Ultrasonic Deep-Plane Neck Lift

Ultrasonic deep-plane neck lift is a new approach for addressing both the subsuperficial musculoaponeurotic system and subplatysmal soft tissues during facial rejuvenation procedures. This innovative surgical approach utilizes 2.2, 2.9, and 3.7 stainless steel probes that are powered by high-frequency ultrasound. Using high-frequency ultrasound in the subcutaneous spaces has been accomplished for the past 20 years with a very suitable safety profile. In this technique, emulsification of the fat layer in both the superficial and deep planes is accomplished with tumescence of the soft tissues in the same fashion as subcutaneous liposuction. In ultrasonic deep-plane neck lift, the superficial and deep layers of fat are targeted for emulsification, and this creates a loosening of these spaces for lifting and repositioning. The procedure facilitates more accurate surgery, because the tissue effects include hemostasis and scalpel- and scissor-free undermining due to the emulsification of the fat layers of the face and neck. The other advantages of ultrasound-assisted facial contouring and rejuvenation include treatment of hard-to-treat areas like the perioral region and distal neck, which can be rapidly and safely undermined utilizing this technology. The third component of ultrasound- and energy-based facial rejuvenation surgery is the long-term remodeling and tightening that occurs beginning approximately 8 weeks after the procedure. When many conventional facelifts are beginning to fall at 3 to 4 months postoperatively, the energy-based facelifts are still tightening and this remodeling continues for up to a year after the procedure. Combining technology with conventional facelift procedures is a new approach to facial rejuvenation and is the result of 15 years of research and cooperation with the aesthetic device industry. The result of this merger of technology with conventional surgery is TESLA Facelifting, the facelift of the future.

Ultrasound-Assisted Rhytidectomy Including Sub-SMAS and Subplatysmal Dissection

Energy-based facelifting techniques are a relatively new genre of surgery. In this approach, the energy-based device-whether laser, radiofrequency plasma, or ultrasound-can be used in the superficial plane to elevate skin flaps before performing more traditional facelift techniques involving the superficial musculoaponeurotic system (SMAS) or platysma. The initial reports of utilizing fiber lasers as surgical tools date back to approximately 2007 and initial lipolasers were used to elevate facial skin flaps. The other energy-based devices were also tested. The author has probably the largest series of energy-based facial rejuvenation procedures, having performed over 3,000 of these procedures. The advantages of laser-assisted rhytidectomy include hemostasis, facilitated dissection in areas hard to elevate conventionally such as nasolabial folds or distal neck and the remodeling and tightening of tissue that results from the activation of the wound healing cascade of neocollagenesis and wound contraction. The author currently has a preference for energy device used during rhytidectomy and it is a high frequency ultrasound energy delivered by a five-ring 2.9- and 3.7-mm probe. The use of the ultrasound dissector in both superficial and deep procedures is highlighted in this article with emphasis on its use for deep cervicoplasty and subplatysmal procedures as well as sub-SMAS elevations of the facial deep plane.

Picosecond Laser: Tattoos and Skin Rejuvenation

Picosecond laser technology was cleared by Food and Drug Administration in 2012 and enhanced our ability to clear both benign pigmentation and dermal ink through a photomechanical impact created in the tissue. This impact created is greater than comparative nanotechnology and can be accomplished with lower fluences and smaller pulse durations. The addition of a diffractive lens array (FOCUS lens) has created a new category in skin rejuvenation by stimulating elastin and collagen through photomechanical and photoacoustic effects and not only through traditional photothermal tissue effects.

Laser-Assisted Facelifting and Energy-Based Rejuvenation Techniques During Rhytidectomy

The use of energy-based devices as surgical tools during rhytidectomy was introduced in early 2007 to 2008 and occurred when the first fiber laser was approved for laser lipolysis. It became evident that the fiber laser-assisted rhytidectomy could offer several advantages compared with conventional rhytidectomy. The use of energy devices now includes temperature-controlled radiofrequency and helium plasma devices. Energy devices continue to offer advantages compared with knife and scissor approaches: improved hemostasis; an ability to dissect into areas without full flap elevation; and the shrink-wrap late effects of collagen remodeling after energy-based treatment, which improves the results of rhytidectomy.

