Superficial Musculoaponeurotic System Plication Research Articles

An Approach to Selection of Face-Lift Techniques for Different Types of Faces: An Analysis of 1000 Asian Patients Over 9 Years.

A face-lift or rhytidectomy is the procedure most directly associated with rejuvenation. There are several surgical techniques for face-lifts, but criteria for the selection of techniques, based on the patient's face shape, are lacking. In this study, we report on our experience with specific indication criteria for each technique and the consequent achievement of good outcomes. From 2015 to 2023, 1 surgeon performed face-lifts on 1000 patients. Three different superficial musculoaponeurotic system (SMAS) techniques (SMAS dissection, SMASectomy, and SMAS plication) were applied depending on the degree of sagging of the patient's lower face, lateral facial profile, and SMAS mobility and condition. Superficial musculoaponeurotic system dissection was considered for the improvement of a square face, sagging jowls, and marionette lines. Superficial musculoaponeurotic system plication was applied with patients with less sagging jowls and prominent zygoma with concave lateral facial profile. SMASectomy was applied with patients with convex lateral facial profiles or when the SMAS was too thin or damaged. Patient postoperative satisfaction was surveyed using the FACE-Q score 1 year post surgery. Most of the patients attained natural-looking and long-lasting aesthetic outcomes and exhibited high satisfaction. The patients indicated that they looked about 11.2 ± 5.2 years younger than their actual age after the surgery. The mean satisfaction scores for each facial feature were as follows: cheeks (91.1 ± 7.8), marionette lines (88.5 ± 13.6), lower face and jawline (92.5 ± 14.2), under chin (87.8 ± 15.1), and neck (86.2 ± 18.5). Complications such as facial nerve injury, infection, hematoma, and flap necrosis were very rare. Establishing criteria for the selection of face-lift surgical techniques based on the degree of lower face sagging, lateral facial profile, and SMAS mobility and condition led to good outcomes. These criteria can be used by physicians to determine the most effective face-lift surgery technique based on a patient's individual features, which may improve surgical outcomes.

An Approach to Selection of Face-Lift Techniques for Different Types of Faces: An Analysis of 1000 Asian Patients Over 9 Years.

A face-lift or rhytidectomy is the procedure most directly associated with rejuvenation. There are several surgical techniques for face-lifts, but criteria for the selection of techniques, based on the patient's face shape, are lacking. In this study, we report on our experience with specific indication criteria for each technique and the consequent achievement of good outcomes. From 2015 to 2023, 1 surgeon performed face-lifts on 1000 patients. Three different superficial musculoaponeurotic system (SMAS) techniques (SMAS dissection, SMASectomy, and SMAS plication) were applied depending on the degree of sagging of the patient's lower face, lateral facial profile, and SMAS mobility and condition. Superficial musculoaponeurotic system dissection was considered for the improvement of a square face, sagging jowls, and marionette lines. Superficial musculoaponeurotic system plication was applied with patients with less sagging jowls and prominent zygoma with concave lateral facial profile. SMASectomy was applied with patients with convex lateral facial profiles or when the SMAS was too thin or damaged. Patient postoperative satisfaction was surveyed using the FACE-Q score 1 year post surgery. Most of the patients attained natural-looking and long-lasting aesthetic outcomes and exhibited high satisfaction. The patients indicated that they looked about 11.2 ± 5.2 years younger than their actual age after the surgery. The mean satisfaction scores for each facial feature were as follows: cheeks (91.1 ± 7.8), marionette lines (88.5 ± 13.6), lower face and jawline (92.5 ± 14.2), under chin (87.8 ± 15.1), and neck (86.2 ± 18.5). Complications such as facial nerve injury, infection, hematoma, and flap necrosis were very rare. Establishing criteria for the selection of face-lift surgical techniques based on the degree of lower face sagging, lateral facial profile, and SMAS mobility and condition led to good outcomes. These criteria can be used by physicians to determine the most effective face-lift surgery technique based on a patient's individual features, which may improve surgical outcomes.

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.

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.

