Aesthetic Surgery Journal最新文献

Background: Radiofrequency-assisted (RF) facial rejuvenation has become a safe and reliable option for "treatment gap" patients, including (1) patients whose skin laxity is not severe enough to warrant a facelift, yet not mild enough to reliably treat with noninvasive procedures; (2) patients who have already undergone a face or neck lift and have recurrent laxity; and (3) patients who would benefit from a traditional face or neck lift but want to avoid surgery and are willing to accept a more modest improvement without extensive surgical scar burden and recovery.

Objectives: In this study we aimed to educate the reader about providing bipolar RF to various anatomic regions of the face.

Methods: A retrospective review of cases was conducted to assess the safety of zone-specific RF-assisted facial rejuvenation in S.A.'s practice.

Results: RF-microneedling with Morpheus8 was performed on 364 foreheads, 364 periorbita, 353 perioral areas, and 233 jawlines. RF-bipolar with AccuTite was performed on 43 nasolabial folds. There were no cases of hyperpigmentation or hypopigmentation, scarring, or prolonged erythema.

Conclusions: The result of patients treated with the combination of bipolar radiofrequency and fractional bipolar radiofrequency microneedling has expanded RF-assisted facial rejuvenation in our practice. We report on an anatomical approach to RF-assisted facial rejuvenation, as well as expanding indications beyond treatment gap patients.

Level of evidence: 4 (therapeutic):

Background: Lateral crura surface problems are one of the most difficult challenges in nose tip surgery. Closed preservation rhinoplasty (CPR) is a revolutionary concept that keeps nose tip flexibility and elasticity. By solving lateral crura surface problems and keeping tip flexibility the surgeon will accomplish a sharper supraalar groove transition between the dorsum and the tip.

Objectives: The convex-concave lateral crura deformity (CCLCD) or S-shaped lateral crura is one of the biggest constraints to accomplishing a beautiful tip and dorsum-tip transition (DTT). This deformity is the reason for the commonly called parenthesis deformity of cephalic malposition. This LLC convex-concave shape creates a C-shaped shadow. This DTT is one of the key areas for accomplishing natural results, and it depends on different nose structures, not just the lower lateral cartilages (LLC).

Methods: A total of 560 rhinoplasty cases were studied retrospectively between September and December 2023. Three hundred and twenty patients had at least 1 year of follow-up. Patients had follow-up at 2 weeks, 1 month, 3 months, 6 months, and 1 year after surgery. No secondary rhinoplasty was included. Only 2 secondary septoplasty cases were included, without any nose skin undermining in the previous surgery. Surgical details were documented, including the 6 fundamental steps of this technique: (1) mucosal lower lateral incision, (2) dorsum subperichondral dissection and vertical scroll release, (3) lateral crura tail caudal release, lateral crura steal and slide-under flap lateralization, (4) upper lateral caudal resection, (5) vertical scroll reconstruction, and (6) turning point extension graft.

Results: Three hundred and twenty patients had at least 1 year of follow-up. In total, 516 patients underwent a closed approach and 47 patients an open approach. All patients had subperichondral dissection of the hump envelope. All patients who underwent a closed approach had a low-strip letdown dorsal preservation technique. All patients who underwent an open approach had a structural technique with spreader flaps or grafts at the keystone area. All the patients underwent osteotomies with a piezoelectric device. Twenty-three revisional surgeries were necessary.

Conclusions: CPR taught us how important ligament and soft tissue preservation are. We learned that the less damage you do to the nose soft tissues and scaffold, the less support you need for it. Surgeons have been overgrafting the lateral crura to solve postoperative problems mainly because of dissection problems and lack of lateral crura support. This paper describes how to solve lateral crura surface problems, keeping the tip flexible and elastic, and also creating a nice and natural supraalar groove transition, by applying 6 surgical maneuvers.

Level of evidence: 4 (therapeutic):

Background: Liposuction has gained significant popularity, leading to increased demand for secondary procedures due to complications such as scars and fibrosis that affect aesthetic outcomes. High-definition liposuction has emerged as a preferred technique, but the presence of fibrosis from previous surgeries may limit its effectiveness.

Objectives: The aim of this study was to explore the application of ultrasound (US)-assisted VASER (vibration amplification of sound energy at resonance; VASER-Solta Medical, Bothell, WA) liposuction in secondary abdominal liposculpture to address these challenges.

Methods: A prospective cohort study was conducted between May 2022 and May 2023 of patients undergoing secondary abdominal liposculpture with US-assisted VASER liposuction, at least 12 months after their initial procedure. Preoperative US examinations were performed to identify and mark findings related to previous liposuction. Data on demographics, photographic results, and complications were collected and analyzed.

