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PubMed1995

A second look at the second-look technique in face lifts.

Hematoma remains a problematic complication of face lift surgery. Sequelae of hematomas may include temporary skin irregularities, a prolonged postoperative recovery period, skin necrosis, and a compromised final result. Attempts to maximize intraoperative and postoperative hemostasis and thus prevent postoperative hematoma formation have focused on the use of local anesthetics with epinephrine modifications, topical thrombin, bed rest, blood pressure control, local anesthetics with intravenous sedation rather than general anesthesia, and the use of the "second-look" technique popularized 30 years ago. When initially practiced by the senior author, the second-look technique resulted in a dramatic decrease in the incidence of hematoma formation from 21.7 to 6.7 percent. It was concluded at that time that the second-look technique was responsible for the reduced incidence of this face lift complication. However, the present series of 82 face lifts performed using a modification of the original Marcaine/epinephrine infiltration technique without the second-look technique demonstrates an overall incidence of hematoma formation of 7.3 percent. These results demonstrate no advantage of the second-look technique over the traditional technique when epinephrine is infiltrated in the fashion described and meticulous hemostasis is obtained.

Adult↗
PubMed1996

Brow lift by flap transposition in the glabrous brow area.

In brow lift, if a direct approach is utilized, the suture line medially is placed in a normal frontalis crease, and then the lateral part of the suture line, by lateral transfer of a small superiorly based flap, is caused to fall into a natural "laugh line" or "crow's feet" crease, three improvements result: 1. Greater control and predictability of shaping and position than with other techniques; 2. A more normal appearance, including better lateral lift and a much more inconspicuous scar than with supraciliary direct lift; 3. A longer-lasting result. In approximately 150 patients, scar appearance has been very gratifying indeed, with only 3 limited segmental scar revisions and 2 secondary midforehead elliptical excisions. It is believed that the principle exhibited in the tightening of the upper suture line by flap transfer, referred to by analogy as the worm principle, accounts for much of the improvement, especially in durability. This principle is seen as an aid in thinking through the mechanics of several other plastic surgical situations as well.

Aged↗
PubMed1996

Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females.

This study correlates brow lift outcomes published in the plastic surgical literature with aesthetic criteria for ideal female eyebrow height and shape. Aesthetic criteria were determined by testing the opinions of 11 cosmetic surgeons and 9 cosmetologists. Eyebrow height and shape were altered with computer graphics to isolate those changes as the only variables of appearance. Plastic surgeons and cosmetologists preferred (p = 0.01) medial eyebrows below or at the supraorbital rim and disliked the medial eyebrow above the rim. Both groups preferred (p = 0.01) eyebrow shape to have an apex lateral slant. One hundred preoperative and 100 postoperative photographs from 16 frequently referenced articles on brow lifts were evaluated. There was a significant (p = 0.0008) increase in the number of medial eyebrows elevated above the rim. The number of medial apex eyebrows increased, and the number of flat brows decreased (p = 0.01). There was no significant increase in the number of apex lateral eyebrows. Three conclusions are made about female eyebrows: (1) The medial eyebrow should be located at or below the supraorbital rim but not above it. (2) Eyebrow shape should have an apex lateral slant. (3) Standard open and endoscopic brow lift operations frequently result in unsatisfactory eyebrow height and shape, judged by these criteria.

Esthetics↗
PubMed1997

The arterial supply of the face lift flap.

The cutaneous arterial circulation of the face lift flap was investigated using multiple anatomic techniques in fresh cadaver specimens. Perforation sites of the transverse facial and submental arteries were preserved or transected according to protocol during bilateral rhytidectomy prior to selective injections with ink or lead oxide. It was observed that the transverse facial perforating artery provides the major direct blood supply to the lateral cheek and preauricular area following rhytidectomy if preserved. This perforator occupies a constant anatomic location 3.1 cm lateral and 3.7 cm inferior to the lateral canthus with 95 percent tolerance limits of +/-1.1 cm. There is greater variability in localizing the submental perforating artery; however, this perforator also contributes significantly to lateral facial blood supply. Both perforator locations are within the area of "standard" undermining for rhytidectomy; however, they may be preserved during this procedure if desired. Transection of the lateral facial perforators leaves vascularization of these cutaneous areas dependent on collateral flow from the pedicle of the face lift flap. The ability to preserve optimal blood supply to the lateral face lift flap may be useful in the clinical setting of a vascularly compromised or smoking patient.