The Use of Multifilament Suture for SMAS Plication in Rytidectomy.

In the public's mind, rhytidectomy, better known as a facelift procedure, is the technique most closely associated with plastic surgery. When done correctly, it yields highly satisfactory results. The aim of our study was to retrospectively review results of our patients whose procedures were performed using the superficial musculoaponeurotic system (SMAS) plication technique. Plication was performed with multifilament braided sutures, which provided a sustainable lift and satisfactory results. This study involves a retrospective review of 137 patients who underwent primary or secondary facelift procedures over a period of 46 months. The average patient age was 59 years, with ages ranging from 30 to 77. Patients were reviewed at 6 and 12 months postoperatively. Subjective evaluation based on photographic analysis was performed pre- and postoperatively. All cases included in this study indicated satisfaction with postoperative results on 1 year postoperative review for both the patients and performing surgeons. Four patients presented with a postoperative hematoma that required surgical intervention. One patient developed skin infection that was followed by skin necrosis. Another patient presented with wound infection that resulted in partial wound dehiscence. Both cases were managed conservatively. With the abundance of techniques directed toward the SMAS layer, it has become a pivot point for facelift procedures. This expansion in approaches places emphasis on the SMAS layer and its manipulations. The type of suture material utilized in SMAS plication is, therefore, undoubtedly essential. Our use of braided multifilament sutures for SMAS plication provided satisfactory results at 1-year postoperative review.

Extended Superolateral Cheek Lift With a Short Preauricular Scar: A Local Anesthesia-based Practicable Technique for the Correction of Moderate-degree Facial Aging Signs.

An ideal technique applicable to middle-aged individuals with a moderate degree of facial aging signs has not yet been established. This study aimed to evaluate the utility of an extended superolateral cheek lift with a short preauricular scar technique for the correction of facial aging signs. A total of 200 female patients (mean age: 43y, range 27-56y) who underwent a local anesthesia-based extended superolateral cheek lift for the correction of facial aging signs confined to the malar and nasolabial area, lower eyelid, jawline, and neck were included. Data on the Global Aesthetic Improvement Scale, patient-reported outcomes, and complications were recorded at 1, 6, 12, and 24 months postoperatively. The Global Aesthetic Improvement Scale scores revealed exceptional improvement in 90% of patients along with no complications at month 24. None of the patients developed a depressed scar, skin necrosis, breaking of the superficial musculoaponeurotic system plication sutures, asymmetry, or facial nerve problems. At postoperative month 24, the appearance was reported to be very much improved by 90% of patients, and 94% of patients reported that they were very satisfied with the treatment and that they would recommend this treatment to friends and acquaintances. Our findings revealed the potential utility of an extended superolateral cheek lift with a short preauricular scar as a local anesthesia-based practicable technique for the correction of facial aging signs in middle-aged patients, offering a favorable postoperative outcome, lack of complications and high patient satisfaction in addition to invisible scars and a short-term postoperative recovery.

Quantifying the Effective Lift of Skin-Only, SMAS Plication, and Extended SMAS Face-Lift Techniques in a Cadaveric Study.

Rhytidectomies are performed to rejuvenate the aging face. Various techniques exist to achieve soft-tissue elevation and skin tightening. This study analyzes three common face-lift techniques: skin-only, superficial musculoaponeurotic system (SMAS) plication, and extended SMAS lifts. The authors characterize effective facial changes with each procedure in a cadaver model. The authors performed face-lift procedures on 18 cadaver hemifaces. Each face was measured along horizontal and vertical vectors. The primary outcome was change along these vectors. Skin-only, SMAS plication, and extended SMAS lifts were performed sequentially on each hemiface. SMAS plication was used to approximate a lateral SMASectomy procedure. Parameter measurements were compared. All three procedures exhibited a significant tightening along horizontal vectors. SMAS procedures provided a significant lift along all vertical vectors, whereas the skin-only lift failed to demonstrate significant vertical elevation. SMAS procedures achieved significantly greater composite horizontal and vertical lifts compared to the skin-only operation. There was only an incremental increase in lift between the SMAS plication and extended SMAS procedures in the upper and midface regions. The extended SMAS led to the greatest lift in the lower face. SMAS procedures provided a greater lift along both horizontal and vertical vectors than the skin lift alone. The increased dissection in the extended SMAS technique resulted in only a modest increase in lift compared to SMAS plication. The extended SMAS approach appears to offer the most benefit at the lower face and may be the best choice for targeting this region.

