Evidence-Based Medicine: Face Lift.

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.

The aging of the face is a multifaceted phenomenon characterized by substantial modifications in different facial structures. Alterations in the skin, including diminished collagen and depletion of subcutaneous fat, coupled with changes in the facial skeleton and soft tissues, collectively contribute to this evolutionary process.1-4 Currently, there is a diverse range of facial rejuvenation techniques accessible to counteract the effects of aging. These popular procedures, encompassing fillers, toxins, thread lifting, lipofilling, and laser treatments, are in high demand.5, 6 Within these minimally invasive interventions, thread lifting emerges as a popular modality for facial rejuvenation. Originally conceived as a facelift technique, thread lifting is now widely recognized as a creative and practical approach to skin rejuvenation by practitioners.7-10 Current research underscores the dependability of thread lifting as a minimally invasive approach, highlighting prompt recovery, elevated patient contentment, and minimal risk of adverse effects.9-14 The aging process is marked by a noticeable reduction in facial volume, which significantly influences the definition of the jawline. This phenomenon results in skin sagging, the formation of jowls, and the emergence of prominent marionette lines. Given the pivotal role of the jawline in facial attractiveness, especially in adults, a holistic approach to facial rejuvenation is imperative. This approach involves a thorough assessment and targeted interventions to address concerns related to the jawline. In cosmetic procedures, a common goal is to address the aging effects, particularly evident in facial features, like marionette lines. Also referred to as melomental folds, these lines are a consequence of facial aging, presenting as downward-curving wrinkles originating from the corners of the mouth. Traditionally, marionette lines were associated with repetitive facial movements and the impact of gravity on less elastic skin tissue. The cosmetic treatment of well-established marionette lines has historically posed challenges. However, there is a noticeable shift away from employing more invasive volumizing thread methods to address these lines, with a preference for less invasive procedures that demonstrate increased efficacy. The utilization of threads has exhibited promise in improving the appearance of marionette lines. The marionette line becomes apparent as the lengthening of the nasolabial fold occurs, typically characterized by a reduction in subcutaneous fat beneath the inner lower aspect of the fold and the accumulation of fat (jowl fat) above the outer upper aspect. This results in a distinct demarcation, facilitated by the mandibular ligament at the lowermost point of the marionette line, which tightens the tissues within the fold, restricting their movement and accentuating the boundary (Figure 1). In such cases, correction of volume asymmetry is often addressed through procedures such as liposuction, transplantation, or filler injections. Specifically, introducing volumizing agents into the vertical direction of the marionette line can mitigate the visibility of the boundary between the two fat layers. The technique involves placing volumizing threads perpendicular to the marionette line, strategically positioned to minimize the visibility of the boundary between the two layers of fat (Figure 2). While conventional multi-threads, composed of numerous monothreads, experience diminished volumizing efficacy due to compression by surrounding tissues upon insertion. Volumizing threads, characterized by multiple monothreads that contribute to reduced pain during procedures and mitigate damage to surrounding blood vessels and tissues, consequently minimizing bruising, swelling, and pain. For the cross technique utilizing volumizing threads, entry points are established inside or outside the marionette line, with specific locations determined by the length of the volumizing threads being used. Inserting the threads across the marionette line along the entry points result in the volumizing thread section within the thick tissue beneath the marionette line providing support, while the upper portion of the thread above the marionette line compresses and pushes the loose skin tissue, creating a lifting effect. This method of inserting volumizing threads vertically along the marionette line promotes collagen growth along the thread direction, tightening the loose skin tissues above the marionette line. Consequently, it reduces the degree to which the skin around the mouth is pressed and folded by facial muscles during expressions. Caution is advised against inserting the threads too deeply, as it may potentially lead to protrusion of the threads into the oral cavity. To employ the cross technique using volumizing threads, an entry point is established inside the marionette line, and its specific location is determined based on the length of the volumizing threads to be used. Inserting the volumizing threads across the marionette line, from bottom to top, through the entry point, the section of the volumizing thread beneath the marionette line enters the thick tissue, providing a supportive base. Simultaneously, the upper part of the volumizing thread exerts pressure on and pushes the loose skin tissue above the marionette line. Placing volumizing threads vertically along the marionette line prompts collagen growth along the thread direction, firming the loose skin tissues above the marionette line. Consequently, when facial muscles move the area around the mouth, the skin around the corner of the mouth is pressed and folded to a lesser extent. When inserting volumizing threads inside the marionette line, care must be taken to avoid injuring the mental artery and nerve emanating from the mental foramen below the corner of the mouth. The mental foramen often lies approximately midway along a vertical line drawn from the corner of the mouth to the mandible's border. In elderly patients with sagging lower facial skin and associated tissues, the prejowl sulcus may accompany the marionette line, causing the area beneath the wrinkle line to appear compressed, resulting in an uneven jawline. The outer region beyond the jaw's tip has a thin subcutaneous fat layer compared to the jaw's tip, and the mandibular ligament along the bone's jawline attaches to the skin, providing a firm pull (Figure 3). Due to this fibrous tissue, if the prejowl sulcus appears significantly compressed, achieving smooth restoration with fillers alone can be challenging. In such cases, combining volumizing threads and fillers can yield more effective results. During the procedure, pre-tunneling between firm fibrous tissues is recommended to create space for the adequate insertion of volumizing threads and fillers, facilitating a smooth advancement of the cannula for their insertion. The cannula entry point is located approximately at the border between the chin and the mandible body, around the visibly depressed area's anterior boundary. Needle puncture is performed at this site, followed by lateral insertion of the cannula, guiding the volumizing thread along the depressor anguli oris and platysma muscles, or the subcutaneous fat layer. After inserting the volumizing thread, any uneven areas are addressed by injecting filler into the dermal or subcutaneous tissue through the same puncture site, ensuring a smoother appearance. By lifting the sagging tissues outside the marionette line and revitalizing the depressed area in front of the wrinkle line, the overall contour around the corner of the mouth improves. For achieving a softer transition between firm and lax tissue boundaries and reducing the folded lines at the border of these tissues, a more supple volumizing thread or monofilament can be employed. When inserting threads parallel to the wrinkle line, placing them slightly inside the wrinkle line can mitigate differences in the skin layer caused by the depressed area. Placing volumizing threads or monofilaments along the wrinkle line encourages collagen growth along the thread direction, firming the skin tissues and reducing symptoms of skin compression and folding in the area in front of the wrinkle line. In elderly patients, sagging of the lower facial skin and connective tissues contributes not only to the marionette line itself but also to the concurrent presence of the prejowl sulcus. This results in the area below the wrinkle line appearing compressed, giving an uneven appearance to the jawline, with the region above the wrinkle line appearing more pronounced. The outer region beyond the jawline tends to have thinner subcutaneous fat layers compared to the chin tip, and the mandibular ligament, running along the bone's jawline, attaches firmly to the