Rhytidectomy Procedures Research Articles

Mechanical fabrication and evaluation of bioresorbable barbed sutures with different barb geometries

Bioresorbable polymeric sutures are gaining interest from surgeons and patients as they reduce surgical stress and trauma. This study involves two bioresorbable polymers, namely, catgut and poly(4-hyrdorxybutyrate) (P4HB) that are used widely in cosmetic procedures. P4HB barbed sutures are favorably used in rhytidectomy (micro-facelifts) procedures while catgut sutures are widely used for external wound closure after surgical interventions. This study involves the mechanical fabrication of catgut and P4HB barbed sutures and compares their mechanical and anchoring properties. Barbed sutures were fabricated with two different barb geometries namely, straight and curved barbs. The mechanical properties were evaluated via tensile testing, and the anchoring performance was studied by means of a suture-tissue pull-out protocol using porcine dermis tissue which was harvested from the medial dorsal site. The fabricated barbed sutures of both materials showed a similar trend compared to non-barbed sutures of decreases in failure stress, strain at failure, and work to rupture or toughness which was reduced by about 70%. At the same time there was a 15% increase in the initial modulus or stiffness of the barbed sutures. The pull-out force for the barbed sutures with straight barbs was similar for both P4HB (5.04 ± 0.8 N) and catgut (4.47 ± 3.8 N), and as expected, were higher than that of non-barbed sutures of the same size. It was also observed that barbed sutures with curved barbs also required a higher pull-out force than those sutures with straight barbs. It was concluded that by barbing sutures with different barb shapes and geometries, a range of barbed suture products could be fabricated, each meeting the closure requirements for different types of tissue and therefore being suitable for different surgical procedures.

Tranexamic Acid in Tumescence for Cervicofacial Rhytidectomies.

Cervicofacial rhytidectomies are one of the most common procedures in the United States. There are many different methods and techniques involved, but all aim to minimize blood loss and procedure time. In our study, we investigated the addition of tranexamic acid (TXA) to tumescent anesthesia during rhytidectomy procedures. Our objective was to analyze the difference in mean procedure time and estimated blood loss in patients undergoing both general and other anesthesia types, with and without the addition of TXA, while maintaining patient safety. Seventy-four patients underwent a standard superficial musculoaponeurotic system plication technique rhytidectomy, with 60 patients undergoing general anesthesia and the remaining 14 undergoing other anesthesia types. Forty patients were treated without TXA, whereas the remaining 34 were treated with TXA. Although the difference was not statistically significant, the addition of TXA resulted in a lower procedure time and estimated blood loss. Within anesthesia type, there was also a slight difference that TXA decreased blood loss and procedure time. We did find that general anesthesia type does significantly impact procedure time and estimated blood loss, when compared with other anesthesia types, independent of TXA use. The use of tumescent TXA may allow for a faster procedure with less blood loss, although further studies with a larger sample size are needed.

Zygomatic Implants through a Face-Lift Approach: Analysis of 30 Years' Experience.

The use of zygomatic implants has been mostly replaced by fat grafting in rhytidectomy procedures. Furthermore, surgeons using implants prefer the intraoral approach. The authors aimed to describe and emphasize the usefulness of the preauricular approach as the best approach for this operation and underline the value of cheek implants as an alternative and/or as an adjunct to fat grafting during face-lift procedures for midfacial rejuvenation. A retrospective study of 350 patients who underwent face-lift procedures with silicone malar implant placement through a preauricular approach was conducted. Postoperative photographs of all patients were examined by two physicians for postoperative volume adequacy, naturalness of appearance, and improvement in asymmetry. Patient satisfaction was evaluated using a questionnaire with an ordinal scale. The large majority of patients [338 of 350 (96.5 percent)] were completely satisfied or satisfied with the aesthetic outcome. The complication rate was very low and comparable to data reported in current literature. The application of cheek implants proved to be a great tool for midfacial volume rejuvenation with or without associated fat grafting. This conclusion was drawn from the answers reported in the questionnaires completed by the two examiners. The main challenge in this operation was the choice of the type, shape, and size of the implant. The preauricular approach should be given preference during this procedure because, compared to the other approaches, it is easier, faster, and more comfortable for both the patient and the surgeon. Therapeutic, IV.