The Hybrid Facelift.

Summary:In facelift surgery, many surgeons tend to choose one superficial musculoaponeurotic system (SMAS) technique over another. SMAS plication augments tissue using folding, which is very useful in deflated faces. In heavy faces, SMAS-ectomy and, to an arguably further extent, full SMAS undermining and excision can reduce volume and avoid the excessive fullness that may follow plication. Not all patients present with uniform deflation or uniform fullness of the face. Some will present with a mixed picture, fullness in one area such as the cheek with deflation in another (eg, over the angle of the mandible). In those patients, plication alone may lead to undesired fullness, typically overaugmenting cheeks or angle of the mandible. SMAS elevation and excision may avoid overaugmentation (arguably better than simple SMAS-ectomy), but it is technically more demanding and consumes longer operative time. An alternative approach is suggested in this article. For those patients with “mixed” pictures, we suggest a hybrid of existing SMAS techniques, in which for each side of the face, the face is divided into upper (cheek) and lower (jawline and neck) areas. Deflated areas are addressed with plication. Full areas are addressed with SMAS undermining and excision. Although this kind of surgical approach might be practiced by some surgeons, it has not been described well in the literature. In a series of 495 facelifts, the author found this “hybrid facelift” technique useful in 61 cases.

Parotid Surgery With Concurrent Bilateral Rhytidectomy

Facial reconstruction after parotid surgery can present an aesthetic challenge. This case series describes an asymmetric cervicofacial rhytidectomy technique at the time of parotid surgery to achieve defect closure as well as volume augmentation of the postablative deformity. While unilateral superficial musculoaponeurotic system (SMAS) flaps after parotid tumor extirpation have been described many times, this is the first reported case series of parotid tumor resection with concurrent bilateral cervicofacial rhytidectomy. This series consists of two adult females with unilateral facial swelling who also desired facial rejuvenation surgery. They separately presented to the University of Texas Southwestern Maxillofacial Surgery team and proceeded to have unilateral parotid tumor removal with concurrent bilateral cervicofacial rhytidectomy. To give context to this case series, the authors also searched the PubMed, Scopus, and Google Scholar databases to look for previously reported similar cases. The authors were able to address the patients’ functional as well as aesthetic concerns with a single surgery in a safe manner. Ipsilateral to the tumor resection, there was a sizeable loss in volume in both cases. Therefore, a vascularized SMAS flap was imbricated to provide volume, while a selective SMAS removal and plication was used on the contralateral side to achieve symmetric volume bilaterally. A comprehensive literature search demonstrated one previous report of concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Despite the prevalence of utilizing a rhytidectomy incision for parotid surgery, there is a dearth of literature describing concurrent bilateral cervicofacial rhytidectomy with parotid tumor extirpation. Functionally, it has been shown to decrease the incidence of gustatory sweating on the side of reconstruction. Aesthetically, the surgeon is not only re-establishing the volume by augmenting the ablative defect, but also creating a symmetrical postoperative appearance by performing a reductive rhytidectomy on the contralateral side. Utilizing an asymmetric bilateral cervicofacial rhytidectomy at the time of parotid surgery can be an efficient technique for aesthetically reconstructing a patient with a parotid mass. It should be considered in patients with benign parotid disease who have the desire for facial rejuvenation surgery.

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

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

Refinements in Tailoring the Lift-and-fill Facelift.

