and peri-orbital area. The procedure includes reducing the hairline, lifting the brows, shaving the orbital region, and applying specific techniques to reduce the frontal bone. This research aims to assess the outcomes, results, and potential complications associated with this surgery among transgender patients. Material and Method: Retrospective review of medical records of 20 patients who attended for facial feminization surgery of the upper face between June 2022 and June 2023, analyzing the previously performed procedures, complications and revision surgery outcomes, and first-time procedures. A literature review was performed for similar studies. Results: 20 patients were included in the study. Among the cohort treated elsewhere (n = 11), the primary complaint was insufficient browbone reduction and anterior frontal sinus table setback. They underwent poorly performed Type 1 reduction when full forehead reconstruction (Type 3/4) was indicated (n = 3), or no reduction was performed during hairline advancement (n = 4). Type 3 forehead reduction with orbital shaving and hairline advancement with simultaneous temporal browlift was most commonly performed in both revision and first-time surgical upper face feminization (n = 15) (75%). Type 1 osteoplasty was performed in four patients (10%), one Type 3 revision surgery was performed after insufficient Type 3 reduction, and one case of shock-induced alopecia was reported, treated with PRP/peptides and a FUE hair graft. Conclusions: The author's preferred technique, 'whole-in-one' upper face feminization by modified bi-coronal incision with frontal trichophytic hyper-beveled incision, provides sufficient insight into the frontal bone and orbital region, the desired forehead osteoplasty and the most efficient insight into the temporal area, enabling safe dissection between fasciae, ligamentous adhesion removal, and periosteal attachment, providing full soft and hard tissue feminization. Nevertheless, feminization procedures should be meticulously planned, and all concerning issues should be addressed during the first surgery in order to prevent revisions, complications, and patient dissatisfaction.

LeFort III Versus Monobloc Frontofacial Advancement: A Comparative Analysis of Soft Tissue Changes

INTRODUCTION

The LeFort III and monobloc are commonly used midface advancement procedures for patients with syndromic craniosynostosis with well characterized postoperative skeletal changes. However, the differential effects of these procedures on facial soft tissues are less understood. The purpose of this study was to critically analyze and compare the effects of these 2 procedures on the overlying soft tissues of the face.

METHODS

Frontal and lateral preoperative and postoperative photographs of patients undergoing monobloc or LeFort III were retrospectively analyzed using ImageJ to measure soft tissue landmarks. Measurements included height of facial thirds, nasal length and width, intercanthal distance, and palpebral fissure height and width. Facial convexity was quantified by calculating the angle between sellion (radix), subnasale, and pogonion on lateral photographs.

RESULTS

Twenty-five patients with an average age of 6.7 years (range 4.8-14.5) undergoing monobloc (n=12) and LeFort III (n=13) were identified retrospectively and analyzed preoperatively and 6.4±3.6 months postoperatively. Patients undergoing LeFort III had a greater average postoperative increase in facial convexity angle acuity (28.2°) than patients undergoing monobloc (17.8°, P =0.021). Patients in both groups experience postoperative increases in nasal width ( P <0.001) and decreases in palpebral fissure height ( P <0.001).

CONCLUSIONS

Both subcranial LeFort III advancements and monobloc frontofacial advancements resulted in significant changes in the soft tissues. Patients undergoing LeFort III procedures achieved greater acuity of the facial convexity angle, likely because the nasion is not advanced with the LeFort III segment.

Quantitative Assessment of Periocular Autologous Fat Transfer Survival Using 3D Stereophotogrammetric Imaging

PURPOSE

To assess periocular autologous fat transfer (AFT) survival by assessment of volume change with sequential 3D VECTRA imaging.

OBJECTIVE

Little is known about the patterns of graft survival of AFT in the periorbital region, especially in cases involving prior radiotherapy or trauma. The aim of this pilot study was to characterize fat survival following AFT in patients with a broad range of clinical indications, with and without a history of prior radiotherapy, for both periocular and orbital AFT, and in a subgroup of patients with an anophthalmic socket.

