Aponeurotic System Research Articles

Post-Treatment Displacement of Facial Soft Tissue Fillers-A Retrospective Ultrasound-based Investigation of 382 Zygomatic Regions.

Clinical and ultrasound experience has revealed that after soft tissue injections of the lateral cheek, the filler may displace from the zygoma to the caudal temporal area. To obtain more data to provide insight into product distribution when soft tissue fillers are injected in the zygomatic region. Two hundred patients were examined with facial ultrasound imaging of the zygomatic and temporal region. Inclusion criteria were simply a positive response on the screening questionnaire as to whether or not they had filler injections placed in their lateral cheek. Control injections were also performed to the zygomatic regions of a body donor and in 10 patients ultrasound-guided. A correlation was found between the layers in which filler was detected on the zygoma and where it was ultimately found in the temples. Four different redistribution patterns were observed: (1) migration of filler within the superficial muscular aponeurotic system (SMAS) on the zygoma into the superficial temporal fascia. Migration of filler from the lateral suborbicularis oculi fat to (2) the deep interfacial plane of the temple or (3) to the superficial temporal fat pad; (4) migration from the supraperiosteal layer of the zygoma to the superficial temporal fat pad. Body donor and patients: filler deposits injected on the zygoma were witnessed to shift during injection into the caudal part of the temple. Soft tissue filler aliquots may be redistributed into the temples after injections of the lateral side of the zygomatic arch. The displacement follows a distinct pattern depending on the initial layer of injection.

Comparison of Resorption in Autogenous Dorsal Onlay Cartilage Grafts: An Experimental Study.

The present study was designed to compare the graft resorption characteristics of autogenous cartilage from the septum, auricle, and costal in the superficial muscular aponeurotic system of the nasal dorsum of the rabbit model. Equal-sized perichondrium-free septal, auricular, and costal cartilage grafts were collected from fifteen New Zealand white rabbits. Cartilage grafts were taken at the scale of two grafts from each animal's ear, two from its costal part, and one from its septum. Costal cartilage grafts that were shaped with a micro-motor device and monopolar electrocautery, elastic cartilage grafts that were shaped with a micro-motor device and monopolar electrocautery, and septal cartilage grafts that were shaped with a scalpel were all implanted into the dorsum of rabbit's noses to create five groups. All autogenous cartilage tissues were removed 3months later. Cartilages were evaluated for histological features, graft mass, and chondrocyte density resorption. The elastic cartilage group, where electrocautery was used to shape the cartilage, had a higher resorption score than the other groups. The costal cartilage graft shaped with a micro-motor was also observed to have the best cartilage regeneration score. We observed that the resorption of costal cartilage was lower than that of ear and septum cartilage. It was determined that micro-motor application for the shaping process caused less resorption and stimulated more regeneration than cautery application. 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 .

Eyebrow Lift: Open-Book ROOF Transposition and Orbicularis-Frontalis Sliding Maneuver.

This article delves into innovative surgical techniques, the open-book ROOF (retro-orbicularis oculi fat) transposition technique (OBRoof) and the orbicularis-frontalis sliding maneuver (OFS), designed for eyebrow and upper eyelid rejuvenation in the aging process. Emphasis is placed on understanding the dynamic changes occurring within the forehead and eyebrow envelope's five layers and their intrinsic relationships as well as the impact of the ROOF ptosis causing upper eyelid hooding. The OBRoof technique is highlighted for its effectiveness in addressing ptotic volume, offering a rejuvenated appearance by relocating volume to the supraciliary region.In the OFS, we explore the concept of extensive dissection above the upper border of the eyebrow to allow for free repositioning of the eyebrow. The stabilization is based on deep-plane facelift concepts, as the orbicularis oculi muscle corresponds to the superficial muscular aponeurotic system, and it is anchored to the deep layers (periosteum) by passing through the frontal muscle.In summary, this article provides a comprehensive exploration of innovative and minimally invasive techniques for eyebrow and upper eyelid rejuvenation, shedding light on their anatomical foundations, procedural intricacies, and the potential for achieving natural and lasting outcomes.