Results: Intraoperative ultrasound (I-US) significantly improved the detection of fibrotic lesions, leading to more precise, rapid, and atraumatic outcomes. The use of I-US optimized surgical procedures, reducing both costs and operation time. Clear communication with patients regarding potential limitations due to chronic damage was essential for setting realistic expectations.

Conclusions: I-US has proven to be an invaluable tool in secondary liposculpture, enhancing surgical precision and outcomes. This methodology allows for better recognition of complications, promoting effective treatment strategies and ultimately improving patient satisfaction in the context of secondary abdominal liposculpture.

Level of evidence: 4 (therapeutic):

Background: Although pure hemi-periareolar incisions for mastectomy can prevent visible scarring, nipple-areolar complex (NAC) necrosis is a potential risk. Superficial-arterial inflow of the NAC can be evaluated by indocyanine green angiography (ICG-A).

Objectives: This study evaluated the impact of ICG-A-assisted periareolar incision on NAC necrosis during nipple-sparing mastectomy (NSM) and direct-to-implant (DTI) breast reconstruction.

Methods: Between December 2018 and November 2021, lateral hemi-periareolar incisions for NSM were routine. After that time, ICG-A-assisted hemi-periareolar incisions were performed between December 2021 and September 2023. The location of the main arterial inflow was evaluated during preoperative ICG-A and the periareolar incision was planned to avoid disruption. NAC necrosis in the ICG-A-assisted and blind-incision groups was compared by univariate and multivariate analyses.

Results: A total of 202 breasts were analyzed, comprising 80 breasts from 75 patients in the ICG-A-assisted group and 122 breasts from 115 patients in the blind-incision group. On preoperative ICG-A, superficial-arterial inflow was observed in 67 of 80 (83.75%) breasts. Perfusion of the nipple without superficial-arterial inflow (base-perfusion pattern) was observed in 13 breasts (16.25%). The main arterial inflow was most common in the upper-medial direction at the areolar margins (65.67%). The full-thickness NAC necrosis rate in the ICG-A-assisted incision group was significantly lower than that in the blind-incision group (2.5% vs 13.1%, P = .010). Multivariate analysis demonstrated that ICG-A-assisted incisions significantly reduced the risk of NAC necrosis (odds ratio, 0.155; P = .030).

Conclusions: ICG-A-assisted pure hemi-periareolar incisions reduced NAC necrosis in DTI breast reconstructions.

Level of evidence: 3 (therapeutic):

Dissecting deep to the superficial musculoaponeurotic system (SMAS), a popular option for facelifts, has the potential for injury to the parotid gland leading to postoperative sialoceles and fistulas. Similarly, deep plane procedures in the neck that include partial submandibular gland resection may lead to salivary gland leaks. We previously described the management of sialocele following rhytidectomy. Since then, administration of botulinum toxin A has emerged as the primary treatment and prevention of this rare complication. The technique of administration and dosage of botulinum toxin in the treatment algorithm is not well defined. We present a literature review and our current protocol for the most efficacious injection technique and dosing to prevent and treat injury to the parotid and submandibular glands.

Background: Deoxycholic acid (ATX-101) is a drug administered by subcutaneous injection for local fat reduction. However, ATX-101 treatment has been reported to cause marginal mandibular nerve injury with noticeable functional deficits when targeting submental fat. As a cytolytic agent with some selectivity for adipocytes, ATX-101 may damage the lipid-rich myelin surrounding peripheral nerves.

Objectives: The aim of this study was to characterize nerve injury caused by ATX-101 injection in an experimental rat sciatic nerve model.

Methods: Injuries to the sciatic nerve caused by intrafascicular and extrafascicular injections of ATX-101, and by lidocaine (positive control) and saline (negative control) injections, were compared. Nerves were harvested at a 2-week endpoint for histomorphometric analysis.

Results: The cross-sectional area of nerve injury was significantly increased by ATX-101 injection. The damaged areas amounted to 75% ± 15% with intrafascicular ATX-101 (P < .001), 41% ± 21% with extrafascicular ATX-101 (P < .01), and 38% ± 20% with positive-control lidocaine (P < .01), compared with 7% ± 13% with negative-control saline. Demyelinating injury was a significant mechanism of injury in the affected nerve fibers compared with uninjured nerve fibers (P < .04), but there was no difference in the axon-to-myelin area ratio between the lidocaine and ATX-101 cohorts. After 2 weeks, Wallerian degeneration was evident with only small regenerating nerve fibers present in the ATX-101-injured groups compared with saline (average fiber width, 2.54 ± 0.26 μm vs 5.03 ± 0.44 μm, P < .001).

