Safety and Adjuncts in Face Lifting:

Current Trends in Deep Plane Neck Lifting: A Systematic Review

INTRODUCTION

The aging neck is a prevalent aesthetic concern, with over 160,000 neck procedures performed in 2020. It is characterized by increased soft tissue laxity and displacement of cervical structures. While nonsurgical interventions like cryoablation and laser resurfacing show promise, their variable responses highlight the necessity for surgical solutions. Traditional neck lifts address superficial structures but often neglect the subplatysmal plane. Recently, deep plane neck lifts have gained attention for addressing deeper anatomical structures. This paper systematically reviews the literature on subplatysmal modifications in cervicoplasty, aiming to clarify the risks and benefits of these evolving surgical techniques.

METHODS

On February 20, 2024, a systematic review adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 guidelines was performed. MEDLINE, PubMed, Cochrane, and Scopus databases were searched for terms related to neck rejuvenation. Independent reviewers screened titles, abstracts, and full texts, including all relevant studies. Data extracted included patient numbers, procedures, outcomes, and complications.

RESULTS

From an initial 771 articles, 57 studies encompassing 8648 patients met inclusion criteria. The most commonly altered anatomical structures during "deep plane" neck lift (DPNL) were the submandibular gland (69.9%), digastric muscles (58.6%), and subplatysmal fat (48.6%). Postoperative complications were reported in 59.6% of studies, with nerve palsy (0.2%-12%) and hematoma (0.2%-4%) being most common. Aesthetic outcomes were less frequently reported (56% of studies); patient satisfaction ranged from 81.6% to 98.6%, while objective measures were reported in only 12% of studies.

CONCLUSIONS

Recent surveys indicate a growing concern over excess laxity under the chin, with patients increasingly seeking neck rejuvenation. Our review found that DPNL techniques vary widely, with the submandibular gland and digastric muscles being the most frequently altered structures. Despite a general lack of standardized outcome measures, patient satisfaction was high. However, DPNL showed a higher rate of postoperative nerve palsy compared to traditional neck lift. Overall, while DPNL demonstrates potential aesthetic benefits, the increased risk necessitates thorough patient counseling and further studies for standardization and comparison.

Differential Fat Grafting to Address Facial Asymmetry in Face Lifting

SUMMARY

The modern face lift is a complex operation involving the repositioning of tissues and the refilling of volume atrophy. Preoperative analysis is key to the successful diagnosis of aging changes. Facial asymmetry is universal, and must be recognized and incorporated into surgical planning. In this article, the authors address the role of fat grafting to manage facial aging in the setting of facial asymmetry.

New autologous fat implantation technique for face lifting: A pilot study

BACKGROUND

Autologous fat injection techniques are specially performed to restore the lack of face volume.

AIM

However, no reports have focused on the effect of sides of injection on the sagging appearance improvements and facial lifting. This study aimed to evaluate face lifting using the autologous fat injection in to sides of the face as a new technique.

METHODS

Ten patients with aging face were involved in this study. The procedure was done in an anaerobic method. To improve the method, to make patients more satisfied and gain better cosmetic outcomes autologous fat was injected on the sides of the face. To give a lifting effect to the face, the fat was injected on the hairline in the temple area, next to the ear, the angel of the jaw and the angel of the mandible leaning behind the ear to cause face lift. The patients were appraised clinically and photographically.

RESULTS

The results showed that this autologous fat injection technique has significant improvement in face lifting.

CONCLUSION

This new fat injection technique in sides of the face can create superior results on face lifting without any adverse side effects.

Use of Intravenous Tranexamic Acid in Patients Undergoing Plastic Surgery: Implications and Recommendations per a Systematic Review and Meta-Analysis

With increasing interest in aesthetic plastic procedures, the event of blood loss has compromised patients' safety and satisfaction. Tranexamic acid (TXA) is a drug used for the reduction of blood loss during surgical procedures. This systematic review aims to evaluate the clinical efficacy and safety of TXA in aesthetic plastic surgery for the reduction of bleeding and related complications. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Electronic databases PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. The medical subject headings (MeSH) keywords used for data extraction were ("TXA," OR "tranexamic acid,") AND ("plastic surgery," OR "aesthetic surgery," OR "rhinoplasty," OR "blepharoplasty,") AND ("blood loss" OR "bleeding" OR "TBL") AND ("Edema" OR "ecchymosis"). A combination of these MeSH terms was used in the literature search. The timeline of research was set from 2015 to January 2024. A total of 7380 research articles were identified from the above-mentioned databases, and only 13 research articles met the inclusion criteria. There was a significant difference in total blood loss (TBL) among patients who had undergone plastic surgery procedures while on TXA as compared to a placebo (mean difference = -6.02; Cl: -1.07 to -0.16; p > 0.00001), and heterogeneity was found (degrees of freedom (df) = 9; I2 = 97%). Only two studies reported the average ecchymosis scores after TXA among interventions in comparison to the placebo group. This review provides evidence that TXA lowers TBL, ecchymosis, edema, and anemia during cosmetic surgery without significantly increasing thromboembolic consequences.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Defining the Cervical Line in Face-Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve

BACKGROUND

Continuous sub-superficial musculoaponeurotic system (SMAS) dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face-lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study was to define the vulnerability of the facial nerve branches in this transitional area from the face-lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia.