Restoring facial superfacial muscular aponeurotic system defects after permanent fillers removal using fascial and SMAS grafts: a preliminary study

Restoring facial superfacial muscular aponeurotic system defects after permanent fillers removal using fascial and SMAS grafts: a preliminary study

Indirect Lip Lift With Modified Suspension Technique to Pyriform Ligament

The lip lift procedure has witnessed a surge in popularity in recent years due to its remarkable ability to bring about a substantial transformation in facial appearance through a minor surgical intervention. The primary objective of the procedure is to diminish the height of the philtrum, consequently enhancing the visibility of the teeth while leaving behind a minimal visible scar along the upper lip vermilion border. In this article, a series of refined modifications to the conventional subnasal technique are introduced. The approach entails the removal of a skin strip while preserving a subcutaneous cuff. This method incorporates central and laterally vectored deep-plane sub-superficial muscular aponeurotic system (SMAS) advancement flaps, complemented by suspensions to the pyriform ligament. Furthermore, a sliding closure technique is introduced through the cuffs, and an enhanced skin suturing method is implemented. These substantial enhancements to the procedure result in a lasting elevation of the lip and a reduction in the visibility of unfavorable scarring. These modifications have emerged through an evolutionary process, driven by the pursuit to improve scar outcomes. The surgical techniques applied in this method effectively address the primary limitations of previous approaches, consistently yielding aesthetically pleasing results over the long term.

The deep cervical fascia neck lift

The main and more frequent problem in face lift is recurrence of neck bands. To improve face lift stability, a new aging analysis is proposed. The visible sign of face aging is skin excess. Superficial musculo aponeurotic system (SMAS) retraction is a much less visible sign. Nevertheless, botulinum toxin injections elongate muscles of the SMAS and rejuvenate the face. In the Face Recurve Concept, MRI studies prove the mimic muscles retraction that comes with aging. Face lift techniques include SMAS plication, traction or excision, which increases discrepancy between the envelope, the skin and the core, the SMAS. As skin excision is poorly efficient because performed posteriorly, far from the anterior skin excess located at the medial neck, the association to SMAS retraction exacerbates the gradient difference between envelop and core. This analysis shows that it is paramount to preserve the SMAS. (1) The sub-skin dissection has to be executed moving beyond the marionette fold and the paramedian neck bands; (2) no action is performed on the SMAS, only an horizontal section of the platysma at the hyoid height that will avoid platysma band recurrence. A botulinum toxin injection performed herein just after, blocks muscle regeneration; (3) the skin is pulled backward with a clear posterior transposition to the platysma. The skin at the cervico-mental angle and all along the cervico-mental crease is fixed to the deep cervical fascia, in the gap between the edges of the sectioned platysma, blocking muscle recreation. A resorbable barbed thread is used, with a first bite made at the cervico-mental angle through the deep cervical fascia then in the direction of the mastoid, with long bites through the deep cervical fascia versus short subcutaneous bites. Thanks to this strong shift, the cervico-mental crease is definitely recreated with no need of pre-auricular skin tension. Thirty-two patients have been operated with this technique on a one-year period. The results are a lot more stable and swelling is lowered down to the minimum.

Study of the Effect of Zhuang Medicine Aponeurotic System Triple Therapy on Lumbar Disc Herniation and Alpha-1 Acid Glycoprotein Level

Objective: To analyze the application effect of Zhuang medicine aponeurotic system triple therapy in the treatment of lumbar disc herniation and its effect on the level of alpha-1 acid glycoprotein (alpha-1 AGP). Methods: 200 patients with lumbar disc herniation were selected and randomly divided into a treatment group and a control group, 100 cases in each group. The control group was given conventional acupuncture, and the treatment group was treated with manipulation + fire needling + cupping. The alpha-1-AGP levels before and after treatment, as well as the lumbar spine function and pain scores before and after treatment, and the adverse reactions occurred during treatment between the two groups were compared. Results: Before treatment, there was no significant difference in alpha-1 AGP levels, lumbar function, and pain scores between the two groups (P > 0.05). After treatment, the lumbar function scores of the two groups were significantly increased, with the treatment group having higher scores than the control group (P < 0.05); the incidence of adverse reactions in the treatment group was 2.00%, which was much lower than the control group (P > 0.05). Conclusion: Appropriate application of Zhuang medicine aponeurotic system triple therapy in the clinical treatment of lumbar disc herniation can promote the improvement of alpha-1 AGP index level, reduce the pain degree of patients, and improve their lumbar spine function. At the same time, Zhuang medicine also has significant advantages in terms of safety, while ensuring the efficacy and safety of the treatment.