Arteries↗
PubMed1997

Why I prefer the endoscopic forehead lift.

The objectives of the forehead lift and the surgical principles of the open versus the endoscopic methods have been outlined. The advantages and disadvantages of each method have been described. Based on this, I state without any reservations my preference for the endoscopic forehead lift because the advantages significantly outweigh the disadvantages. Based on these and on the enthusiasm of surgeons and the high degree of patient satisfaction and acceptability, I predict that the endoscopic method with its many variations will replace the traditional open approach as a first alternative for forehead lift and upper face rejuvenation.

Adult↗
PubMed1998

The subperiosteal endoscopic laser forehead (SELF) lift.

The subperiosteal endoscopic laser forehead lift is shown to be an effective tool for plastic surgeons. By combining the use of the carbon dioxide laser with the already established technique of endoscopic forehead lift, improved results are achieved. The technique of endoscopic forehead lifting lends itself to new advancements in laser technology. Through the use of flexible laser wave guides or rigid laser extensions, the efficiency and safety of the procedure is proven. Skin excision and fixation have not been necessary. Twenty patients have undergone this procedure successfully; long-lasting results are demonstrated.

Adult↗
PubMed1998

Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair.

Traditional face lift and blepharoplasty techniques are based on two consistent principles. Conventional face lift techniques have always incorporated unopposed lateral vector tissue advancement, which is typical of subcutaneous lifts or rhytidectomies that include the platysma muscle (SMAS) or cheek fat (malar fat). When they are not adequately repositioned, the tissues of the lower eyelid and upper cheek continue to age, which may create a "lateral sweep" of the lower face as those malar soft tissues descend at a more rapid rate than the repositioned SMAS. Removal of the lower eyelid fat in conventional blepharoplasties may also lead to a more hollow-appearing lower eyelid. Hollow eyes and the lateral sweep could be prevented with a rhytidectomy technique that includes orbicularis repositioning and preservation of the lower eyelid fat with an arcus marginalis release. All patients who have been operated on who exhibit these unfavorable signs can have an impressive correction by utilizing the principles of superomedial vector orbicularis repositioning to counter the "lateral sweep" and arcus marginalis release to recreate a youthful shallow and narrow lower eyelid contour. This technique is invaluable to patients seeking secondary surgery to regain harmony of the rejuvenated face.

Humans↗
PubMed2001

Volumetric face lifting.

The evolution of the face-lift technique used by the author, and the major contribution toward this development from Sydney Coleman's description of lipostructure, are described. At present, the superficial adipocutaneous system (SACS) face lift is almost always associated with a lipostructure performed in the same operative session. In most anatomical locations the structural fat grafting is done before the subfat undermining, although some minor touch-up lipostructure may be done at the end of the face lift.

Adipose Tissue↗
PubMed2002

The SOOF lift: its role in correcting midfacial and lower facial asymmetry in patients with partial facial palsy.