Helium Plasma Dermal Resurfacing With and Without Concurrent Aesthetic Surgery of the Face and Neck: A Retrospective Review.

BackgroundHelium plasma dermal resurfacing (HPDR) is an emerging off-label use for an existing FDA-approved device.ObjectivesRetrospective evaluation of patient satisfaction and adverse events (AEs) following facial skin resurfacing with HPDR technology.MethodsSingle-site, retrospective review of 301 patient charts following HPDR treatment of the face. Patient satisfaction data were collected during review of medical records. AE data were analyzed to determine the effects of demographic, procedural, and posttreatment variables on the presence or absence of AEs.ResultsHPDR was performed concurrently with other facial/non-facial surgical procedures in 193 of 301 patients (64.1%) including over undermined facial skin in 58 patients (19.3%) during rhytidectomy. No serious AEs were observed. Nonserious AEs were noted, however, in 20 patients (7.3%) and included erythema/prolonged erythema, hyperpigmentation, milia, slow healing, and upper lip hypertrophic scar. Among the 288 patients returning for follow-up (mean 2 months postprocedure), satisfaction with HPDR treatment results was documented in 275 patients (95.5%); the remaining 13 patients’ charts did not reference satisfaction or dissatisfaction, and no AEs were recorded for this patient subgroup.ConclusionsThis retrospective study supports the use and safety of HPDR technology for facial skin rejuvenation; no serious AEs and relatively few nonserious AEs were observed following either sole modality HPDR or HPDR with concurrent treatment of undermined skin tissue during rhytidectomy procedures. Patient satisfaction and observed results are comparable to full-field laser skin resurfacing treatments.Level of Evidence: 3

The Effects of Using Tranexamic Acid in Tumescent Solution During Rhytidectomy Surgery

Introduction: Tranexamic acid (TXA) is a common adjunct to assist in hemostasis in a wide variety of applications. Although TXA has gained more popularity in facial cosmetic surgery, there are limited studies evaluating the effects of TXA in rhytidectomy patients, especially when used in tumescent solution. Purpose: The purpose of this study was to evaluate the effects of TXA on surgical time, postoperative ecchymosis, and need for aspiration when used in tumescent solution during cervicofacial rhytidectomy procedures. Materials and Methods: The authors designed a retrospective cohort study from an eligible population of all patients treated with cervicofacial rhytidectomy using tumescent solution at Williamson Cosmetic Center in Baton Rouge, LA, from January 1, 2019, to December 31, 2019. The outcome variables were surgical time, need for postoperative aspiration, and the duration of bruising postoperatively. The primary predictor variable was the use of TXA in the tumescent solution. Statistical analysis was performed using t tests and chi-square analyses. Results: Overall, 70 patients were included in the study with a mean age of 61.4 ± 7.2 years and 90% were female. Forty-five patients were in the TXA group and 25 in the non-TXA group. The use of TXA in tumescent solution was statistically significant for reducing ecchymosis ( p < .001). The majority of patients in the TXA group (60%) had bruising cleared by day 7, whereas the majority of patients in the non-TXA group (52%) had bruising cleared by day 28. There was a statically significant reduction in frequency of postoperative aspiration in the TXA group (8.9% in TXA group vs 40.0% in the non-TXA group, P = .002). The study did not demonstrate a significant difference in surgical time between the two groups. Discussion: Although there is a lack of recognition of the potential benefits of TXA, there has been an increased off-label use by numerous surgical specialties. Routes of administration include topical, oral, intravenous, local infiltrative, and by tumescent anesthesia. Improvements in intraoperative hemostasis and postoperative ecchymosis are some of the main benefits of TXA. Conclusions: Utilizing TXA in tumescent solution in patients undergoing cervicofacial rhytidectomy procedures is associated with an improvement in postoperative ecchymosis duration and a decreased need for postoperative aspiration compared with the non-TXA group.