METHOD

A single-institution, prospective cohort study involving 18 applications of AFT for volume augmentation in the periocular and orbital area. All patients had sequential 3D VECTRA photographs following a validated standardized protocol. Patient demographics, including gender, age, ethnicity, underlying diagnosis, and volume of fat injected, were also collected.

RESULTS

In total 13 patients were enrolled, 9 female (69.2%) and 4 male (31.0%). Mean age at the time of surgery was 47.8 years. Patients had volume deficiency secondary to a variety of causes; the most common cause was postenucleation socket syndrome following trauma in 6 patients (46.2%). The mean fat survival volume at the 1-month postoperative point was 70% and 55% by 6 months. AFT conducted with a multiport cannula for fat harvesting use had an initial higher rate of fat reabsorption with ANOVA p = 0.002, however, this was not observed at the later follow-up periods. There was no statistically significant difference in fat survival between abdominal or thigh donor fat sites. There was no statistically significant difference in residual injected volume at the early follow-up period between patients who had prior radiotherapy and those who did not p = 0.8496.

CONCLUSION

AFT is an effective treatment for periorbital volume compromise with an acceptable survival rate in all categories of patients. Complex etiologies such as radiotherapy-related orbital and midface dysgenesis should not be a contraindication for AFT, with no difference in outcomes.

Positional relationships of the origin and course of zygomaticus major with the nasal ala, tragus, philtrum, and lateral canthus for aesthetic treatments and surgeries

PURPOSE

The aim of this study was to characterize the origin and course of the zygomaticus major muscle (Zmj) with its topographic relationships with the nasal ala, tragus, philtrum, and lateral canthus.

METHODS

The Zmj was examined in 50 specimens of 25 embalmed adult Korean cadavers. Facial muscles were dissected to expose the origin and course of the Zmj in 48 specimens of 24 cadavers. The 25th cadaver was sectioned to obtain images of the Zmj.

RESULTS

The positional relationships of the Zmj origin with the nasal ala and the tragus were classified into three categories. A horizontal line through the center of the Zmj origin and the nasal ala passed through the tragus in 20 of 48 specimens (41.7%), the intertragic notch in 18 specimens (37.5%), and above the tragus in 10 specimens (20.8%). In a horizontal section of the head, the Zmj origin was located near the level of the nasal ala and tragus. In a coronal section of the head, the fibers of the Zmj arising at its origin were located close to the zygomatic bone, lateral to the zygomaticus minor muscle.

CONCLUSION

By combining dissection with the analysis of sectioned images and ultrasound images of the Zmj, this study has yielded positional information for easily predicting the location of the origin and the course of the Zmj and its related structures underlying the skin.

Titanium plates salvage in irradiated facial areas with the lipomodeling technique

Major defects of the facial structures cause severe functional and aesthetic impairment. For composite defects with bone loss, the use of a titanium plate bridging the bony defect, associated or not to a soft tissue pedicled flap is to be considered in complex cases, or for patients with high comorbidities. The principal limit of this technique is the risk of plate exposure, especially for patients who had adjuvant radiation therapy. We present two clinical cases of patients who had a facial reconstruction using a titanium plate associated with a locoregional soft tissue flap, and who presented a near-exposed plate a few years after the first surgery and adjuvant radiation therapy. In order to prevent plate exposure, we performed several lipomodeling sessions between skin and plate. Our results are very encouraging, with no plate exposure and thickening of the soft tissues which cover the plate at 10-years follow-up. The knowledge of the possibility to use fat grafting transfer could therefore lead to a strong return to the use of titanium plates in facial reconstruction.