Individualizing facelift techniques through proper preoperative analysis is an important technique that can successfully enhance the patient’s overall result.1–5 Accurate preoperative analysis is key in the decision-making process for how the superficial musculoaponeurotic system (SMAS) is shaped and lifted. Techniques that center on SMASectomy and SMAS stacking with wide skin undermining allow for exceptional results without the need for an extended sub-SMAS dissection.5–13 The area to be undermined is first injected with 120 mL per side of dilute lidocaine (1:400,000) solution with epinephrine. Skin incisions and flap undermining are identical in both approaches. The procedure is started by creating a curvilinear skin incision parallel to the root of the helix followed by a separate intertragal incision. The incision continues following the lobule facial sulcus, leaving approximately 1 mm of facial skin on the lobule. Next, the incision is completed staying 2–3 mm onto the postauricular skin, then curving at the auricularis posterior down along then into the hairline. The skin flap is sharply dissected off the underlying SMAS as outlined below. These zones are not based on anatomical landmarks but are instead used to help simplify the flap undermining process. (See Video [online], which demonstrates the authors’ lift-and-fill facelift.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"SMAS Stacking. Video 1 from “Refinements in Tailoring the Lift and Fill Facelift”","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_7nq17ych"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} There are 3 zones of dissection: The first zone is composed of 2 lines: the first from the alar base to the tragus and the second from the tragus down to the anterior border of the sternocleidomastoid. The second zone is from posterior to the sternocleidomastoid to the post auricular neck area. The third zone is everything cephalic from a line drawn from the alar base to the lobule. Differences in facial length must be recognized because altering the direction of SMAS movement can help balance final facial shape.5,14 Facial analysis can identify variations in facial structure: long versus short and narrow versus wide. The most common combinations of these being long/narrow and short/wide.15 Identification of the long side of the face will dictate the direction of SMAS pull, with long faces requiring a horizontal pull and short faces necessitating a more oblique vector. Facial fullness is also an important factor to consider when deciding between SMAS plication (SMAS stacking) and SMASectomy. Faces with excess facial fullness need to have volume removed, which is accomplished with SMASectomy to create a more balanced facial structure. For the SMASectomy, only a superficial portion of the SMAS is excised, preserving the facial nerve branches below.16,17 If the face is overly thin, then this may be corrected through SMAS stacking, which creates more fullness in the malar region. Therefore, for the esthetic management of a long/narrow face, SMAS stacking with a horizontal vector of pull allows for malar fullness while correcting for excess facial length. Similarly, a short/wide face is best treated with SMASectomy and plication in a more oblique vector to maintain facial length while correcting for excess malar fullness, creating a more youthful look. Filling of deflated facial fat compartments using autologous fat is an essential supplement to any rhytidectomy. The “lift-and-fill” technique has modernized facial rejuvenation, with precise volume augmentation as a compulsory component of complete facial rejuvenation.15,18 We are able to accurately and precisely augment deflated facial fat compartments while the SMAS and its involved structures are selectively repositioned. The superficial and deep fat compartments as well as the lift-and-fill technique have been extensively researched with excellent long-term results.15 A complete understanding of preoperative facial structure allows for the surgeon to customize the lift-and-fill facelift technique to produce increased balance and correction of preoperative asymmetries. By altering the direction of SMAS pull and through the manipulation of SMAS volume, a complete restoration of malar fullness and facial width is accomplished.

Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms

Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers. The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: ("fat grafting" OR "lipotransfer" OR "lipofilling" OR "fat transfer") AND ("facelift" OR "rhytidectomy" OR "SMASectomy" OR "facial rejuvenation"). Data on techniques, outcomes, complications, and patient satisfaction were collected. The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub-superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments. Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities.

Triple-C SMAS Plication Facelift for Natural Facial Rejuvenation.

