Three-Dimensional Arterial Distribution Over the Midline of the Nasal Bone

Background A comprehensive understanding of arterial variations around the midline of the nose is of great importance for the safety of filler injection. Objectives The aim of the study was to clearly define the 3D location of the arteries along the midline of the nasal bone. Methods The arterial structures overlapping the nasal bone along the midline were observed in seventy-nine cadavers. Results The present study found that 0~3 named arteries per nose segment could be identified. All of the arterial structures were located in or above the superficial musculoaponeurotic system (SMAS) layer overlapping the nasal bone. The probability of encountering named arteries at five defined points, P1-P5, was 5/79 (6.3%), 4/79 (5.1%), 1/79 (1.3%), 6/79 (7.6%) and 9/79 (11.4%), respectively. The depth of the main arterial trunk was 1.2 ± 0.4 mm, 1.6 ± 0.6 mm, 1.8 ± 0 mm, 1.0 ± 0.4 mm, 0.9 ± 0.5 mm below the skin at P1-P5, respectively. Conclusions We confirmed that sub-SMAS injection along the midline through a needle is anatomically reliable and that a technique with one entry point through the rhinion via a cannula can easily keep the needle sufficiently deep for safe nasal filler injection.

The Effect of Extended SMAS Face-lift on Earlobe Ptosis and Pseudoptosis

In this study, we explore the changes in the earlobe segments following an extended superficial musculoaponeurotic system (SMAS) face-lift and neck lift. We proposed to delineate the effect of the cheek and neck skin tension vectors on the earlobe based on the amount of excised skin length. A retrospective study identified patients who underwent extended SMAS rhytidectomy performed by the senior author (A.M.) at the Cosmetic Plastic Surgery Institute (CPSI) from 2017 to 2020. A total of 34 North American Caucasians, who had preoperative and postoperative photographs available for comparison, were evaluated. Preoperative and postoperative cephalic (the distance from the intertragal notch to the otobasion inferius, abbreviated as I to O) and caudal earlobe segment (the distance from the otobasion inferius to the subaurale, abbreviated as O to S) heights were collected. The change from the postoperative to preoperative measurements was calculated. The effects of the degree of cheek skin (superior ear [SE]) and neck skin (mastoid peak [MP]) excision lengths were then determined by comparing the change in I to O and O to S. The postoperative attached cephalic segment (15.94 ± 1.02 mm) increased significantly compared with the preoperative attached cephalic segment (12.99 ± 1.03 mm). The postoperative free caudal segment (3.62 ± 0.81 mm) decreased significantly compared with the preoperative free caudal segment (5.44 ± 0.95 mm). The SE median was found to be 3.0 cm and the MP median was found to be 3.5 cm. I to O increased by 3.85 mm for SE ≤3.0 cm compared with only 1.57 mm for SE >3.0 cm. O to S decreased by 2.79 mm for SE ≤3.0 cm compared with only decrease of 0.14 mm for SE >3.0 cm. I to O increased by only 1.67 mm for MP < 3.5 cm. O to S decreased less dramatically by 0.55 mm for MP ≤3.5 cm compared with decrease of 2.39 mm for MP >3.5 cm. These data demonstrate that more aggressive SE >3.0 cm cheek excision lengths resulted in a protective effect on decreasing the free caudal segment of the earlobe. More aggressive excisions of the cheek demonstrate a protective effect on preserving the free earlobe caudal segment, whereas more aggressive neck skin excisions result in higher propensity for loss of the free earlobe caudal segment. In our study, we demonstrate findings observed with clinical observations that a face-lift and neck lift will result in increase in the attached cephalic earlobe segment height (I to O) and a decrease in caudal free earlobe segment height (O to S). These findings may assist plastic surgeons when trying to fine-tune the earlobe aesthetics during face-lift and neck lift. If the patient has a small free hanging earlobe, the more aggressive pull on the cheek flap will result in less reduction in the earlobe hang.

NAL Neck Artificial Ligament Lifting: Neck Rejuvenation with Polytetrafuotoethylene (PTFE) Bands

Background: The current surgical method allows a short recovery and minimally invasive technique with polytetrafluotoethylene (PTFE) bands application, minimal skin excision for a fallen platysma muscle and skin laxity in facelift surgery; the clinical advantage of this method is a short recovery and an anatomic less invasive dissection, ideal for also younger patients who want more and more short healing times. Methods: Retrospective analysis of a 294 cases series of patients seeking platysma and skin laxity increase of neck-face region were included in the study. All of them were primary neck-face lift performed with PTFE bands of dual mesh that are customized for suture to the platysma and anchored to the mastoid, creating a neck artificial ligament (NAL) that is buried into the muscle and tightened, without modifying the superficial musculoaponeurotic system and platysma. Result: Data collection on surgery time, implant dimension selection, and postoperative complications were included. The most frequent complications were rare and include 5 case of superficial epidermolysis (healed within 21 days) and 1 case of mild band infection (treated with antibiotics). The surgical results are still stable over time, like those of a normal facelift after 6 months. Conclusion: minimally invasive NAL application avoids a large dissection and deep modifications of the superficial musculoaponeurotic system and platysma getting a strong upward tension that lasts over time with stable results. Keywords: Cervicoplasty, Neck, Rejuvenation, Aging, Mandible, Platysma Muscle.