Cardiovascular anomalies in patients with Tessier syndrome: a systematic review

Tessier clefts are skeletal and soft tissue abnormalities of a neonate's facial structures. They could be classified as syndromic and non-syndromic clefts, which can be attributed to disruptions in fetal development and genetic mutations, respectively. Reported cases of these clefts typically document the presence of additional abnormalities associated with these clefts. In this systematic review, we analyzed reports of Tessier clefts accompanied by cardiovascular anomalies, as one of the commonly encountered anomalies. We systematically searched PubMed (MEDLINE), Scopus, Web of Science, Science Direct, and Google Scholar. We selected and included case reports, case series, and case reviews on patients with Tessier cleft and cardiovascular anomalies. The critical appraisal of the included studies was performed by two independent investigators using the Consensus-based Clinical Case Reporting Guideline Development (CARE) checklist. Overall, 20 reports (18 case reports and 2 case series) were eligible for inclusion in this review. Tessier clefts 3 and 30 were the most commonly observed. In addition, the most prevalent cardiovascular anomalies consisted of the ventricular septal defect (VSD), double-outlet right ventricle, and atrial septal defect (ASD). Most of the patients received cosmetic and cardiovascular surgeries. However, some were not proper candidates for cardiovascular surgery because of their unstable condition and therefore did not survive.   Conclusion: Regardless of the focus placed on the cleft and subsequent plastic surgery procedures in these cases, it is important to prioritize other abnormalities that may be associated with mortality. A complete cardiovascular system and associated disorders assessment should be performed before facial cosmetic surgeries. What is Known: • Tessier clefts are congenital defects in the soft tissues and bones of the face and like many other congenital defects, they are accompanied by defects in other parts of the body. • In the current literature, the emphasis is on clefts and the cosmetic issues rather than the coinciding defects, particularly cardiovascular anomalies. What is New: • Review the cardiovascular anomalies that are commonly encountered in patients with Tessier clefts.

Measuring Outcomes in Aesthetic Surgery by Board-Certified Plastic Surgeons

SUMMARY

Aesthetic surgery is a visual specialty in which plastic surgeons and patients work together to enhance or restore facial and body harmony. The field of aesthetic surgery is advanced through descriptive technical procedures and outcomes research. With increasing competition in cosmetic medicine, aesthetic surgery stands to benefit from an evidence-based approach to document the high standards of care from board-certified plastic surgeons. In this article, the authors highlight challenges, current objective and subjective outcomes, and a path forward.

Facial Masculinization Surgery: An Analysis of Interest Trends Using Search Term Analysis

INTRODUCTION

Facial masculinization surgery (FMS) is increasingly popular among cisgender and transgender men. The benefits of FMS are focused on facial identity and have been proven to decrease gender dysphoria in this population. Previous research showed increasing interest in gender affirmation surgery and facial feminization surgery, but the prevalence of FMS has not been explored. It is difficult to find these data based on surgical records alone because institutions do not have standardized methods of reporting and lack publications in the field. Our study aimed to analyze public interest in FMS by using worldwide Google Trends to quantify these trends.

METHODS

A worldwide Google Trends search was completed from January 1, 2008, to December 31, 2022, for terms focused on FMS. Then, search terms were analyzed for nonfacial masculinization procedures and were aggregated. Lastly, a PubMed search was conducted for the terms "transgender" and "facial masculinization" from January 1, 2008, to December 31 st , 2022, to compare publication rates.

RESULTS

Our data showed an increasing interest in FMS through Google search trends since the year 2008. A similar trend was demonstrated for non-FMS gender-affirming terms. PubMed analysis showed "transgender" medicine publishing rates were approximately 39.65 times greater than "facial masculinization" publishing rates, although "facial masculinization" medicine did produce a positive trend over the study period of approximately 4 publications per year. The medical literature on transgender surgeries rapidly outpaces publications specifically focusing on FMS.

CONCLUSION

Our study showed increasing interest in gender affirmation surgery over time, particularly FMS. These increasing trends should encourage greater scientific exploration of FMS and research to properly quantify and assess surgical outcomes in this special population. Additional educational interventions for both the general public and medical providers, to increase awareness of unique challenges that impact this community and highlight changes in health care coverage over time, should be created to keep pace with increasing patient demand and address the physical, systemic, and psychosocial issues faced by people who identify as transgender.