Pulsed and Fractionated Techniques for Helium Plasma Energy Skin Resurfacing

Energy-based skin rejuvenation has, like other forms of aesthetic treatments, the capability of achieving desirable end results. These end results must be balanced with the degree and duration of morbidity, which affect recovery from treatment. Renuvion skin resurfacing protocols include a free hand approach and we describe our preferred approach of pulsing and fractionating the helium plasma resurfacing energy.

Easy Platelet-Rich Fibrin (Injectable/Topical) for Post-resurfacing and Microneedle Therapy

The process of obtaining blood biologics, including platelet-rich plasma (PRP) and platelet-rich fibrin (PRF), can be complicated and expensive and is influenced by many vendors and proprietary techniques. The indications for PRP/PRF use remain controversial, and complicated or expensive modes of generating this biologic may lead to many facial plastic surgeons to pass on the use of these potentially useful agents. The lack of standardization of PRP procurement also has led to difficulties in assessing clinical efficacy and comparing study protocols.

Renuvion/J-Plasma for Subdermal Skin Tightening Facial Contouring and Skin Rejuvenation of the Face and Neck

The Renuvion/J-Plasma helium based plasma device from Apyx Medical has technological features that result in a unique and effective method of action for the contraction of subdermal soft tissue. The device achieves soft tissue contraction by instantly heating tissue to temperatures greater than 85°C for between 0.040 and 0.080 seconds. The tissue surrounding the treatment site remains at much cooler temperatures resulting in rapid cooling of the tissue through conductive heat transfer. Compared to bulk tissue heating devices, this method of action results in effective soft tissue contraction with a lower risk of injury to surrounding tissue.

Perioperative Care Considerations and Management of Complications Involving Surgical and Technology Procedures

Technology impacts the lives of everyone nowadays and has had perhaps a greater impact on the lives of facial plastic surgeons and the patients they seek to help with both surgery and procedures. This article will discuss modern technology's impact on intervening in the aging process including technology used for facial and skin rejuvenation and reconstruction concentrating on the techniques and care to minimize complications as well as dealing with complication from the treatments.

Cool Atmospheric Plasma (J-Plasma) and New Options for Facial Contouring and Skin Rejuvenation of the Heavy Face and Neck

Treating patients with heavy or thick features comes with challenges not present in those patients lacking these physical characteristics. The authors report our experience with cool atmospheric plasma for facial contouring and skin rejuvenation of the heavy face and neck including rhinophyma. Cool atmospheric plasma is generated by running helium gas over radiofrequency energy. The resulting plasma is a fourth state of matter and has enhanced clinical effects for ablation and thinning of skin and soft tissues as well of contouring and tightening of deeper soft tissues and fascia. Cool helium plasma has been a very effective tool for skin rejuvenation and skin tightening as well as using it as a tool for nonexcisional microinvasive face and neck rejuvenation. Future research may indicate that it can help treat primary or recurrent superficial cutaneous malignancies.

Use of a controlled subdermal radio frequency thermistor for treating the aging neck: Consensus recommendations

INTRODUCTION

A new temperature-controlled device has been used as a percutaneous radio frequency probe to treat lax submental and other facial areas. It has significant advantages over other esthetic devices as it provides the dual benefit of fat lipolysis and skin tightening. Our goal here is to present consensus recommendations for treating the aging neck.

METHODS

A panel of 11 expert physicians convened in Dallas, Texas, on October 15, 2016 to arrive at a consensus on the best current practice for submental skin tightening and contour improvement. Prior to the meeting, a comprehensive review of the literature was performed and a survey was sent to esthetic dermatologists and plastic surgeons who were queried about various aspects of neck rejuvenation.

RESULTS

The literature search revealed 10 different technologies for neck rejuvenation evaluated in double-blind (n = 2) and single-blind (n = 1) clinical trials and other clinical evaluations (n = 21). The survey was sent via an email to 1248 individuals and was completed by 92 respondents. Review of the data and discussion by meeting attendees generated eight consensus recommendations.

DISCUSSION

Subdermal monopolar radio frequency represents an effective means for disrupting fat volume and skin tightening of the face, neck, and jawline. For suitable patients, this treatment can be used to achieve significant esthetic improvements.