skin. This ligament pulls and tightens the skin, creating a firm grip. To address the displaced fat contributing to jowling and achieve a more harmonious result, it is advisable to perform oblique cog thread lifting in conjunction with vertical lifting along the wrinkle line, directing the threads towards the ear region (Figure 4). This simultaneous approach helps target the specific fat deposits responsible for jowling, providing a comprehensive solution for a more aesthetically pleasing outcome. In cases where the prejowl sulcus itself appears significantly compressed due to ligamentous tissues, achieving a more favorable outcome can be facilitated by concurrently employing volumizing threads and fillers in the affected area (Figure 5). During the procedure, it is essential to pre-tunnel the firm ligamentous tissues, creating adequate space for the insertion of volumizing threads and fillers. The cannula entry point is typically situated around the border area between the chin tip and mandible body, where the region appears compressed and receded. Following needle puncture at the front boundary of the compressed area, the cannula is inserted outwardly to place volumizing threads along the depressor anguli oris and platysma m. or the submuscular fat layer. Irregularities post volumizing thread insertion can be addressed by injecting fillers into the dermal or subcutaneous tissue through the same puncture site, promoting a smoother appearance. In essence, it is crucial to recognize that employing diverse threads beyond simple single vectors and threads allows for longer lasting thread lifting (Figure 6). Particularly, the insertion of cross-pattern volumizing threads that traverse both tissues reduces the disparity between sagging tissue with jowling on one side, inducing adhesion and significantly extending the duration. Additionally, for refining the overall contour after repositioning sagging tissues beyond the marionette line and revitalizing the depressed areas in front of the wrinkle line, a softer form of volumizing threads or monofilaments may be utilized. When inserting threads parallel to the wrinkle line, placing them slightly inward compared to the wrinkle line helps improve the difference in skin layers due to the compressed areas. The insertion of volumizing threads or monofilaments along the wrinkle line encourages collagen growth in the thread direction, tightening the skin tissues and reducing symptoms of skin folding in front of the wrinkle line. The utilization of various threads aims to induce synergy among the inserted threads, enhancing overall effectiveness. A 53-year-old female presented with a concern related to the marionette line. Comparative images were captured in both the pre-procedural and 4-month post-procedural stages (Figure 7). The intervention involved the vertical insertion of two lines of 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) along the marionette line wrinkle. This placement strategically stimulated collagen production along the thread direction, leading to the tightening of skin tissues and the amelioration of symptoms associated with skin compression and folding. 0.1 cc of dental lidocaine was injected at the entry site prior to the insertion of the thread. The threads were precisely introduced into the subcutaneous layer, facilitated by an 18G needle following an initial puncture. The thread was inserted into the subcutaneous layer (layer II) while pressing the jowl flat with the palm. Cannula was retracted with rotating the cannula at the end of the insertion. A 55-year-old woman expressed a marionette line-related concern. Comparative photographs were taken before the procedure and 2 months after the procedure (Figure 8). In the anterior cheek area, 21G volumizng polydioxanone threads (LVDR Volume, Sihler, Korea) were introduced, and along the marionette line wrinkle, two sets of 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) were vertically inserted. Before inserting the thread, 0.1 cc of dental lidocaine was administered at the entry site. A puncture was then created with an 18G needle and the thread was placed at the subcutaneous level (layer II). The cannula was retracted by rotating it at the end of the insertion. Evident enhancements were observed in both the volumizing effects of the anterior cheek and the refinement of the marionette line. A 46-year-old female patient, with a history of facelift surgery several years ago, sought thread lifting for correction of the marionette line and prejowl sulcus. For this purpose, 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) were inserted vertically along the marionette line in two lines, and one line each was inserted directly into the prejowl sulcus. Prior to threading, 0.1 cc of dental lidocaine was injected at the entry point. An 18 G needle was used to create a puncture and the thread was then inserted into the subcutaneous layer (layer II). The cannula was retracted by rotating it at the end of the insertion. Improvement in both areas was observed. Post-procedure photos were taken 6 months later. Typically, the reduction of fat occurs on the inner lower side of the wrinkle line, while fat (jowl fat) accumulates on the outer upper side, creating a distinct boundary. Additionally, the presence of the mandibular ligament at the lowest point of the marionette line causes the tissues on the inner side of the wrinkle line to contract, preventing them from moving and resulting in a clear demarcation.15 In such cases, correction is achieved through procedures like liposuction, grafting, or filler injections to address the asymmetry in volume. This involves elevating the cheek area as much as possible, reducing volume, creating elasticity, and augmenting volume on the medial side. Contemporary aesthetic clinics have witnessed a surge in the popularity of knotless thread lifting devices utilizing absorbable threads. Despite its widespread adoption, a notable drawback of this procedure lies in its applicability to only a moderate degree of facial tissue laxity.16-18 The development of marionette lines, influenced by facial anatomy and aging dynamics, manifests as visible sagging around the mouth. These lines, influenced by factors like muscle composition and tissue depth variations, contribute to a downturned appearance reminiscent of a marionette puppet's mouth. Effectively addressing these lines often involves a comprehensive approach, employing minimally invasive procedures like thread lifting and fillers to mitigate sagging and enhance facial aesthetics. Techniques emphasizing specific anatomical considerations and precise thread insertion have demonstrated promise in effectively treating and minimizing these lines, thereby reducing risks and improving outcomes. Favorable anatomical characteristics for absorbable thread lifting include a low body mass index, minimal soft tissue fullness, robust underlying bony structures providing support, and good skin quality. Conversely, individuals with obesity and thicker soft tissues may yield less favorable results, underscoring the importance of meticulous patient selection for optimal outcomes. To combat significant skin sagging, the strategic insertion of 1–3 additional cog threads along the cheek has proven effective. Concurrently, addressing additional marionette lines and lifting the chin involves using 3–5 extra cog threads perpendicular to the chin line, resulting in more favorable outcomes. The thread technique boasts advantages such as avoiding general anesthesia and scarring due to its incision-free nature. It has demonstrated efficacy in treating uneven facial textures, midface slackness, and mild to moderate jowls in specific patient groups. Complications associated with this procedure are infrequent and generally minor, establishing the utilization of threads for aesthetic facial rejuvenation and lifting as a safe method. All authors have reviewed and approved the article for submission. Conceptualization: Kyu-Ho Yi and Soo Yeon Park. Writing—original draft preparation: Kyu-Ho Yi and Soo Yeon Park. Writing—review and editing: Kyu-Ho Yi and Soo Yeon Park. Visualization: Kyu-Ho Yi and Soo-Yeon Park. Supervision: Hong, Kyu-Ho Yi and Soo-Yeon Park. This study was conducted in compliance with the principles set forth in the Declaration of Helsinki. There is no financial disclosure to report. I acknowledge that I have considered the conflict of interest statement included in the "Author Guidelines." I hereby certify that, to the best of my knowledge, that no aspect of my current personal or professional situation might reasonably be expected to significantly affect my views on the subject I am presenting. This study was performed in line with the principles of the Declaration of Helsinki. The data that support the findings of this study are available from the corresponding author upon reasonable request.