Background:Various methods are used to reposition the superficial musculoaponeurotic system (SMAS) during facelift procedures. This study presents a novel, radially oriented, layered SMAS plication: the triple-C SMAS plication. This technique utilizes customizable vectors in the pattern of a “C” to plicate the SMAS in 3 layers to lift and tighten the deep structures of the face.Methods:A retrospective review was performed of patients undergoing the triple-C SMAS plication over a 1-year period. Patients with a length of follow-up less than 100 days were excluded from the study. Demographic data, operative data, complication rates, and satisfaction rates were assessed.Results:One hundred ninety-one consecutive patients underwent a triple-C SMAS plication over a 12-month period. One hundred ten patients met inclusion criteria. Average follow-up was 404.5 days. Complications assessed included temporary facial nerve neuropraxia (0.91%), major hematoma (1.82%), minor hematoma (2.73%), seroma (4.54%), great auricular nerve injury (0%), postauricular skin slough >2 cm (1.82%), and infection (0.91%). Two revision procedures were performed (1.82%). Patient satisfaction rate was 96.4%.Conclusions:Traditional SMAS plication techniques involve single-layer, straight-line plications to lift the lower face and neck, limiting their versatility. The triple-C SMAS plication represents a novel technique to safely and effectively elevate the deep structures of the face in a radial pattern to restore a more youthful contour to the malar area, jawline, and neck. This represents a unique strategy for face lifting by which excellent results can be consistently obtained.

Periauricular Purse-String Reinforced with SMAS plication and Malaria Fat Pad Elevation for Mid-and Lower Facial Rejuvenation: FACE-Q Report.

Facial aging is a complex process influencing every layer of the facial structure. Most accepted surgical techniques for facial rejuvenation involve certain manipulation of the superficial musculoaponeurotic system (SMAS). Out of these SMAS-based techniques, SMAS plication or suspension provides excellent outcomes with shorter convalescence and fewer potential complications. Herein, we would like to present our own technique combining SMAS plication, periauricular purse-string, and malar fat pad elevation technique for mid and lower facelift. Through a classical periauricular and temporal incision, a periauricular permanent purse-string suture was woven into the SMAS to suspend sagging soft tissue of the mid and lower face after superficial undermining, then plication of inner and outer SMAS of the purse-string loop was performed to further secure suspension, and at last the malar fat pad was elevated for midface rejuvenation. The shape of the loop varies with patients' age; for younger patients, the loop is more vertical, and for older patients, the loop is more horizontal. Patient-reported outcomes were described using the FACE-Q questionnaire. From January 2010 to June 2015, a total of 138 patients were treated with this technique by a same surgeon. Follow-up duration ranged from 1 to 6 years. Preoperative and postoperative photographs were recorded and analyzed. The complications rates were low, and satisfaction rates were high. Patients felt that they appeared 7.3 years younger than their actual age on average and were most satisfied with the appearance of their lower face and jawline. Periauricular purse-string reinforced with SMAS plication and malar fat pad elevation technique produces esthetically pleasing outcomes, besides being simple, safe, and personalized.

Is deep plane rhytidectomy superior to superficial musculoaponeurotic system plication facelift?

Is deep plane rhytidectomy superior to superficial musculoaponeurotic system plication facelift?

A Retrospective Analysis of Secondary Revisions after Face Transplantation: Assessment of Outcomes, Safety, and Feasibility

Face transplantation has emerged as a viable option for certain patients in the treatment of devastating facial injuries. However, as with autologous free tissue transfer, the need for secondary revisions in face transplantation also exists. The authors' group has quantified the number of revision operations in their cohort and has assessed the rationale, safety, and outcomes of posttransplantation revisions. A retrospective analysis of prospectively collected data of the authors' seven face transplants was performed from April of 2009 to July of 2015. The patients' medical records, preoperative facial defects, and all operative reports (index and secondary revisions) were critically reviewed. The average number of revision procedures was 2.6 per patient (range, zero to five procedures). The median time interval from face transplantation to revision surgery was 5 months (range, 1 to 10 months). Most interventions consisted of debulking of the allograft, superficial musculoaponeurotic system plication and suspension, and local tissue rearrangement. There were no major infections, allograft skin flap loss, or necrosis. One patient suffered a postoperative complication after autologous fat grafting in the form of acute rejection that resolved with pulse steroids. Secondary revisions after face transplantation are necessary components of care, as they are after most conventional free tissue transfers. Secondary revisions after face transplantation at the authors' institution have addressed both aesthetic and functional reconstructive needs, and these procedures have proven to be safe in the context of maintenance immunosuppression. Patient and procedure selection along with timing are essential to ensure patient safety, optimal function, and aesthetic outcomes. Therapeutic, V.