MODIFIED COMPOSITE PLANE FACELIFT WITH EXTENDED NECK DISSECTION.

The attenuation of retaining ligaments with aging leads to downward displacement of facial fat compartments, and is responsible for many of the stigmata that occur with aging. The zygomatic cutaneous and masseteric cutaneous ligaments prevent the transmission of adequate traction to the malar portion of the dissection during traditional low SMAS facelift techniques which involve plication or imbrication of the exposed surface of the SMAS because they do not include surgical release of these ligaments. Inadequate release of these ligaments, especially the zygomatic cutaneous ligament may lead to an unbalanced, unnatural appearance with unopposed nasolabial folds. In contrast, extended facelift techniques (extended SMAS, High SMAS, deep plane facelift, composite plane facelift) involving the release of these ligaments and can reposition the ptotic malar fat, and diminish the nasolabial folds. Additionally, the composite and modified composite plane facelifts include orbicularis oculi muscle elevation and can achieve a more harmonious rejuvenation. However, due to facial nerve injury risk, many facelift surgeons either inadequately release these ligamentous attachments or prefer less invasive techniques. Modified composite plane facelift allows safe release of the zygomatic cutaneous ligament, and safe entry into the right plane leaving all malar fat pad attached to the skin. Modified composite plane facelift technique also produces combined, balanced, and harmonious rejuvenation of the midface, cheek, lower face, and neck without requiring a separate midface lift procedure or a transblepharoplasty approach. Extending the subSMAS/subplatysmal dissection inferior to the angle of mandible, releasing of the cervical retaining ligaments, and adding a horizontal platysma myotomy below the angle of the mandible significantly improves the cervical contouring and enhances the jawline rejuvenation. This paper explains modified composite-flap facelift with extended neck dissection in a step by step manner, and highlights anatomical details to perform a safe, effective and successful extended face and neck lift surgery.

Facelift Surgery after Permanent Filler: Outcomes after Removal of Permanent Filler under Local Anesthesia.

Background:Permanent fillers were previously used to fix wrinkles associated with aging as they were considered a reasonable choice for facial rejuvenation. However, the subsequent removal of permanent fillers is of great concern to surgeons before performing a facelift surgery. Many studies have evaluated the outcomes of facelift surgery; however, we sought to evaluate the outcomes of facelift surgery which required removal of fillers beforehand.Methods:This retrospective cohort study evaluated the outcomes of 50 patients with regard to patient satisfaction and postoperative complications of facelift surgery with removal of permanent filler under local anesthesia. A short scar rhytidectomy with superficial muscular aponeurotic system plication was performed. Preoperative and postoperative photographs were analyzed by two independent surgeons to report asymmetry scores ranging from one to three (one none, two slight, and three obvious asymmetries). Patient satisfaction scores were also recorded.Results:The preoperative presentations of the permanent filler were asymmetry (82%) and disfiguring facial edema (26%). Removing fillers under local anesthesia is generally tolerable, with 56% of patients tolerating rhytidectomy. The degree of the participants’ satisfaction after follow-up was satisfactory; two-thirds of patients (62%) were satisfied. There was a significant difference between surgeons’ preoperative and postoperative assessment of asymmetry scores (P < 0.05).Conclusions:Permanent filler removal with concomitant face-neck lift surgery has satisfactory outcomes. The procedure length was primarily determined by the patient’s skin characteristics and the severity of the local condition.

Combined sternocleidomastoid and superficial muscular aponeurotic system flap reconstruction after malignant parotid tumor excision: a case report

Combined sternocleidomastoid and superficial muscular aponeurotic system flap reconstruction after malignant parotid tumor excision: a case report

Biplanar Lipoabdominoplasty: Introducing the Subscarpal Lipo Aponeurotic System.

