Light-Guided Percutaneous Neck Rejuvenation With Division of Platysma Bands and Suture Suspension: A Multicenter Retrospective Study.

BACKGROUND: Traditional invasive suture suspension techniques have proven efficacy and durability. A previously described percutaneous placement of a neck suspension suture with light guidance has transformed this into a minimally invasive technique. This novel technique provides a major advance for minimally invasive neck rejuvenation. OBJECTIVES: The authors sought to describe their experience with light-guided percutaneous neck rejuvenation over the past 4.5 years, including technique, patient selection, safety profile, and expected outcomes. METHODS: Data were retrospectively reviewed for all patients who underwent the procedure with 5 surgeons across 4 aesthetic plastic surgery practices from January 2018 through May 2022. Inclusion criteria were mild to moderate neck laxity, prominent anterior platysma bands, and desire to improve neck contour. Patients undergoing concurrent skin incision >5 mm (ie, open rhytidectomy or platysmaplasty) were excluded. RESULTS: A total of 391 patients meeting criteria were identified during the study period. No hematomas were documented. Four patients (1%) developed infection at the suture site, 1 resolving on antibiotics and 3 requiring suture removal. Eighteen (4.6%) developed recurrent platysmal bands, and 7 (1.8%) had residual loose skin. Four (1%) experienced transient marginal mandibular neuropraxia. Mean length of follow-up time was 240 days. CONCLUSIONS: Light-guided percutaneous suture suspension is a safe and viable option for improving neck contours. Although it does not address extensive skin laxity or excess submental fat, it can be combined with energy-based tissue tightening, submental liposuction, or skin excision. In selected patients, this minimally invasive procedure provides predictable results with a low risk of complications.

Roundtable Discussion: Making Sense of Current Liposuction Technologies.

Suction-assisted lipectomy (or "liposuction") is a fundamental technique for all plastic surgeons, and like many procedures in aesthetic surgery, its applications are continuing to evolve. With the rapid introduction of new technologies, many plastic surgeons are left with questions about how these new devices work, what results to expect, and how to best apply these technologies in their practice. We recognized that there is a need for unbiased recommendations to guide surgeons on how to approach current liposuction devices (as well as their adjuncts) and how to use them effectively for their patients. Using available literature and personal experience, we answer the most common questions that we hear from our plastic surgery colleagues.

Comparison of a Novel Silicone Gel Wound Dressing vs Bacitracin After Follicular Unit Extraction Hair Transplantation.

BACKGROUND: Follicular unit extraction (FUE) hair transplantation subjects are excellent candidates to assess wound dressings. The wound surface area is large and adequately delineated to allow randomization, while in-patient split scalp designs allow patients to serve as their own controls. OBJECTIVES: This randomized, single-blinded, split-scalp comparison trial compares a novel, film-forming silicone gel-Stratamed (SM; Stratpharma AG, Basel, Switzerland)-to Bacitracin (Bac; McKesson Medical-Surgical Inc., Richmond, VA) in subjects undergoing FUE. METHODS: Twenty subjects were randomized to receive SM and Bac on alternating sides of the scalp. Primary outcome measures included blinded clinician assessments of edema, erythema, crusting, healing response and outcome preference. Secondary measures included subject-reported assessments of pain and pruritis as well as FaceQ scores taken at post-FUE days two through six. RESULTS: Twenty subjects were enrolled. Nineteen completed the trial. All subjects were non-smokers, and none had medical comorbidities expected to impact wound healing. An average of 1778 follicles per subject were harvested. No adverse events were reported, and all subjects healed by day 7. Healing response and outcome preference were significantly higher at day 1 in the SM group and by day 7, both groups were similar. There were no significant differences between groups for edema, erythema, or crusting. There were no significant differences between groups for subject-reported outcomes of pain, pruritis, or FACE-Q scores. When asked which product they preferred using, 44% of subjects preferred using SM versus 22% who preferred Bac. CONCLUSIONS: The SM wound dressing was well-tolerated in patients undergoing FUE. SM may speed the healing response in the early phase of wound healing.

Temperature-Controlled Monopolar Radiofrequency in the Treatment of Submental Skin Laxity: A Prospective Study.

BACKGROUND: Laxity of the submental area is a common cosmetic complaint of the aging population. OBJECTIVES: The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift. METHODS: A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes. RESULTS: At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as "improved" at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation). CONCLUSIONS: Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months.