Lower body lift and abdominal surgery after massive weight loss

Following the establishment of modern body lift procedures by Ted Lockwood, who sadly passed away in 2005, other innovative approaches are also now available. The main idea behind these operations, similar to modern face-lifting procedures, is to reconstruct the superficial and deep tissue layers (comparable to the superficial musculoaponeurotic system of the face) and the overlying skin. Large areas of tissue undermining and separation are, however, necessary to allow sufficient mobilization and tightening to achieve improvement in function and form. At the same time, it should not be forgotten that patients who have undergone major weight loss often have intrinsic medical problems such as diabetes mellitus, high blood pressure, nicotine abuse, and hormonal changes. These factors must be considered when planning the reconstruction. The problems and solutions derive from the authors’ experience over the last 15 years at the Department of Plastic Surgery at the Dreifaltigkeits-Hospital in Wesseling, Germany. These surgical procedures create great wound cavities but have associated risks that are manageable when planning and surgery are carried out meticulously.

Revisiting the Embryology of the Facial Muscles, the Superficial Musculoaponeurotic System, and the Facial Nerve

The facial muscles are responsible for nonverbal expression, and the manner by which these muscles function to express various emotions are reviewed. How one recognizes these various facial expressions and how individuals can alter their facial expression are discussed. The methodology for cataloging facial expressions is also presented. The embryology of the facial muscles; the facial ligaments; and the supporting superficial musculoaponeurotic system, which magnifies the muscle movements, is also reviewed as is the embryology of the facial nerve, which innervates these muscles. Also, a detailed MR imaging atlas of the facial muscles is presented.Learning Objective: The reader will learn how the facial muscles develop and how they are the means of human nonverbal emotional expression. The anatomy of the facial ligaments and the superficial musculoaponeurotic system are also discussed

The Multiple Rhomboid Vector Suture—Our Experience of Two Years with a Modified Suspension Approach for SMAS Plication Facelifts

Purse string sutures in superficial musculoaponeurotic system (SMAS) plication facelifts may cause technique-related problems, such as soft tissue deformities, dimpling, and bulkiness inside and between the independent sutures. Therefore, the authors have developed a new approach named the multiple rhomboid vector (MRV) suture. A total of 103 patients (89 female, 14 male patients; median age: 57 years) received a primary rhytidectomy with the MRV SMAS plication suture in our clinic (2015–2017). Intraoperative time to perform the suture per side was recorded. Postoperative complications and dimpling and bulkiness of subcutaneous tissues were judged by three independent surgeons from 1 (= none) to 4 (= extreme) after 1 week, 1, 3, 6, and 12 months. A standardized survey, the FACE-Q questionnaire, was performed to evaluate postoperative patient satisfaction. Mean time to perform the suture was 5:14 minutes per side (minimum: 3:20 minutes, maximum: 5:53 minutes; standard deviation: 0:51 minutes). During the follow-up period, four complications were detected (two cases of temporary neurapraxia of the marginal branch of the mandibular nerve {n = 2 [1.9%]} and two cases of retroauricular hematoma {n = 2 [1.9%]}). Postoperative dimpling or bulkiness of subcutaneous tissues was judged as absent. Overall patient satisfaction rate, after the surgery was performed, was measured as “very high.” The MRV suture offers a combined horizontal and vertical suspension approach, which effectively addresses the different vectors of age-related facial soft tissue descent with complication rates equal to other surgical lifting techniques. Apart from that, it may help reduce the possibility of contour irregularities, whereby it must be noted that a thorough preoperative assessment together with the patient and surgical planning is crucial to ensure realistic expectations of the surgical outcome.

The Selection of Facelift Approach on the Basis of Midfacial Ptosis

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

Rhinoplasty Dissection Planes (Subcutaneous, Sub-SMAS, Supra-perichondral, and Sub-perichondral) and Soft Tissues Management

Rhinoplasty as an operation is akin to a game of chess, where every maneuver will influence the eventual outcome. Undoubtedly, more than one approach to the nasal soft tissues envelop can produce beautiful and safe results as will be described in the paper namely, the subcutaneous, sub-superficial musculoaponeurotic system, supra- and sub-perichondral planes. For different justifiable reasons surgeons have their preferences, regarding dissection planes on the tip, middle and upper thirds, and regarding the manipulation of the soft tissue layers and nasal ligaments. The concept of the nasal layers and the presence of relevant ligamentous structures and how to restore them in an anatomical fashion, will help to understand the logic behind various approaches.