Background:Preservation of Scarpa’s fascia in abdominoplasty has been previously presented. Herein we introduce the subscarpal lipo aponeurotic system (SLAS) and the technique of preserving the SLAS and its tightening in lipoabdominoplasty.Methods:A retrospective cohort study of patients who underwent lipoabdominoplasty performed by a single plastic surgeon (YW) between 2014 and 2019 was conducted. We compared postoperative complications, aesthetic outcomes, and procedure lengths between standard and biplanar lipoabdominoplasty with SLAS tightening. Supra-scarpal fat and SLAS tissue specimens were obtained for histological analysis.Results:In total, 179 patients underwent biplanar lipoabdominoplasty with SLAS tightening and were compared with a control group of 65 patients who underwent standard lipoabdominoplasty. Fifty-four patients (29.9%) underwent concomitant umbilical, epigastric, or postoperative ventral hernia (POVH) repair. No major complications were encountered other than one skin necrosis in a standard lipoabdominoplasty. Moderate complication rate was 10.05% in the biplanar group, compared with 16.92% in the standard lipoabdominoplasty. The average length of the procedure and overall aesthetic results were equivalent.Conclusions:The SLAS can be individually dissected and used during abdominoplasty. No statistically significant differences were found in complication rates, length of procedure, or aesthetic outcomes between standard and biplanar lipoabdominoplasty with SLAS tightening. Further investigation is needed. Nonetheless, we postulate that patients who would benefit the most from this procedure are those with weakening of the abdominal wall, and with some fullness of the hip line, as this technique adds reinforcement to the lower abdomen and “pulls in” the flanks.

The applications of real-time imaging with transillumination, ultrasound, and Doppler for thread lifting

Thread lifting has gained popularity in recent years because of its minimally invasive properties. Regardless of the technique used, the key is threading in the optimal anatomical plane and suspending the correct target tissue. Failure to meet these objectives may result in chronic pain; contour irregularity; thread migration or exposure; and nerve, vessel, and gland injuries. The knowledge of facial anatomy alone is insufficient to corroborate the anatomical variations of a patient. Ultrasound-guided thread lifting can be performed because the trocar presents a hyperechogenic signal with bayonet and reverberation artifacts. Ultrasound is an effective tool because it can provide real-time images of the layers of the facial anatomy, fat pads, muscles, fascia, ligaments, superficial muscular aponeurotic system, arteries, and parotid duct. Transillumination, however, can be conducted to verify the presence of superficial vessels and prevent venipuncture and injury to homonymous arteries. The combination of transillumination and ultrasound provides three-dimensional information. In this study, to evaluate facial anatomy and guide threading, reconfirm the position of the thread, and prevent malpractices, practical strategies such as transillumination, ultrasound, and Doppler imaging are recommended for improving patient safety during, before, and after the procedure.

A New Approach to Thread Facelifting.

Facial rejuvenation has traditionally been achieved by repositioning soft tissue via invasive surgery. The present work describes a thread-based, face-lifting (TBFL) technique (BussoLyft&trade; that has provided reproducible and predictable results for 200 to 300 patients. To reposition the orbital, nasolabial, and jowl fat pads, three primary vectors (one vertical, two oblique) are established on the side(s) of the face that requires lifting. The vertical vector for the orbital fat pad is volumetric and the oblique vectors for the nasolabial and jowl fat pads lift by thread-tissue engagement and repositioning. Repositioning the superficial fat pads of the orbital, nasolabial, and jowls areas results in a pleasant cosmetic outcome. In the treated nasolabial and jowl fat pads, the primary repositioning vector results from engaging cogs with fat septa, which places fat in a cosmetically optimal position. The primary mobilization of the superficial fat pad through the septal attachments to the dermis and superficial fascia creates a secondary movement and repositions the overlying skin and underlying superficial muscular aponeurotic system (SMAS). Very few threads are needed to reposition full-face superficial fat. By optimizing every step of thread placement, the TBFL technique provides an efficient and effective method to reposition facial fat pads. J Drugs Dermatol. 2021;20(10):1085-1090. doi:10.36849/JDD.6139.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

The Nasolabial Area Shown on Histology and P45 Sheet Plastination.