Conclusions: ATX-101 can cause extensive nerve injury in rats. The mechanism of action for ATX-101 does not preferentially target myelin more than other common neurotoxic agents. Appropriate knowledge of surgical anatomy and injection technique is necessary for any practitioners administering ATX-101 injections.

Background: Endoscopic brow lift is an integral component of upper face surgical rejuvenation protocols. Lateral relapse is one of the leading causes of dissatisfaction after endoscopic brow lift.

Objectives: In this study I introduce and evaluate the vertical internal brow suspension (VIBS), a novel fixation technique designed to prevent lateral brow relapse following endoscopic brow lift.

Methods: A retrospective review was conducted on 118 consecutive endoscopic brow lift cases performed by the author between January 2019 and June 2024 with the VIBS technique. Additionally, a subgroup of 29 patients who underwent isolated endoscopic brow lifts with at least 1 year of follow-up were included in a quantitative analysis of long-term brow position and forehead height.

Results: Significant increases in brow height across all measurement levels (P < .001) were observed in the quantitative analysis subgroup. No significant change in forehead height was noted (P = .927). The VIBS technique also beneficially reduced apparent forehead height in patients with initially high foreheads. Frontal suture extrusions (6.8%) and temporary hair loss around scalp incisions (5.1%) were the most common complications observed in the retrospective analysis of 118 patients.

Conclusions: The VIBS technique effectively prevents lateral brow relapse, achieving stable lateral brow elevation. It is a safe technique with minor complications. It addresses one of the long-standing challenges of the endoscopic brow lift surgery, representing a valuable advancement in upper face rejuvenation procedures.

Level of evidence: 4 (therapeutic):

Background: Preservation rhinoplasty, particularly dorsal preservation, has gained prominence with the advent of piezoelectric instruments, which minimize trauma and enhance precision in bone reshaping. This approach presents unique challenges, especially in closed techniques, where spatial limitations complicate the use of piezotomes.

Objectives: To evaluate outcomes of piezo-assisted preservation rhinoplasty using specialized instrumentation to enhance visibility, precision, and postoperative recovery in closed rhinoplasty procedures.

Methods: In a cohort of 734 patients undergoing primary rhinoplasty, piezoelectric instruments facilitated closed preservation techniques between May 2021 and April 2023. Cases were documented with a focus on instrument adaptation, bone reshaping precision, and the mitigation of postoperative complications.

Results: A 6% revision rate was observed, predominantly for dorsal contour adjustments, with minimal intraoperative bleeding, swelling, and postoperative pain, demonstrating the effectiveness of piezoelectric assistance. The SS18 and SS4 inserts by Woodpecker were specifically optimized to enhance cutting efficiency for PPE removal and lateral and transverse osteotomies.

Conclusions: Piezo-assisted rhinoplasty improves precision and reduces trauma, supporting advanced closed preservation rhinoplasty techniques. Despite nowadays all the osteotomies can be done using the ultrasonic piezotome, enhanced instrument design may further refine outcomes, facilitating minimally invasive, aesthetically superior results.

Background: FACE-Q Aesthetics scales assess patient-important outcomes following both surgical/nonsurgical facial cosmetic interventions. Convergent validity is the degree to which the scores of one measurement relate to another measuring a similar construct.

Objectives: This study aims to establish the convergent validity of 11 FACE-Q Aesthetics appearance scales using the MERZ Aesthetics scales.

Methods: Data were collected from an online international sample of participants aged ≥20 years, who presented to a dermatologist or plastic surgeon within the last 12 months for a minimally invasive facial aesthetic treatment. Participants provided demographic and clinical data and completed 11 FACE-Q Aesthetics scales and 12 MERZ Aesthetics scales. Hypotheses regarding the strength of correlations between scales were generated a priori. Adequate convergent validity was based on percentage of correct hypotheses (>75%) and/or correlation ≥0.50 with an instrument measuring a similar construct.

Results: 1259 participants were included in this survey. Participants were on average 42.6 (±11.9) years old, and mostly female (72.5%), Caucasian (76.9%), and living in the United States (49.9%) or the United Kingdom (42.9%). FACE-Q Lines Overall, Lower Face and Jawline, Appraisal of Lines - Forehead/Between Eyebrows/Crow's Feet/Lips/Nasolabial Folds/Marionette, and Lips scales demonstrated adequate convergent validity with patient reported MERZ Aesthetics scales. The FACE-Q Face Overall and Cheeks scales did not show adequate convergent validity.

Conclusions: This study provides evidence of convergent validity for FACE-Q Aesthetics appearance scales. Establishing validity of these scales remains an iterative process and further studies comparing the FACE-Q to other related measurement tools are required to strengthen this evidence.