METHODS

Ten fresh and five preserved cadaveric facial halves were dissected under 4× loupe magnification. The skin was reflected, followed by elevation of a SMAS-platysma flap, with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications.

RESULTS

Cervical and marginal mandibular branch anatomy was found to be similar to that of the other facial nerve branches, all of which initially course deep to the deep fascia in their postparotid course. The emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (cervical line).

CONCLUSIONS

Continuous dissection of the SMAS in the cheek, with subplatysmal dissection in the neck crossing over the mandibular border, is possible without jeopardizing the marginal mandibular or cervical branches if done proximal to the cervical line. This study serves as the anatomical justification for continuous SMAS-platysma dissection, and has implications for all types of SMAS flap manipulations.

Cutis Laxa and the Value of Rhytidectomy: 4 Patients and Years of Follow-Up

The modalities of the esthetic treatment of cutis laxa (CL) patients have rarely been discussed. Here, the authors present 4 CL rhytidectomy cases. The surgery method was designed based on the traditional full-incision face-lift technique combined with lamellar superficial musculoaponeurotic system flap elevation and plication. Temporal, buccal, mandibular, and cervical regions were targeted. The shortest follow-up was 30 months, and the longest was 72. The results were assessed by subjective satisfaction and third-party photo evaluation. The subjective satisfaction was graded into worse than preoperation, no improvement, slight improvement, moderate improvement, and obvious improvement. The satisfaction rate was the sum of moderate and obvious improvement. Eighteen uncorrelated professionals participated in the third-party photo evaluation, in which the preoperative and follow-up photos were presented, and frontal, temporal, mid-face (including jowl), and cervical (including mandibular line) regions were evaluated as improved or nonimproved. The outcome of the subjective satisfaction was graded as no improvement (2/12, 16.7%), slight improvement (3/12, 25%), moderate improvement (4/12, 33.3%), and obvious improvement (3/12, 25%). The satisfaction rate was 58.3%, most investigators denied the frontal and temporal region improvement, 60% observed mid-face improvement, and 80% noticed cervical improvement. Most patients and their parents had positive attitudes towards the treatment results; however, the full expectation was not achieved. The cervical region maintained the best improvement after our treatment and the mid-face ranked second. This surgery method conduces to the esthetic requirement of CL patients; however, skin laxity remains a challenge.

The Application of Subcutaneous Radiofrequency After Liposuction for the Lower Face and Neck Contouring Under Local Anesthesia

BACKGROUND

Radiofrequency-assisted liposuction (RFAL) is a new choice in energy-assisted body-contouring techniques. The purpose of this study is to observe the clinical effect and safety of RFAL on lower face and neck contouring under local anesthesia, and different outcome compared with traditional liposuction.

METHODS

From November 2016 to November 2020, a total of 72 patients with fat accumulation and skin laxity in lower face and neck, including 42 patients underwent subcutaneous radiofrequency after liposuction (group A) and 30 patients underwent traditional liposuction only (group B). The patient's parameters recorded involved age, sex, body mass index, the volume of fat aspirated, energy delivered, operative time, and complications. They were photographed for comparison before and after treatment. At 3 and 6 months after the operation, improvement in skin tightening and patient satisfaction was surveyed postoperatively and assessed by third-party surgeons.

RESULTS

At 6 months after the operation, evaluations scores of the contouring outcome had significant difference between 2 groups (3.0±0.9 versus 2.5±1.0, P =0.045). There was no significant difference at 3 months (2.8±1.0 versus 2.6±1.0, P =0.265). Although the satisfaction rate of group A was higher than that of group B both at 3 months (76.2% versus 66.7%) and 6 months (80.9% versus 60.0%), there were no significant differences in average score ( P >0.05). No significant complications or adverse events requiring further medical or surgical intervention after treatment.

CONCLUSION

Subcutaneous radiofrequency after Liposuction is a safe and effective treatment that can achieve significant improvement of the fat accumulation and skin laxity of the lower face and neck under local anesthesia.

Advances in Face-Lift Surgical Techniques: 2016-2021

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery

BACKGROUND

Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients.

OBJECTIVES

This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes.

METHODS

A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed.

RESULTS

Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001).

CONCLUSIONS

TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.

LEVEL OF EVIDENCE: 4

Facial Aging Surgery: Healing Time, Duration Over the Years, and the Right Time to Perform a Facelift

BACKGROUND

The "time variable" assumes paramount importance, especially regarding facial rejuvenation procedures. Questions regarding the length of recovery time before returning to work, how long the results will last, and the ideal time (age) to undergo this particular type of surgery are the most commonly asked by patients during the initial consultation.