The aim of this study was to elucidate the relationships between the nasolabial fold and superficial fascia on histology and P45 sheet plastination.Two centimeter width specimen of the nasolabial area were harvested from the skin to periosteum. Then, 10-μm sections were made, stained with Masson trichrome, and observed under a light microscope. Three head and neck specimens were sliced in horizontal sections (46 slices) using P45 sheet plastination (polyester resin corrosion-resistant method designed to preserve biological sectional specimens in situ). Through slicing, bleaching, dehydration, casting, forced impregnation, curing, cutting, and sanding the molds, P45 plastination provided good light transmission, allowing the internal structures within the sheet to be revealed clearly in their intact form.The observations on histology and P45 sheet plastination correlated well. The nasolabial fold consisted of the superficial fatty layer of superficial fascia (SFS). At the beginning of the alar groove level, the nasolabial groove was located on the point where the medial limit of SFS met the levator labii superioris. At the alar base level, the nasolabial groove was located where the medial limit of the SFS met levator labii superioris. At the mouth corner level, the nasolabial groove was located where the medial limit of the SFS met the modiolus, including the orbicularis oris. The superficial fascia became scanty near the nasolabial groove, and the SFS comprised the nasolabial fold.The results of the present study may be helpful for applying subcutaneous dissection or sub-superficial muscular aponeurotic system dissection in rejuvenation of the nasolabial area.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Commentary on: Identifying Regional Viscoelastic Properties of the Superficial Muscular Aponeurotic System.

Facelift Surgery: History, Anatomy, and Recent Innovations.

Facelift surgery has become a beautifully predictable, safe, and extremely effective operation. Our patients can expect natural and long-lasting results as a direct outcome of our improved understanding and applications of surgical facial anatomy. Rhytidectomy, once an operation of simple well-placed elliptical skin excisions, evolved to include longer skin flaps, skin and platysma flaps with various superficial muscular aponeurotic system (SMAS) manipulations, and various deep plane techniques involving the skin and SMAS as a single unit composite flap. Extended deep plane rhytidectomy and vertical vector neck and SMAS lifting have emerged in recent years as techniques that extend the traditional deep plane dissection into the neck in a subplatysmal plane to allow for release of the platysma from the cervical retaining ligaments. This, ultimately, allows for the creation of a dramatically more youthful appearing face, neck, and jawline.

Deep-Plane Approach to the Vertical Platysma Advancement: Technical Modifications and Nuances over 25 Years.

In this article, we will provide the reader with the anatomical and embryologic evidence supporting the use of the deep-plane approach in rhytidectomy and insight into the evolution of the technique into the vertical platysma advancement. The original description of the deep-plane technique only described a basic superficial muscular aponeurotic system dissection in the midface with the ability to use tension on the flap without aesthetic consequences. This plane of dissection provides additional advantages not previously described, including access to deeper anatomical structures such as the buccal fat pad, and allows in vivo assessment and treatment of jowling. We describe how extension of this dissection and selective release of facial ligaments allows us to optimize treatment outcomes and longevity, especially in cases of difficult anatomy or revisions. Further advancements include case-specific facial volume enhancement, created by complex flap design, and facial narrowing by preauricular contouring and parotid hypertrophy treatment. Insights into anatomical landmarks, technical nuances, and alternative approaches for facial variations are presented.

The Facelift in South American Patients.

South America is a vast territory; its people were made from all parts of the world. The miscegenation made a unique population comprised of Indian, Asian, Caucasian, African, Mestizo, Mulatto, and Zambo. The South American patients tend to have a wider face with a skin-soft tissue envelope (S-STE) that is thicker, heavier, and has less elasticity than the Caucasian patient. Upper eyelids may hood easily. In the same way, malar eminences and round face look are more prominent. The chin can be a little retracted. With aging, the S-STE tends to sag more, making nasolabial folds and jowl area more prominent, and redundant neck skin will appear loose and heavy. Facelift is popular in South American patients. They have peculiar characteristics like heavy dark sebaceous skin which lead to peculiarities in face lifting. It is usually a procedure designed to rejuvenate all thirds of the face. In the forehead, skin excision in temporal incisions is usually necessary. Midface subperiosteal lift is a possibility for heavy skin patients who need great improvement in the center of the face. The neck lift is almost indispensable to the rejuvenation of the lower third. Extended superficial muscular aponeurotic system or deep plane dissection is commonly performed so the soft tissues of the midface, the jowls, and the neck can be lifted to reestablish their youthful relationship with the underlying skeleton.

Facelift With Power-Assisted Dissection: A Preliminary Report.

Subcutaneous elevation of the skin has remained a key component in all facelift techniques. The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss. The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck. Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema. The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.