The Use of Tranexamic Acid in Facial Cosmetic Surgery Procedures: A Technical Note

Tranexamic acid (TXA) has been widely used as an antifibrinolytic in dentoalveolar surgery and only recently has its effects been explored in facial procedures. Multiple studies have reported the use of TXA in facial cosmetic surgery; and to date, only a limited number of them utilized TXA as a local infiltrative technique for rhytidectomy procedures. We present a technical note to using lower concentrations of TXA in tumescent anesthesia for an array of facial cosmetic procedures. Our experience thus far has shown improved hemostasis, reduction of intraoperative bleeding and a more profound reduction in postoperative ecchymosis, edema and seroma formation.

A comparison of the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing hematoma and seroma in rhytidectomy: A randomized, double-blind, controlled study

One of the most feared complications of rhytidectomy is the formation of hematoma and seroma, which may harm patients' health and compromise the surgical outcome. To compare the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing surgical complications such as hematoma and seroma following rhytidectomy procedures. A prospective, randomized, double-blind, controlled study was conducted to compare the efficacy of the two interventions. Seventy-two patients were selected and divided into two groups of 36 (autologous fibrin glue versus suction drainage). Forty-eight hours after the procedures, all patients underwent ultrasound examination, always by the same radiologist, to measure the volume of exudate under the facial skin flaps. The mean total volume of exudate was 3.21 mL in the suction drainage group and 1.02 mL in the fibrin glue group, with effect size of 68.1% and confidence interval of 55.3 to 77.2 (P < 0.001). Results significantly favor the use of fibrin glue and show that it was 68.1% more effective than suction drainage in preventing hematoma or seroma in rhytidectomy procedures.

Demystifying the Deep Plane Facelift: What It Means Anatomically and Why It Works

Rhytidectomy is a common procedure performed by facial plastic surgeons. On well-selected patients, rhytidectomy rejuvenates the aging face by repositioning soft tissues and improving facial shape. The fundamental goal of rhytidectomy, or facelift surgery, is to provide a more youthful facial appearance by elevating soft tissues that often descend with aging. The success and longevity of any rhytidectomy procedure are based on the individual patient's anatomy and aging and on the mobilization, elevation, and fixation of the soft tissues during the facelift procedure. Although surgeons often use many terms to describe a given facelift technique, anatomical terms are best used to name the facelift procedure, as the plane of dissection and the vector of elevation are what determines the end result. This paper attempts to simplify and demystify the deep plane facelift procedure and to describe the anatomy that makes this technique successful.

Rhytidectomy: A Realself Social Media Analysis.

Importance: Social media has become a mainstream method of allowing patients to report and rate their satisfaction with cosmetic procedures and providers. To date, very few studies have published patient-reported satisfaction with the rhytidectomy procedure. Objective: We sought to perform a social media analysis of the rhytidectomy procedure. Design, Setting, and Participants: Data were extracted from 1876 consecutive rhytidectomy online reviews completed by individuals on "facelift" from the RealSelf website, from April 2017 to June 2019. Patients who did not undergo the procedure were excluded. Main Outcomes and Measures: Reasons for pursuing surgery, choosing a surgeon, and liking the surgical outcome were identified. Surgical and demographic variables, cost, and overall "Worth It" scores were recorded. Data were analyzed using SPSS Version 25. Valid frequencies and percentages are presented excluding missing data. Results: Of the data that could be extracted from 1876 RealSelf reviews, the majority of reviewers were female (88.3%), aged between 60 and 69 years (40.1%). Predominant reasons reviewers chose their surgeons related to favorable surgeon personality/demeanor (20.0%) and establishing a positive rapport with the surgeon during the consultation who was able to answer the patients' questions. In total, 85.0% (1045) of reviewers felt surgery was "Worth It," whereas 0.7% (8) were undecided and 14.4% (177) felt it was not worth it. The aggregate "Worth It Rating" of rhytidectomy, using RealSelf's methodology (i.e., not including unsure responses) was 96.9. The main reasons those who liked their surgical outcome related to reviewers looking younger and "fresher" (31.1%), natural or "not fake" (18.4%), and developing positive emotional responses including feeling more confident and happier (18.2%). Of those who did not feel the surgery was "Worth It," postoperative scarring, short-lasting results, and ineffective and/or poor results were common reasons why reviewers did not like their outcome. Conclusions and Relevance: The overall satisfaction with rhytidectomy surgery was high within this cohort, which is in keeping with satisfaction rates reported in the literature. Many patients chose their surgeon based on favorable personality traits and emotional connections rather than other factors.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients.

Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure. We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates. A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of -$1331 (95% CI -$2032 to -$631). Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy. 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 .

Abstract: Predictors of Hospital Costs in the Self-Pay Rhytidectomy Patient: Analysis of 1,890 Patients

INTRODUCTION: Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority of U.S. healthcare policy makers as projections of healthcare costs in the U.S. are shown to be unsustainable. This study aims to analyze specific patient and hospital factors that may augment the marginal charges of the procedure. METHODS: We conducted a retrospective cohort study using the National Inpatient Sample. Our cohort consists of self-pay, elective (non-emergent) patients aged over 18 who underwent rhytidectomy between 2013–2014. Mean marginal cost increase patient characteristics and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates. RESULTS: A total of 1,890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8,907 [$6,976 – $15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8,181-$17,120), West coast region ($7,539; 95% CI $6,412-$8,666) and combined rhinoplasty ($7,824; 95% CI $3,808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4,147; 95% CI $2,804-$5,490) and diabetes mellitus ($5,622; 95% CI $3,233-$8,011). High volume hospitals had a decreased cost of -$1,331 (95%CI -$2,032 to -$631). CONCLUSION: Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma) and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy.

Rhytidectomy: Analysis of Videos Available Online.

AbstractThe objective of this study was to examine YouTube videos related to rhytidectomy created by both physicians and nonphysicians to determine the content of the videos, the selected topics of discussion, and other important parameters using a cross-sectional analysis study design. A YouTube search result for the keyword “facelift” was performed. Videos pertaining to the rhytidectomy procedure were included in this analysis. Authorship, length of video, primary objective, and total views were recorded. Total 80 videos (81%) were authored by physicians, 14 (14%) were authored by patients, and 5 (5%) were authored by a third party. Fifty-eight (59%) videos were shorter than 5 minutes, and 41 videos (41%) were longer than 5 minutes. Fifty-two (53%) videos were viewed fewer than 10,000 times, and 47 videos (47%) were viewed more than 10,000 times. Forty (40%) videos had a primary objective of providing information, 13 (13%) had a primary objective of providing the patient's perspective, and 46 (46%) had a primary objective of advertising a physician's practice. A chi-square test for independence with threshold of significance &lt; 0.05 was used to compare whether or not the primary objective of the videos depended on the type of authorship. A significant difference was found between physician- and patient-authored videos. In addition, the 12 (12%) videos with the most views of videos included in this study were responsible for 75% of the total views of videos included in this study. Advertising was a goal of both physician- and patient-based videos, but physician-based videos were more likely to provide information about the procedure whereas patient-based videos more commonly presented a patient's personal perspective. The most popular 12% of videos were responsible for 75% of total views in this analysis, indicating that a small minority of perspectives dominates the YouTube viewership regarding rhytidectomy. The general public may be misled by information found by viewing these videos as the Internet generally lacks safeguards for quality or accuracy. It may be prudent for academic or professional organizations to provide videos intended to achieve a more neutral, well-informed perspective.