Perceived Age and Gender Perception Using Facial Recognition Software Following Facial Feminization Surgery

Measures of success for facial feminization surgery (FFS) have previously included improved rates of external gender perception as female and patient-reported outcome measures. In this study, we used artificial intelligence facial recognition software to objectively evaluate the effects of FFS on both perceived gender and age among male-to-female transgender patients, as well as their relationship with patient facial satisfaction. Standardized frontal preoperative and postoperative images of 27 transgender women undergoing FFS were analyzed by Amazon's AI facial recognition software to determine gender, femininity confidence score, and perceived age. Female gender-typing, improvement in gender-typing (preoperatively to postoperatively), and femininity confidence scores were analyzed. To assess patient satisfaction, FACE-Q modules were completed postoperatively. Preoperatively, FFS images were perceived as female 48.1% of the time, and postoperatively, this improved to 74.1% ( P =0.05). Femininity confidence scores improved from a mean score of 0.04 preoperatively to 0.39 postoperatively ( P =0.003). FFS was associated with a decrease in perceived age relative to the patient's true age (-2.4 y, P <0.001), with older patients experiencing greater reductions. Pearson correlation matrix found no significant relationship between improved female gender typing and patient facial satisfaction. Undergoing surgery at a younger age was associated with higher overall facial satisfaction ( r =-0.6, P =0.01). Transfeminine patients experienced improvements in satisfaction with facial appearance, perceived gender, and decreases in perceived age following FFS. Notably, patient satisfaction was not directly associated with improved AI-gender typing, suggesting that other factors may influence patient satisfaction.

Facial Feminization: Perioperative Care and Surgical Approaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the regional anatomy involved in facial feminization surgery, the key differences between the male and female face, and surgical approaches for modification. 2. Appreciate the integration of preoperative virtual planning and nonoperative approaches for facial feminization care. 3. Understand the perioperative process and potential complications and sequela. 4. Understand the importance of transgender care acceptance as it pertains to clinical outcomes.

SUMMARY

Facial feminization surgery (FFS) is composed of a broad spectrum of gender-affirming surgical procedures with the goal of modifying specific facial features to create a more feminine appearance. As FFS continues to evolve as a subspecialty of transgender care, it is important to consider the psychosocial evaluation, evolving aesthetic tastes, nonoperative facial feminization care, preoperative virtual planning, specialized instrumentation, and potential complications/sequelae when performing these procedures. Computed tomographic imaging and virtual preoperative planning may be used to assist the surgeon with morphologic typing of the brow, supraorbital rim, chin, and lateral mandible regions and aid in performing safer, more efficient procedures. The increasing number of FFS procedures performed on transwomen annually has been supported by objective outcome studies that demonstrate progress in minimizing both misgendering in social environments and reducing dysphoric feelings.

Quantifying outcomes of autologous fat transplantation in different facial deformities: A systemic review and meta-analysis

BACKGROUND

Autologous fat transplantation has become a common treatment for facial deformities. However, facial deformities are the result of complex diseases with different causes, and there has been no review on the effectiveness of autologous fat transplantation for facial deformities of different aetiologies.

METHODS

A systematic literature search of the Web of Science, Embase, and Medline Ovid databases was performed up to December 2022. Two investigators independently performed screening and data extraction according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by a meta-analysis using random-effects model for surgeon and patient satisfaction, facial symmetry, and complication rates. Twelve-month postoperative fat graft retention was estimated by meta-regression.

RESULTS

Thirty-one studies met the criteria, including 13 case series studies, 14 cohort studies, and four randomized clinical trials, with a total of 1572 patients. Follow-up visits within 6-12 months were performed in most of the studies. The results of the meta-analysis showed high overall surgeon satisfaction of 97% (95% CI: 92%-100%) and patient satisfaction of 95% (95% CI: 89%-99%), with a low complication rate of 3.4% (95% CI: 1.9%-5.9%). At 12 months postoperatively, a lower retention rate of 43% (95% CI: 28%-58%) was estimated in cases of acquired atrophic deformities compared with 64% (95% CI: 57%-71%) in cases of mixed deformities. Overall, autologous fat transplantation improved facial symmetry by 13% (95% CI: 8.4%-18%).

CONCLUSION

Autologous fat transplantation is generally a safe and effective procedure that can compensate for facial volume deficits and improve facial symmetry but may be less effective in cases of acquired atrophic facial deformities.