A facelift, also known as a rhytidectomy, is a surgical procedure that improves visible signs of aging in the face and neck, such as sagging caused by relaxation of the skin, deepening of the fold lines between the nose and corner of the mouth, fat that has disappeared or fallen, the development of jowls in the cheeks and jaw, loose skin, and excess fat of the neck that can appear as a double chin or "turkey neck." A number of factors can cause the face to lose its youthful contours, including thinning skin, fat loss, gravity, sun damage, smoking, heredity, and stress. Brow lifts and eyelid surgeries are additional operations that can be used in conjunction with a facelift to revitalize aging eyes. It may be suggested to use fillers or fat transfer to replace the lost fatty volume. Skincare procedures including lasers, dermabrasions, and peels could be recommended to enhance the skin's texture and quality. In the century since it was first introduced, the facelift procedure has seen a significant change. Numerous safe, reliable, and efficient surgical techniques have been developed because to the information gathered by earlier surgeons. There is currently disagreement in the literature regarding the most effective strategy. This indicates that, in the hands of an experienced surgeon, several available surgical options are comparable. Many proponents of the various popular approaches have developed strong cases to back up their positions. The lack of consensus emphasizes how crucial it is to constantly innovating in order to meet patient expectations, enhance longevity, and achieve good surgical outcomes. Similarly, further examination of current methods via carefully planned research is essential for the final creation of a "gold standard." One can observe a similar level of progress in facelift development over the next century, with a focus on the use of new technology and a tendency in that direction. This review article focuses on face lift technique and associated problems experienced medical professional.