Purse-string platysmaplasty: the third dimension for neck contouring

Techniques and concepts for treatment of the aging neck have been evolving since the late 1960s and rely on two-dimensional anterior approximation with lateral imbrication of the platysma with or without submental fat reduction, However, the medial approximation can sometimes give a "boxy" appearance to the anterior neck, especially if anterior shifting of the platysma recurs after platysmaplasty with laxity redeveloping in this midline location. The "purse-string" platysmaplasty (PSP) is a new concept in neck contouring that facilitates an enhanced definition for the cervicomandibular transition to better simulate the well-defined contour of this transition that is present in youth. It aids in the contouring of difficult poorly defined necks and in male patients. The PSP adds a "third dimension" to neck recontouring by invaginating the platysma with a plication suture and pexing the platysma, without incising it, to deeper neck fascia with a technique that adds support and definition to the neck contour. The PSP can be performed in patients undergoing a full rhytidectomy as well as in individuals having isolated neck rejuvenation. The PSP is especially helpful in rejuvenating the male lower face and neck because of the relatively heavier deeper structures of the male neck and the need to enhance definition along the jawline.

Rejuvenation of the forehead and eyelid complex

The goal of this article is to explain both the options and the techniques that are available when considering the rejuvenation of the eyelid and brow complex. We first explain the relevant anatomy. We then list and explain the different techniques with both the brow lift and the blepharoplasty. During this discussion we also explain a newer technique that we have been using. This combines the endoscopic technique with a trichophytic incision. The selection of patients is discussed in reference to which technique is appropriate given each patient's particular anatomy and desired effects. We also highlight the unique differences that the male patient presents.

Laser Facial Plastic Surgery for Men

The demand for laser facial plastic surgery for men has been increasing. Because men tend not to wear make-up and do not wish to take the time off from work associated with surgical procedures, they prefer laser type procedures that usually have minimal associated recovery. These procedures can be used to treat multiple conditions including: photoaging, acne, acne scars, superficial cutaneous problems, and rhinophyma.

Aesthetic Facial Surgery of Male Patients: Demographics and Market Trends

Evaluation of member survey data from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and the American Society for Aesthetic Plastic Surgery (ASAPS) from 2000 through 2004 reveals several procedure-specific as well as overall trends regarding utilization of aesthetic facial enhancement services. This gender-specific 5-year retrospective review indicates that males undergo significantly fewer procedures than females except for surgical hair restoration and otoplasty. There is a slight general trend toward decreased surgical but increased nonsurgical facial enhancement procedures. On a case per physician basis, AAFPRS physicians performed significantly more procedures for both males and females for every procedure and every year evaluated. Evaluation of age group data indicates that the 40- to 59-year-old age group accounts for the majority of surgical and non surgical facial enhancement requests. Despite anticipated growth of the 60- to 79-year-old age group, the 40- to 59-year-old age group is projected to remain relatively stable. Although continuing to pursue aesthetic facial enhancement services in significant numbers, men still represent a vast untapped market. This study yields important demographic and trend information that has implications for the current and future delivery of aesthetic facial enhancement services.

Subperiosteal Deep Plane Rhytidectomy: The Composite Midface Lift

Techniques for facial rejuvenation have long involved specific remedies for each facial segment affected by the aging process. Traditional facial rejuvenation techniques have addressed the anterior neck and platysma complex as well as the acquired jaw deformity. These techniques often left the nasolabial complex and the "infraorbital hollow" un-addressed. Modern techniques, including the composite rhytidectomy, the subperiosteal midface lift, and the deep-plane and the triplane rhytidectomy, have contributed to redefining the challenge of correcting the problem of the orbicularis-malar soft tissue complex descent and as such focus on a particular segment of the facial rejuvenation. This evolution of the facelift demonstrates that one size does not fit all and that surgeons should consider their rejuvenations to be not a generic facelift but a midface, lower face, and neck lift. This concept has evolved into our appreciation of distinct surgical zones. This is especially important in males, and adjunctive techniques such as the ones we describe may add benefit and enhance the final result in male patients. As discussed, the male anatomy, because of its increased surface area and weight, is more difficult to gain leverage with in rejuvenation procedures. The author describes his preferred technique for facial rejuvenation in males, the subperiosteal deep plane rhytidectomy (SPDPR), which combines a deep plane rhytidectomy with a subperiosteal dissection. Although combining subperiosteal "release" of midfacial anatomy has been reviewed by other authors, the combination of subperiosteal release and deep-plane rhytidectomy has not been previously reported or advocated. The operative technique, complications, and results of this combined technique are reviewed. The procedure as described is used as an isolated procedure for midfacial descent as well as an incorporated technique when completing a "full" rhytidectomy.