Subperiosteal face lifting has gained wide acceptance in aesthetic surgical practice. It may also have a role to play in patients with partial facial palsy. These patients demonstrate poor static position of the mouth but maintain some degree of facial movement. This study examined the role of subperiosteal facial suspension as an alternative treatment modality in this patient group. In this series, five patients with varying degrees of partial facial palsy underwent subperiosteal face lifting, including sub-orbicularis oculi fat elevation via a temporal, lower lid, and buccal approach, thereby mobilizing and elevating and suspending the zygomaticus major and levator labii superioris muscles on the facial skeleton. An attempt was made to categorize the patients according to overall House-Brackmann score. It was not possible to precisely classify the patients by this method, although the approximate scores were two patients scoring 3, two patients scoring 4, and one patient scoring 5. To overcome inconsistencies with this method, the degree of static and dynamic asymmetry of the mouth and also the excursion of the mouth were graded separately. Four patients with mild to moderate dynamic and static asymmetry (House-Brackmann score of approximately 3 and 4) who maintained excellent or good excursion of the mouth achieved excellent or good results. One patient with poor excursion and severe partial facial palsy (House-Brackmann score of 5) was improved but remained markedly asymmetric (follow-up, 4 months to 1 year). Subperiosteal face lifting is a useful therapeutic modality for management of selected patients with mild partial facial palsy. These patients demonstrate asymmetric static position but maintain some degree of muscle excursion. Patients with severe facial palsies with poor muscle excursion continue to require muscle transfer or sling procedures. The authors hope that long-term follow-up will confirm the sustained effect of midfacial suspension in this selected patient group.

Adipose Tissue↗
PubMed2002

Midface lift of the malar fat pad: technical advances.

Most of the advances of the past decade in face lift technique have been directed to correcting the aging changes of the midface. With many midface lift techniques, patients typically experienced a prolonged period of periorbital ecchymosis and edema. Pessa's description of the anatomy of the malar septum has led to modifications of the senior author's (J.Q.O.) malar fat pad lift technique, designed to minimize postoperative ecchymosis and edema following mobilization of the malar fat pad. Preoperatively, markings of the cutaneous insertion of the malar septum are placed at the infraorbital location. This line approximates the caudal margin of the musculus orbicularis oculi. Dissection under the malar fat pad is performed sharply under direct visualization. Care is taken to stay caudal to the malar septum insertion as marked on the skin. Refinements in the dissection of the midface malar fat pad have not altered the effective repositioning achieved. By leaving the malar septum intact, the amount of postoperative edema and ecchymosis is less than formerly associated with the dissection over the infraorbital orbicularis. With rare exception, patients were able to resume their usual activities and employment after a recovery period of 10 to 21 days postoperatively.

Adipose Tissue↗
PubMed2002

A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure.

In 1990, the author reported on a series of 403 cases of deep plane face lifts, the first published technique describing the repositioning of the cheek fat, known as malar fat, in face lift surgery. This study examines the long-term results of 20 of the original series in an attempt to determine what areas of the rejuvenated face (specifically, the malar fat) showed long-term improvement. The results were judged by comparing the preoperative and long-term postoperative views in a half-and-half same-side hemiface photograph. The anatomy of the jawline (superficial musculoaponeurotic system [SMAS]), the nasolabial fold (malar fat), and the periorbital diameter were evaluated. The results confirmed that repositioning of the SMAS remained for longer than improvement in the nasolabial fold and that the vertical diameter of the periorbit did not change at all. The early results of malar fat repositioning shown at 1 to 2 years were successful, but the long-term results showed failure of the early improvement, manifested by recurrence of the nasolabial folds. There was, however, continuation of the improved results of the forehead lift and SMAS maneuvers of the original procedure. The conclusion is that only a direct excision will produce a permanent correction of the aging nasolabial fold.

Adipose Tissue↗
PubMed1989

Strain in fibers of a lumbar disc. Analysis of the role of lifting in producing disc prolapse.

A three-dimensional nonlinear finite element model has been used to predict the strain in the disc fibers of a lumbar motion segment under various single and combined loads such as those representing symmetric and non-symmetric liftings. A progressive failure analysis also has been performed under loads representing lifting while bending to one side: assuming yield and ultimate fiber strains of 14 and 16%, respectively. Large tensile strains of about 10% in the disc fibers are predicted under the maximum loads simulating symmetric lifting. Addition of lateral bending and twisting significantly increases the maximum fiber strain to more than 20%, and hence augments the risk for disc rupture. The maximum fiber strain occurs in the innermost annulus layer at the posterolateral location. Loss of intradiscal pressure or volume has a marked diminishing effect on the magnitude of maximum fiber strain predicted under flexion loadings. Failure analysis indicates that rupture initiates in the fibers in the innermost layer at the posterolateral location. With a slight increase in the loads, rupture progresses radially to the adjacent outer layer. Further progress of rupture in the fibers toward the annulus outer periphery resulting in complete radial fissure and disc prolapse appears to require additional increase in the loads. In the presence of large intradiscal pressure, the generated partial or complete radial fissure is likely to result in annulus protrusion or disc herniation, respectively. The results of clinical, epidemiologic, and experimental studies support the failure mechanism predicted in the present study.