Facelift Techniques That Restore Facial Volume.

The aging face results in increase in laxity of the skin and the underlying supporting tissue. There is a fundamental volume loss in the face and it is most apparent in the midface. A traditional superficial musculoaponeurotic system (SMAS) rhytidectomy addresses the laxity of the face but not volume loss. Multivector high SMAS plication allows for natural excess tissue to be placed into the area of volume loss, thereby addressing midface volume loss. This technique is easy to perform, reproducible, and effective with the added benefit of helping to volumize the lower face.

Rhytidectomy Utilizing Bidirectional Self-Retaining Sutures: The Bidirectional Lift and the Extended Bidirectional Lift.

This article outlines a new rhytidectomy technique, developed by the author, that utilizes bidirectional self-retaining (barbed) sutures for superficial musculoaponeurotic system (SMAS) plication and, in some instances, skin closures. Short-scar and traditional versions of the procedure are presented, and the history of purse-string SMAS plication and the advantages for using self-retaining sutures in this application are discussed.

Cervicofacial Rhytidectomy without Notorious Scars: Experience of 29 Years

Presentation and evaluation of results of the surgical technique of cervicofacial rhytidectomy used by the senior author (F.P.), using the classification of facial aging to determine the stage of pre- and postsurgical age. The surgical technique was used in 1,181 patients operated on in the past 29 years, starting in 1983. We analyzed retrospectively 318 patients operated on between the years 2001 and 2008, of whom 71 patients met the selection criteria. Postoperative follow-up period was from 6 months to 5 years. All patients in stage I showed clinically visible rejuvenation postoperatively. Significant improvement in facial rejuvenation in stages II and III of aging was shown, with a postoperative change of stage. The technique of cervicofacial rhytidectomy with short flap, facial superficial musculoaponeurotic system (SMAS) imbrication, cervical SMAS plication, inconspicuous incisions, and postauricular z-plasty allows for successful and sustainable results over time, with short recovery time and minimal complications. The classification of facial aging pre- and postsurgery has been useful for the assessment of surgical results.

Anatomical Comparison of Platysmal Tightening Using Superficial Musculoaponeurotic System Plication vs Deep-Plane Rhytidectomy Techniques

To quantify the degree of submental platysmal tightening that can be accomplished with superficial musculoaponeurotic system (SMAS) plication vs deep-plane rhytidectomy techniques in a cadaveric anatomical study to help dictate the need for midline platysmal surgery when using different rhytidectomy techniques. The lateral distraction of the medial edge of the platysma muscle was measured during tightening of the SMAS-platysmal complex on 5 cadaver heads. The measurements were taken after the following 3 rhytidectomy techniques: SMAS-platysmal plication, deep-plane rhytidectomy, and extended deep-plane rhytidectomy continuing the flap below the angle of the mandible into the neck with release of the platysma and cervical retaining ligaments. The medial edge of the platysma muscle was distracted laterally 427% more with deep-plane rhytidectomy compared with SMAS-platysmal plication (P < .001). Extending the deep-plane rhytidectomy flap into the neck to release the cervical retaining ligaments resulted in 554% greater lateral distraction of the medial edge of the platysma muscle compared with SMAS-platysmal plication (P < .001). This represents 30% greater advancement compared with the traditional deep-plane technique (P = .05). Extending a traditional deep-plane rhytidectomy inferiorly to release the lateral platysma and cervical retaining ligaments to the sternocleidomastoid muscle achieves the greatest lateral motion of the midline platysma, theoretically obviating the need for midline platysmal plication except in cases of severe platysmal laxity and banding. Because of the limited platysmal motion during SMAS plication, midline platysmal plication should routinely be used as an adjunct procedure except in cases of no or minimal platysmal laxity.