OBJECTIVES

The authors endeavored to determine the healing time, optimal age to perform the surgery, and duration of the results after cosmetic face surgery.

METHODS

A 35-year observational study of 9313 patients who underwent facial surgeries was analyzed. The principal facial rejuvenation interventions were divided into 2 subgroups: (1) eyelid and periorbital surgery, including eyebrow lift, blepharoplasty, and its variants and midface lift; and (2) face and neck lift. Significant follow-ups were conducted after 5, 10, and 20 years. To evaluate the course of convalescence, the degree of satisfaction with the intervention, and the stability of the results, a questionnaire survey was administered to a sample of 200 patients who underwent face and neck lifts.

RESULTS

The answers given indicated that surgery performed according to rigorous standards allowed for a relatively rapid recovery, and the positive results were stable up to 10 years after surgery. The level of patient satisfaction also remained high even after 20 years.

CONCLUSIONS

The "right time" for a facelift, taking into account age, recovery time, and the longevity of the results, is an important consideration for both the patient and the cosmetic surgeon.

LEVEL OF EVIDENCE: 4

Clinical Effects of the Combination of Rhytidectomy and Temporomandibular Joint Disc Repositioning Surgery

OBJECTIVE

This study aims to investigate the clinical effects of the combination of rhytidectomy and temporomandibular joint (TMJ) disc repositioning surgery in internal derangement (ID) stage IV-V and facial aging patients.

METHODS

Eighteen facial aging with bilateral ID IV-V patients were enrolled in this study. All of them had undergone temporomandibular disc repositioning surgery and rhytidectomy by the same surgeon (Yao Min Zhu). Pre-/post-surgical clinical manifestations, facial photography, radiographic data were recorded and analyzed, as well as doctor, patient, third-party evaluation of postsurgical facial appearance satisfaction.

RESULTS

The average age of 18 female patients was 52.9. The average of presurgical visual analog pain scale score was 5.94, ranged from 4 to 8. After 6 months, the average of postsurgical visual analog pain scale score was 0.28, ranged from 0 to 1 (P > 0.05). The average maximal mouth opening of presurgical and postsurgical was 2.19 and 3.29 cm, ranged from 1.2 to 2.8 cm and 3.0 to 3.5 cm, respectively (P < 0.05). Postoperative magnetic resonance imaging showed the location of the bilateral TMJ discs directly above the mandibular condyle. The satisfaction rate of doctors, patients and third-party with facial appearance was 95% to 98%, 96% to 99% and 96% to 99%, respectively, with an average of 95.72%, 98.11%, and 97.50%.

CONCLUSIONS

For patients with bilateral ID IV-V and facial aging, the combination of disc repositioning surgery and rhytidectomy is a very feasible procedure to treat TMJ disorders and improve patients' facial appearance and satisfaction.

Conservative Neck Rejuvenation

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

Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection

Facelifts are frequently combined with fat injection to restore volume. However, the efficacy of simultaneous fat grafting has not been objectively evaluated in a large number of patients that includes a control group. This study was undertaken to fill this gap in our knowledge base.

Hypoglossal-Facial Side-to-End Neurorrhaphy With Concomitant Masseteric-Zygomatic Nerve Branch Coaptation and Muscle Transfer for Facial Reanimation: Technique and Case Report

BACKGROUND

Hypoglossal-facial direct side-to-end neurorrhaphy has become widely used for facial reanimation in patients with irreversible facial nerve damage. Although this procedure achieves good restoration of facial function, it has disadvantages such as mass movement and lack of spontaneity.

OBJECTIVE

To present a new facial reanimation technique using hypoglossal-facial direct side-to-end neurorrhaphy with concomitant masseteric-zygomatic nerve branch coaptation and secondary muscle transfer to reduce mass movement and achieve a spontaneous smile in patients with facial paralysis.

METHODS

This article describes a novel facial reanimation technique that employs hypoglossal and masseteric nerve transfer combined with secondary vascularized functional gracilis muscle transfer.

RESULTS

Details of the technique are reported in a patient with complete facial paralysis after brain surgery. The hypoglossal nerve was partially served and connected to the mastoid segment of the facial nerve by side-to-end anastomosis to restore facial symmetry. A nerve supplying the masseter muscle was coapted with a zygomatic branch by end-to-end anastomosis to restore voluntary movement of the oral commissure, as well as to assist with eye closure. A cross face sural nerve graft was connected to zygomatic branches on the healthy side. In the second stage, a vascularized functional gracilis muscle graft was transplanted using the cross face nerve graft as the donor nerve to restore a natural smile.

CONCLUSION

Hypoglossal-facial neurorrhaphy with concomitant masseteric-zygomatic nerve branch coaptation and muscle transfer is an alternative facial reanimation technique that reduces mass movement and achieves a natural smile.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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