Biomechanical Phenomena↗
PubMed1991

Trunk muscle and lumbar ligament contributions to dynamic lifts with varying degrees of trunk flexion.

This study was done to assess the interplay between muscular and ligamentous sources of extensor moment during dynamic lifting with various loads and flexion angles of the trunk segment for 15 subjects lifting a total of 150 loads. Ligament forces predicted from an anatomically detailed biomechanical model did not generally contribute more than 60 Nm for most of the lifts because the lumbar spine was only flexed to a moderate and constant degree for each load condition. In contrast, additional moment demands associated with increases in hand load were supported by muscle. Although the compression forces on the L4-5 intervertebral disc were fairly insensitive to the interplay between the recruitment of muscle and ligament, the shear force was significantly higher with a greater degree of lumbar flexion. The risk of injury may be influenced more by the degree of lumbar flexion than the choice of stoop or squat technique.

Adult↗
PubMed2003

Advances and controversies in face lift surgery.

PURPOSE OF REVIEW: The only constant in face lift surgery is the goal-rejuvenation of the lower two thirds of the face and neck. Societal shifts have focused patients on less invasive procedures, with less downtime and more rapid return to daily activities. RECENT FINDINGS: The lateral SMASectomy procedure has proven to be an effective technique, with a high degree of safety, minimal morbidity, and high patient satisfaction. Additionally, younger patients often require less extensive procedures to achieve an aesthetically desirable result. Recent advances such as the short scar face lift with SMASectomy, and the S-lift, have centered upon less invasive approaches to lower face and neck restoration. The optimal technique for correction of platysma bands also remains elusive, with multiple options available. All procedures dramatically benefit from the use of tumescent anesthesia to decrease operative time, postoperative morbidity, and recovery time. SUMMARY: There is no single ideal technique for each patient. The procedure used must be individualized for each patient's unique anatomy and goal for surgical restoration.

Aging↗
PubMed2002

Endoscopic subperiosteal midface lift: surgical technique with indications and outcomes.

PURPOSE: To review the surgical technique of the endoscopic subperiosteal midface lift and present our clinical outcome in 22 consecutive patients. METHODS: We retrospectively evaluated the clinical outcomes of 39 endoscopic subperiosteal midface lifts in 22 consecutive patients. Of the 39 sides, 21 had a lower eye conjunctival spacer graft inserted (15 hard palate mucosal graft, 6 AlloDerm). The success of the procedure was graded based on the aesthetic and functional results. Subjective and objective assessments were made using history, examination, and photos. RESULTS: Results for the clinical outcome were graded as excellent, good, fair, or poor. Among the 39 sides, indications for the procedure included facial rejuvenation (41%), postblepharoplasty lower eyelid retraction (26%), eyelid retraction secondary to midfacial ptosis (15%), severe cicatricial ectropion (13%), and paralytic ectropion secondary to 7th nerve palsy (5%). The operating surgeons evaluated the clinical outcome as "excellent" in 24 sides (61%), "good" in 10 sides (26%), "fair" in 2 sides (5%), and "poor" in 3 sides (8%). The procedure was successful at increasing malar projection, improving lower eyelid fullness, and elevating the lower eyelid in cases of lower eyelid retraction. The procedure was less effective in decreasing the prominence of the deep nasolabial fold. CONCLUSIONS: The endoscopic subperiosteal midface lift is an effective method for elevating the midface. A more youthful appearance is achieved with the procedure, and when necessary, recruitment of anterior lamella allows elevation of the lower eyelid to correct retraction.