The speciality of plastic surgery has blossomed in the last decade. Rejuvenating and reshaping parts of the body that look either worn out or ungraceful can have important positive psychological effects and give patients a new lease on life. Just about any part of the body can be reshaped: face, nose, breast, hips, thighs, knees, arms, abdomen, and so on. Surgeons are using new approaches and the classical scalpel is replaced frequently with new technologies, such as the laser and liposuction techniques. Nowadays, an increasing number of men and women resort to the many face-lifting techniques, for personal and even professional reasons. Face lifting or other plastic surgery interventions, tightens their skin and therefore modifies their features in a way that makes them look less tired and more fit and competitive. More than ever before, people change jobs, and men and women in their forties or fifties think that they can increase their chances of getting a good professional position if they look younger. About ten years ago, women and men undergoing face lifts were made to look many years younger. Today, such drastic interventions and changes are no longer fashionable. Candidates for face lifts want more subtle changes, for example, getting rid of wrinkles or looseness of the skin.

Minimally invasive facial rejuvenation techniques, including collagen biostimulators and energy-based technologies, have gained popularity alongside surgical facelift (rhytidoplasty). While biostimulators present overall tissue remodeling (collagen, elastin, extracellular matrix), their impact on facelift surgery remains controversial due to a lack of robust scientific evidence. To assess surgeons' perceptions on the effects of biostimulators use and facelift surgery, including surgical difficulty, complication rates, and modifications in surgical planning. A survey was conducted with 63 facial surgeons, including plastic surgeons and otolaryngologists, evaluating their experiences with facelift procedures in patients previously treated with biostimulators. Questionnaire included patient history, preoperative assessment, surgical challenges, operative time, complications, and changes in surgical approaches. Most respondents (70%) performed both surgical and minimally invasive procedures, while 28% offered biostimulators through other professionals. When asked about surgery: 59% believed biostimulators could delay facelift surgery and 43.8% adjusted their surgical approach, especially in cases presenting fibrosis whereas 50.8% reported longer operative times, and 84.4% noted increased complication rates. Among complications, 91.8% reported difficulty in tissue dissection, 73.3% observed postoperative skin irregularities, and 57.4% noted prolonged inflammation. The type of biostimulator influenced surgical difficulty (97%), and intraoperative recognition was highest for threads (76.6%) and CaHA (57.8%). There was no consensus on the ideal interval between biostimulator application and surgery, but procedures performed within six months were seen as more challenging. Biostimulators may delay the need for facelift surgery but can increase intraoperative difficulty and complications. As their use expands, both cosmetic and surgical professionals must refine their techniques to ensure optimal outcomes. Also it may be considered that HCP using biostimulators and threads should advise the patients of these difficulties. Further clinical studies are needed to establish clear guidelines. 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.