The Effects of an Antistick Phospholipid Solution on Bipolar Electrocautery Efficacy in Rhytidectomy

Ensuring adequate intraoperative hemostasis is crucial in avoiding serious complications of rhytidectomy surgery such as hematoma formation and skin flap necrosis. Charring of bipolar electrocautery arms can lead to ineffective hemostasis, frequent wiping to ensure hemostatic efficacy and prolonged operative time. We investigate the impact of a commercially available antistick coating solution (Electro Lube) on intraoperative wiping frequency of bipolar electrocautery arms and operative time for rhytidectomy procedures. Fifty patients undergoing rhytidectomy were prospectively enrolled in a randomized, split-face study. All patients enrolled were seen and evaluated in a private facial plastic and reconstructive surgery practice, and were operated on by a single surgeon in either an accredited ambulatory surgical center under deep, intravenous sedation or in a monitored office setting under light, oral sedation. Electro Lube was utilized to coat bipolar electrocautery arms for one side of the rhytidectomy procedure on each patient, letting the contralateral side serve as control. Total number of wipes to clean the cauterizing arms of the bipolar cautery per procedure was counted, and operative time, from skin incision to skin trimming, was measured. Total wipe count in the intervention group (n = 50) was 13 (0.26 wipes/procedure) versus 47 in the control group (n = 50) (0.94 wipes/procedure), a difference that was found to be statistically significant ( P = .0013). Average operative time in the intervention group was 27.52 minutes versus 28.35 minutes in the control group. This difference was also found to be statistically significant ( P = .043). The use of Electro Lube to coat bipolar electrocautery arms may have clinical utility to simplify and reduce intraoperative wiping and shorten operative time in rhytidectomy procedures and other cosmetic or reconstructive procedures where frequent use of bipolar electrocautery to maintain intraoperative hemostasis is crucial.

The anatomic study and clinical application of the premasseter space

Through the anatomy study of the premasseter space, further improved the anatomic knowledge of the premasseter space and explored its application in rhytidectomy, in order to reduce the risk of facial nerve injury. To further improve the anatomic knowledge of the premasseter space and to determine its application in rhytidectomy. The anatomy of the premasseter region was investigated in 12 fresh cadaver (24 hemi-faces) dissections;810 patients of SMAS rhytidectomy procedures were observed. ①There were several soft tissue spaces superficial to the masseter muscle, and the boundaries were strengthened by retaining ligaments. Adjacent spaces were separated by numerous weak fiber membranes connecting the SMAS and masseter fascia.② The space was further divided into two parts; one part was located under the platysma and another part was under the aponeurosis of SMAS. The former part was easier to identify and dissect. ③ The relaxation, expansion, and sliding of the space is an important reason in the face sags with aging, which is referred to as the layered ptosis theory. The soft tissue space superficial to the masseter muscle have two different characteristics. The different nature of the two parts of the space can easily mislead dissection to the wrong layer, which is the important anatomical factors for the risk of facial nerve damage in rhytidectomy. The layered ptosis theory seem to better explain the process of aging. The primary treatment of aged face was facial space dissection and tighten.

Comparative Anatomy and Facial Aging in the Animal Kingdom.