Upper Lid Blepharoplasty

Upper lid blepharoplasty is the most commonly performed operation in patients seeking facial rejuvenation. When evaluating the patient, attention should be focused on the possibility of concomitant eyelid or eyebrow ptosis. Meticulous planning and technique are required to achieve high levels of patient satisfaction.

Multimodality aesthetic skin rejuvenation

Patients requesting skin correction and rejuvenation are motivated by a number of clinical problems. Photo damage, abnormal pigmentation or vascularity, textural problems, rhytides, and laxity due to chronological aging are the primary complaints of the majority of patients. Advances in new technology in the past decade have provided the skin correction specialist with new options for treatment. Specialists with multiple technology options then face a new dilemma. What is the best treatment plan for individual patients when many options exist? Over the past five years we have developed an approach to our patients based on an individualized treatment plan consisting of a prescribed series of skin correction treatments utilizing the most specific rejuvenation techniques for each clinical problem. Multimodality aesthetic skin rejuvenation (MMASR) emphasizes the corrective process and utilization of the most appropriate technology for the patient's clinical skin problem as evidenced by the clinical examination. MMASR also takes into consideration patient bias, cost concerns, expectations of treatment, and feasibility of combining different technologies in the same treatment session. Combining skin rejuvenation techniques with surgical rejuvenation is also reviewed as an option for patients with both facial laxity and clinical skin problems.

Primary laryngeal and nasal septal lesions in pemphigus vulgaris

Synchronous laryngeal and nasal septal lesions in pemphigus vulgaris are rare. The authors report a case of pemphigus vulgaris in an elderly man who was seen with lesions of the supraglottic larynx and nasal septum. The classic skin changes of pemphigus eventually developed, and the patient responded to daily treatments of 80 mg of prednisone. Steroids and immunosuppressive agents remain the treatment of choice, but a favorable prognosis is still dependent on early diagnosis and institution of therapy.

Primary laryngeal and nasal septal lesions in pemphigus vulgaris

Synchronous laryngeal and nasal septal lesions in pemphigus vulgaris are rare. The authors report a case of pemphigus vulgaris in an elderly man who was seen with lesions of the supraglottic larynx and nasal septum. The classic skin changes of pemphigus eventually developed, and the patient responded to daily treatments of 80 mg of prednisone. Steroids and immunosuppressive agents remain the treatment of choice, but a favorable prognosis is still dependent on early diagnosis and institution of therapy.

Vocal cord paralysis in children 1 year of age and younger

Twenty-two patients 1 year of age or younger were diagnosed as having unilateral or bilateral vocal cord paralyses between 1962 and 1985. There was a marked male predominance, and 12 of the paralyses were bilateral. Congenital neurological malformations were the cause in six patients, birth trauma in five, surgery in four, syphilis in one, and six cases were idiopathic. Tracheotomy was necessary in 11 of the patients with bilateral paralyses. Ten of the 16 patients for whom follow-up was available had resolution of the paralysis from 1 week to 5 years of age. The importance of making an accurate diagnosis is stressed, as is using the fiberoptic laryngoscope.

Neurotropic melanoma of the head and neck

Neurotropic melanoma is a lesion which simulates a cutaneous fibrous tumor whose clinical course is characterized by local infiltration, multiple recurrences, and commonly by metastasis. Like adenoid-cystic tumors of the head and neck, the neurotropic melanoma has a predilection for perineural invasion and extension along peripheral nerves. Its microscopic picture is characterized by atypical "neuroma-like" patterns of Schwann cells and spindle cells, by poorly defined margins, and by neurotropism. Lentigo malignant melanoma (LMM) is a precursory lesion. The neurotropic melanoma is of particular interest to the head and neck surgeon because in the less than 50 reported cases of this rare tumor the preponderant sites were head, neck, and lip. We report two cases of neurotropic melanoma of the head and neck which demonstrate the characteristic perineural invasion of cranial nerves and extension along cranial nerves to the central nervous system. The clinical and pathologic features of the neurotropic melanoma are reviewed and the key diagnostic and therapeutic considerations in these patients are discussed.