Facial aging drives a growing demand for esthetic procedures, with nonsurgical options often falling short in longevity compared to surgery. Despite primary face and neck lift techniques receiving substantial attention, revision procedures have been relatively overlooked in terms of their unique surgical management, complication incidence, and preventive strategies. The authors present a 40-year experience with revision face and neck lifts, comprising 283 cases. The primary focus was on the high-SMAS flap technique in revision surgeries, with data collected on complications compared to primary procedures and existing literature. Secondary analysis investigated the time-lapse between primary and revision surgeries in the author's series (secondary and tertiary rhytidectomy) compared to the literature findings. Out of 283 cases, 232 were secondary and 51 were tertiary procedures. Overall complication rates in secondary cases mirrored those of primary procedures, with no statistically significant difference observed (p > 0.05). The mean interval between procedures was 9.0years (range: 3.4-28.8years), with a significant statistical difference (p < 0.05) observed between the first and second procedures (10.7years, range: 3.8-18.8years) and the second and third procedures (7.8years, range: 3.5-10.8years). Results indicate that high-SMAS flaps yield consistent and satisfying outcomes, even in secondary and tertiary cases. Complication rates are comparable to primary surgeries, underscoring the importance of meticulous attention to detail in managing the complexities associated with previous surgeries and the aging process. 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 .

One of the weak points in face lifts is their failure to fully correct the ptosis of the labial commissures. This article illustrates a new technique to optimize this commissural repositioning in face lifts by using the muscular balances of the lower half of the face. There is, in effect, a third type of muscular balance, which acts on the commissural modiolus and is created by the opposing forces of the levator muscles (notably the zygomaticus major and the levator anguli oris) and the depressor muscles (principally the depressor anguli oris). Rarely a purely cutaneous problem, labial commissural ptosis is more a part of mediofacial ptosis affecting the entire soft tissue. I have used the malar subperiosteal face lift technique, the only approach that allows the centrofacial features to be lifted as a whole block, since late 1996 and have treated a series of more than 30 patients affected with mediofacial ptoses involving the malar eminences, the nasolabial folds, and the labial commissures. Retensioning the levator muscles was combined with wholesale subperiosteal release of the depressor muscles, notably the depressor anguli oris. Patient follow-up has lasted between 6 and 20 months. In all instances, this use of the lower facial muscular balances allowed optimal repositioning of the labial commissure. In particularly outstanding cases, unilateral release of the depressor muscles was used to correct facial asymmetry at the level of the lip commissures and thereby restore harmony and alignment. In 10 of our cases, this slackening of the depressor muscles was also used in conjunction with a peripheral face lift; the resulting heightening of the commissures was, in these cases, perhaps less spectacular, but it invariably contributed to the rejuvenation of the face.

The thread lift is becoming an increasingly popular treatment within the field of aesthetic medicine. The procedure can be performed using polydioxanone (PDO) threads to lift, tighten and rejuvenate areas of sagging skin, and minimise fatty tissue. This allows for the non-surgical redefinition of facial contours and enhancement of skin integrity. Thread lifting with PDO can also provide certain aspects of the much sought after surgical facelift in a clinic setting. PDO threads aim to promote targeted lipolysis of fatty areas and neocollagenesis in sagging skin, as well as lift the treated areas. However, it is important to note that the extent of these enhancements varies between individuals, and can carry unwanted side effects. The author draws on his experience to discuss the importance of managing patient expectations pre and post PDO thread lifting, describe the treatment's mechanisms of action, and highlight important considerations for aesthetic practitioners who wish to pursue these treatments.