Adult↗
PubMed2003

Anthropometric measurements of the endoscopic eyebrow lift in the treatment of facial paralysis.

Endoscopic eyebrow lift was performed on 51 patients presenting with eyebrow ptosis due to facial paralysis. The resulting anthropometric measurements of eyebrow position were analyzed statistically to evaluate the effectiveness of this method. When preoperative eyebrow differences between the paralyzed and nonparalyzed sides were measured, the average difference at midpoint was 4.4 mm, and at the highest point, 4.6 mm. When the same points were measured postoperatively, the average difference at midpoint was 2.4 mm, and at the highest point, 2.3 mm. The difference in eyebrow height between the paralyzed and nonparalyzed sides correlated positively with age, both preoperatively and postoperatively. However, differences between preoperative and postoperative eyebrow height (which reflects the effectiveness of endoscopic eyebrow lift) at the highest point did not correlate with age and at the midpoint displayed a slightly negative correlation with age. These results suggest that endoscopic eyebrow lift is effective among young patients whose eyebrow ptosis is minor and is relatively ineffective among elderly patients whose eyebrow ptosis is severe. The conventional method of juxta-brow excision is indicated for elderly patients, for whom the operative scar is almost inconspicuous.

Adolescent↗
PubMed2005

Angle-splitting ostectomy followed by face lift for elderly patients with prominent mandibular angles.

A prominent mandibular angle is a relatively common aesthetic problem among Asians, and the reduction angle-splitting ostectomy is now becoming a very popular procedure in Asian countries. Although this operation is usually performed on young patients, the same aesthetic demands are also seen in the elderly. In this report, the authors describe their experience with angle-splitting ostectomies followed by face lifts in three patients older than 50 years. The angle-splitting procedure was the same as that performed in young patients, and clinical results were assessed with photographs and three-dimensional computed tomographic scans. The facial contours after angle-splitting ostectomy were satisfactory, but the patients showed postoperative redundancy of the skin, especially along the jaw line, because of the loss of bony protrusion laterally. Therefore, the patients underwent subsequent superficial musculoaponeurotic system cheek lifts. The final aesthetic results were satisfactory in all cases. When surgeons want to perform the angle-splitting ostectomy safely and effectively on the elderly, they should be aware of the risks and indications specific for elderly patients, and a multidisciplinary support system should be available. Subsequent face lifts can improve skin redundancy and lead to better cosmetic results.

Aged↗
PubMed2006

A clinical retrospective study comparing two short-scar face lifts: minimal access cranial suspension versus lateral SMASectomy.

BACKGROUND: The purpose of this study was to retrospectively compare the short- and long-term cosmetic outcomes of two minimal incision rhytidectomies and analyze their advantages and disadvantages. METHODS: The results of minimal access cranial suspension face lift versus minimal incision rhytidectomy with lateral SMASectomy were evaluated after 1 and 24 months. Statistical analysis considered surgeon/patient satisfaction, time used in the procedures, pain, and learning curves. Photographs were sent to the patients and two plastic surgeons, unfamiliar with the cases, for evaluation of results that were assessed by an objective grading system described by Strasser. RESULTS: Eighty-two patients completed 1 and 24 months' follow-up. Complications were two hematomas, two retroauricular-lobule dog-ears, and one hypertrophic preauricular scar. Surgical time was longer for the SMASectomy. Postoperative pain was worse for minimal access cranial suspension face lift. There were no differences in cosmetic results between the two techniques at 1-month and 2-year follow-up. Incorporating age, sex, postoperative pain, and duration of surgery as confounding factors did not modify the model. Surgeon/patient satisfaction showed no difference with either technique, but the photographic evaluation of all cases at 24 months revealed that more than 50 percent of the sample needed a tuck procedure to correct jowling and redundant skin. CONCLUSIONS: Advantages of short-scar face lifts are the avoidance of the postauricular and occipital incisions, and the disadvantages are the moderate results in the neck and nasolabial folds and their potential short duration. For 24 months in this study, the duration of results was similar for both minimal access cranial suspension and lateral SMASectomy.

Adult↗