Since the beginning of modern plastic surgery discipline, facial aging has been a significant interest to plastic surgeons. One turning point for aesthetic surgery was the recognition that facial aging is more than skin deep and that any attempts at facial rejuvenation must address the subcutaneous connective tissue (i.e., fat, fascia, and muscle) [1,2,3]. Having been exposed to Tord Skoog's presentation and the 1969 publication, two surgeons from the Tessier group published the now-famous cadaveric study on the superficial fascia of the face, which was popularized under the term superficial muscular and aponeurotic system [4]. Subsequent to this, plastic surgeons began to abandon simple rhytidectomy procedures but instead developed a wide variety of techniques by which the deeper connective tissue is mobilized to restore a more youthful contour to the face. Outside of the plastic surgery literature, a different discipline has been interested in the convergence and divergence in the anatomy and functions of the facial muscle. While the nature of facial soft tissues interested plastic surgeons because of potential applications in aesthetic and reconstructive operations, biologists and comparative anatomists were more interested in what similarities and differences could be observed across facial structures of various animals because these similarities and differences were helpful in understanding the evolution of muscles innervated by the seventh cranial nerve (CN-VII). In this editorial, we would like to review the non-plastic surgery literature on the evolution of facial muscle (CN-VII muscles) and question again the nature of facial aging.

Role of Tisseel Fibrin Sealant on Postoperative Seroma and Hematoma Rates in Rhytidectomy Patients

Introduction: Rhytidectomy has become a popular procedure for the surgical treatment of the aging face and facial rhytids. Advances in autogenous, allogenic, xenographic, and synthetic sealant and hemostatic agents, working on multiple locations of the clotting cascade, are used by various specialties. Tisseel, a fibrin sealant (Baxter Healthcare Corporation, Westlake Village, Calif), can be categorized as a hemostat and sealant agent. In the rhytidectomy literature, the use of the allogenic product Tisseel has been reported to lead to superior results with fewer complications when compared with traditional suturing techniques and meticulous intraoperative hemostasis. The ability of this fibrin sealant to reduce the rate of postoperative fluid collections, such as hematoma and seroma, is currently under investigation. Materials and Methods: We conducted a retrospective cohort study. Patients from 2 medical centers were divided into 2 groups. Group 1 served as the control, in which biplane rhytidectomy procedures were completed with no fibrin sealant. In group 2, the experimental group, the fibrin sealant agent was used during the rhytidectomy procedures. In the experimental group, all patients underwent a biplane rhytidectomy procedure with 2 mL of fibrin sealant applied directly under the surgical flap to the subcutaneous surfaces. The effect of each treatment on the postoperative rate of formation of seromas and hematomas was assessed and recorded within a 3-day period after the surgery. Results: The difference in the rate of postoperative seroma or hematoma development in the control group versus the experimental group was not found to be statistically significant. Conclusions: The use of fibrin sealant can complement good surgical hemostatic technique, but the material cannot be relied on to reduce postoperative rates of hematomas and seromas after rhytidectomy procedures.

Anatomical Landmarks to Avoid Injury to the Great Auricular Nerve During Rhytidectomy

An estimated 116 086 facelifts were performed in 2011. Regardless of the technique employed, facial flap elevation carries with it anatomical pitfalls of which any surgeon performing these procedures should be aware. Injury to the great auricular nerve (GAN) is the most common of these injuries, occurring at a rate of 6% to 7%. We report our findings on the location of the GAN on the basis of anatomical landmarks to aid surgeons with planning their surgical approach for safe elevation of rhytidectomy skin flaps in the lateral neck region. Sixteen fresh cadaveric heads were dissected under loupe magnification. All specimens were dissected in a 45-degree (facelift) position in which a mid-sternocleidomastoid (SCM) incision was used for exposure. Measurements from the bony mastoid process, bony external auditory canal, external jugular vein, and anterior border of the SCM to the GAN were taken in each cadaver. The GAN follows a consistent course over the mid-body of the SCM before bifurcating into anterior and posterior branches and terminal arborization. Regardless of the length of the SCM, the GAN at its most superficial location was found to be consistently at a ratio of one-third the distance from either the mastoid process or the external auditory canal to the clavicular origin of the SCM. Knowledge of the anatomy, course, and location of the GAN along the surface of SCM muscle based on anatomic landmarks and distance ratios can facilitate a safer dissection in the lateral neck during rhytidectomy procedures.