The face lift procedure is often performed in aesthetic plastic surgery. It corrects the stigmata of age, i.e. the multiple facial wrinkles and the sagging of the atrophic soft tissues by undermining and retensioning the superficial and deeper facial and cervical structures. Since the public can not fully appreciate the extent and the inconveniences involved with this operation, emphasis must be laid on an exact preoperative information of the patient with regards to possible complications, the pros and cons of this procedure and the results to be expected. In this paper the face lift operation is explained in detail and the indications and contraindications given. The most frequent postoperative complications are outlined and the preventive measures and modalities of treatment discussed. From the medico-legal point of view it is important that such an operation is performed by a certified and well experienced plastic surgeon.

As demand for a youthful appearance has increased, various techniques for face lifting and contouring have been used to reduce excess fat deposition and improve skin laxity. Recently, radiofrequency (RF)-assisted lipolysis and liposuction (RFAL) has been introduced for body and face contouring. This study aimed to evaluate the clinical improvement and safety of a new RFAL device for face lifting and contouring. A prospective study was conducted in 20 Korean patients who underwent an internal real-time thermosensing monopolar RFAL procedure. Prior to treatment and 12 and 24weeks after treatment, digital photographs were taken, and the degree of improvement as measured by investigators and patients was recorded. Skin elasticity was measured using a Cutometer (CT575, Courage and Khazaka®, Cologne, Germany). Safety profiles were also evaluated at each visit. Results showed favorable improvement in skin laxity and fat deposition. Both investigators' evaluations and patients' evaluation showed significant improvement between 12 and 24weeks. Although the changes in skin elasticity measured by the Cutometer were not statistically significant, all three treated regions showed a trend toward improvement. No major side effects such as infection or burn were observed. The internal, real-time thermosensing monopolar RFAL device showed clinical efficacy and safety. After further studies with more patients and longer follow-up periods, internal real-time thermosensing monopolar RF devices might become one of the popular treatment options for face lifting and contouring.

Background Hematoma is the most common early complication following facelift surgery, leading to increased morbidity and suboptimal aesthetic outcomes. Hemostatic nets, adapted from abdominoplasty techniques, aim to reduce hematoma formation by eliminating dead space and stabilizing tissue planes. Objectives To evaluate the effectiveness and safety of hemostatic nets in facelift (rhytidectomy) procedures and determine their impact on postoperative complications, particularly hematoma formation. Methods A systematic review and meta-analysis were performed in accordance with PRISMA guidelines and registered on PROSPERO (CRD420251027741). A comprehensive search of PubMed, Embase, and Scopus was conducted through April 2025 to identify studies evaluating the use of hemostatic nets in facelift procedures. Eligible studies included adult patients undergoing rhytidectomy, comparing outcomes with and without hemostatic net use. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for key complications. Results Seven studies involving 1,919 patients were included. Meta-analysis of five studies revealed a significant reduction in hematoma risk in the hemostatic net group (OR: 0.085; 95% CI: 0.01–0.57; p=0.0113). There were no statistically significant differences in skin necrosis (OR: 0.29; p=0.1057) or transient ischemia/edema (OR: 0.70; p=0.1855). Seroma and infection rates were low and comparable between groups. Conclusions Hemostatic nets significantly reduce hematoma incidence without increasing other postoperative complications. Their integration in facelift procedures represents a safe and effective adjunct, warranting further investigation through prospective, high-quality trials.

Deep-plane or composite flap facelift techniques allow deep structural rejuvenation of the face by release of retaining ligaments in the subsuperficial musculoaponeurotic system (sub-SMAS) plane with elevation and fixation of the SMAS/platysma/skin flap as a single, "en bloc" unit. This means that in the cases with mild to moderate skin laxity, the preauricular incision serves the purpose of access only. The author therefore developed an endoscopic-assisted, en bloc composite flap face and neck lift without a preauricular incision. The technique uses the prezygomatic and premasseteric (facial) and subplatysmal (neck) spaces as ideal optical cavities for endoscopic dissection and ligament release. Verticalization of fixation vectors and modified concho-mastoid traction sutures are used to minimize preauricular skin redundancy. The surgical procedure is described in detail. Clinical experience in 41 consecutive cases and comparison to other techniques with respect to relevant anatomy are also presented. This endoscopic en bloc composite flap facelift technique consistently and safely produced results comparable to conventional, "open" composite flap facelifts done by the same surgeon on similar candidates during a prior period.