Secondary Rhytidectomy

Secondary rhytidectomy procedures present an additional level of complexity in comparison with primary procedures. Patients may seek secondary rhytidectomy, in part, as a result of complications stemming from the initial procedure, because of the natural process of aging, or a combination of the two. The aim of this literature review was to examine the difference in patient characteristics, techniques, and challenges specific to secondary face lifts. A literature search was performed on secondary face-lift procedures using MEDLINE, PubMed, and Cochrane databases. Using the keywords "facelift," "face lift," "rhytidoplasty," and "rhytidectomy" combined with "secondary," "reoperation," "revision," and "multiple," an initial search was performed. Then, all abstracts were evaluated for relevance. The search yielded 291 articles with these key terms. The articles were reviewed for relevance and, in total, 13 were identified specific to secondary rhytidectomy procedures. Six were retrospective studies and the rest were expert special topic articles. Although there are limited data specific to secondary rhytidectomy procedures, several important principles were evident from these retrospective reviews and editorial articles. It is important to assess whether the patient is exhibiting stigmata of the primary rhytidectomy procedure or natural signs of aging, such as volumetric deflation and recurring ptosis of previously lifted tissues. Accurate and systematic preoperative analysis is key for successful planning and execution of secondary rhytidectomy procedures.

Facial Rejuvenation and Volumization Using Implants

Whereas traditional concepts of facial aging focus on the descent of soft tissue secondary to gravitational effects, it is now well established that volumetric changes involving different levels of soft tissue loss reveal craniofacial skeletal deficiencies that, together, contribute to the changes evident in the aging face. Thus, effective facial rejuvenation requires a comprehensive paradigm that identifies and addresses all anatomic elements involved in the aging process. Contemporary practices in facial rejuvenation have expanded far beyond the rhytidectomy procedure to involve deeper and more fundamental levels of dissection for the purpose of elevating and replacing volume. Alloplastic implants offer a long-term, multidimensional solution to facial rejuvenation by concomitantly augmenting skeletal deficiency, restoring lost soft tissue volume, and smoothing irregularities in the facial contour. Facial augmentation using implants represents a straightforward, simple procedure with minimal risks and long-lasting benefits. By applying accurate and judicious techniques for preoperative analysis, selecting the appropriate implant, and with correct surgical placement of the implants, the facial plastic surgeon can achieve successful facial volumization and restore the youthful appearance of the aging patient.

Surgical Anatomy of the Lower Face: The Premasseter Space, the Jowl, and the Labiomandibular Fold

The anatomic basis for the jowl has not been fully described. A formal analysis was performed of the sub-superficial musculoaponeurotic system (SMAS) areolar tissue layer, which overlies the lower part of the masseter. For this research, facial dissections were performed on 16 fresh cadavers ages 12 to 89 years, and detailed anatomic observations were made during the course of several hundred rhytidectomy procedures. Tissue samples from varying age groups were examined histologically. The areolar cleavage plane overlying the lower masseter has specific boundaries and is a true space named the "premasseter space." This space is rhomboidal in shape, lined by membrane, and reinforced by retaining ligaments. The masseter fascia lines the floor, and branches of the facial nerve pass under its deep surface. Histologically, the floor is formed by a thin layer of dense connective tissue, which undergoes minor deterioration in architectural arrangement with age. The roof, lined by a thin transparent and adherent membrane on the underside of the platysma, has a less dense collagen network and contains more elastin. With age, there is a significant reduction in the collagen density of the roof. Expansion of the space with aging, secondary to weakness of the anterior and inferior boundaries, results in formation of the jowl. Medial to the premasseter space is the buccal fat in the masticator space, which descends with aging and contributes to the labiomandibular fold and jowl. Application of the premasseter space in surgery provides significant benefits. The SMAS incision should be forward of the traditional preauricular location to be over the space, not behind. Because the space is a naturally occurring cleavage plane, dissection is bloodless and safe, as all facial nerve branches are outside. The premasseter space should be considered as the preferred dissection plane for lower (cervicofacial) facelifts.