Facial aging is a multifactorial process that results from deflation and descent of facial soft tissue. Modern deep layer face-lift techniques aim to restore a youthful facial shape by using the superficial musculoaponeurotic system (SMAS) to reposition descended facial fat into areas of deflation within the lateral cheek and malar eminence. Although there are many advocates of various SMAS techniques and numerous descriptions of methods to manipulate and fixate repositioned facial fat, there is no consensus in the literature as to a "best" SMAS technique. The authors' investigation aimed to determine whether there should be a consensus on the preferred method of SMAS manipulation in terms of improving contour in the aging face. A systematic review was performed to investigate the current body of literature on SMAS face-lift techniques. Careful review of operative technique was performed, and techniques were classified as medially or laterally based, depending on the extent of sub-SMAS dissection. Analysis of aesthetic outcomes and complications was performed to determine the superiority of one technique over another in achieving a youthful facial contour. A total of 17 articles were selected for review that clearly described operative technique and reported aesthetic outcomes. Patient satisfaction and improvement in overall facial contour was noted across studies. Various SMAS techniques can provide excellent aesthetic outcomes; however, medially based "deep plane" techniques, which carry dissection medial to the stout retaining ligaments, have not been shown to provide significant improvement in the appearance of the midface or improved longevity of results.

INTRODUCTION: In patients with significant loss of the buccal fat pad, especially in the presence of strong malar projection, aging takes on an almost “skeletal” quality. In such patients, the loss of fat between the highlight areas of the malar and gonial regions may be better treated by injections directly into the buccal fat pad. Herein, we describe the methods and results of transoral buccal fat augmentation during facelift surgery. METHODS: Fat is harvested using disposable Caraway harvest cannula; processed with a bi-laminar filtration system and injected with disposable 18 gauge cannula. Intravenous clindamycin is given 1 hour before surgery and the intraoral mucosa at the site of injection is re-prepped with betadine. The upper lip is retracted and approximately 1–1.5 cm above and medial to the Stensen’s duct, the injection cannula is threaded carefully through the mucosa and guided by palpation/ultrasound into the buccal fat pad. The cannula is then moved radially and clockwise from 12:00 to 6:00 and counterclockwise from 12:00 to 6:00 filling the buccal space with 2–5 ml of fat, depending on physical findings. RESULTS: As part of a prospective IRB study on fat grafting, 8 female patients aged 52 to 78 (mean=64) underwent buccal fat injection using the transoral approach (total injection = 4ml to 10ml). No intraoperative or perioperative complications of nerve injury or infections occurred. Based on physical findings, patients had anywhere from a 20% to 80% improvement in buccal fat fullness at a mean follow up of at eighteen months. Aesthetic improvement was observed in all patients. A fresh cadaver dissection was performed to demonstrate the relationship between buccal fat pad to Stensen’s duct, the marginal mandibular nerve and to map out the anatomy defining the buccal fat pad. CONCLUSIONS: Buccal fat injection is a powerful technique that restores the deep fat compartment between the zygoma and mandible, anterior to the masseter. Loss of subcutaneous fat is variable and in part based on the skeletal anatomy, patient age, and facial muscle activity. Restoration of the buccal fat pad volume can help reestablish harmony and balance to the face.

The understanding of facial anatomy and its changes through aging has led to the development of several different facelift techniques that focus on being less invasive and traumatic and, at the same time, providing natural long-lasting results. In this article we describe step by step our facelift technique as it has been done over the past 10 years by the senior author. This is a retrospective, descriptive, transversal study in which all patients who underwent a rhytidectomy using our technique from January 2002 to September 2012 were included. All patients were operated on under local anesthesia and superficial conscious sedation. All surgeries were performed by the same surgeon. A complete step-by-step description of the surgical technique can be found in the main article. Between January 2002 and September 2012, a total of 113 patients underwent facelift surgery. Of these, 88.9 % were women and 11.1 % were men. The mean age was 55.3 (± 8.66) years. Primary surgeries represented 80.3 % (n = 94), secondary 18.8 % (n = 22), and tertiary 0.85 % (n = 1). Only one major complication, representing 0.8 %, consisting of a right-sided temporal paresis with 2 months complete recovery was seen. The minor complications rate was 23.1 %. The most common minor complication was hypertrophic/keloid scars which made up 77.8 % of all minor complications. The technique described provides good and long-lasting aesthetic results with shorter scars, smaller areas of dissection (without temporal and postauricular flaps), and a shorter recovery period. 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 http://www.springer.com/00266 .