Bipolar Radiofrequency as an Adjunct to Face and Body Contouring: A 745-Patient Clinical Experience.

BACKGROUND: Radiofrequency (RF) technology has ushered in a new paradigm in body contouring for patients with mild to moderate skin laxity who desire fat removal without exacerbating skin laxity issues. A bipolar internal RF device, used as an adjunct to liposuction, has been found to be simpler and more accurate than previous technologies. OBJECTIVES: The aim of this study was to review the authors' clinical experience with bipolar RF-assisted liposuction (RFAL). METHODS: We conducted a review of our large experience with bipolar RFAL, evaluating the nuances from appropriate patient selection and specific treatment areas. The review covered 745 patients treated from January 2017 to January 2020 at 2 centers. A retrospective chart review was performed of the first and last 50 patients treated at each center (for a total of 100 patients in each group) to assess trends in outcomes and adverse events. RESULTS: Results were generally excellent from physician evaluation, and overall patient satisfaction was high (96%). The two most common adverse events were temporary swelling (9%) and nodules (8.5%). Selected examples of a variety of cases are reviewed. CONCLUSIONS: The ability to tighten skin with a minimally invasive tool adds much to the contemporary approach to the body-contouring patient with skin laxity. Adverse events were minimal and greatly decreased after an initial short learning curve. Bipolar RFAL is a strong addition to our surgical armamentarium and has become an essential tool for our practices.

Comparison of Cellulite Severity Scales and Imaging Methods.

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.

Marginal Mandibular Nerve Mapping Prior to Nonablative Radiofrequency Skin Tightening.

BACKGROUND: Aging skin and increased skin laxity is a prevalent concern of patients. Nonsurgical treatments, such as radiofrequency, are increasing in popularity due to decreased pain, downtime, and scarring. ThermiRF (Thermi, Irving, TX) is a subdermal radiofrequency treatment for tightening skin. When applying radiofrequency treatments to the neck, it is important to avoid ablating the marginal mandibular nerve and causing nerve trauma. OBJECTIVES: The purpose of this study was to locate and record the position of the marginal mandibular nerve in 72 patients undergoing subdermal radiofrequency skin tightening, to determine how often the nerve correlates to its textbook anatomic position. METHODS: Marginal mandibular nerves were located with a nerve stimulator and marked with the subject in both upright and recumbent positions. Photographs were taken and the nerve position in relation to the mandible was recorded. RESULTS: The marginal mandibular nerve was in its correct anatomic position above the mandible in 18% of patients. Nerve position did not shift between the upright and recumbent positions. Only 10% of patients had left-right nerve symmetry. CONCLUSIONS: To avoid nerve injuries, nerve mapping prior to nonablative radiofrequency treatment is recommended. The marginal mandibular nerve is not always in its correct anatomic position or symmetric to the opposing side. Its location cannot be assumed from the textbook anatomic position or from a single-side mapping.

Treatment of Atrophic Facial Acne Scars With Microneedling Followed by Polymethylmethacrylate-Collagen Gel Dermal Filler.

BACKGROUND: Microneedling and soft-tissue filler injections have been used independently to improve acne scarring. The effectiveness of a combined approach using microneedling followed by polymethylmethacrylate (PMMA)-collagen gel has not been carefully studied. OBJECTIVE: The goal of this study was to assess the effectiveness and safety of microneedling alone versus microneedling followed by injection of PMMA-collagen gel filler for correction of atrophic facial acne scars. METHODS: We conducted a multicenter, open-label, randomized, prospective study on subjects with distensible atrophic acne scars in the face to determine whether microneedling with PMMA-collagen gel is a superior acne scar treatment over microneedling alone. Forty-four subjects received 3 microneedling treatments over a 12-week period followed by randomization to treatments with PMMA-collagen gel (treatment group) or no further treatment (control group). RESULTS: At 24 weeks, the treatment group achieved a statistically significant improvement in acne scores over microneedling alone. The improvement continued at 36 weeks. At 24 weeks, the treatment group showed a strong trend in improvement on the Physician Global Aesthetic Improvement Scale compared with microneedling alone.

Prediction of Treatment Outcomes for Neck Rejuvenation Utilizing a Unique Classification System of Treatment Approach Using a 1440-nm Side-Firing Laser.

BACKGROUND: The appearance of a youthful neck is lost with age causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle. This system will correlate with specific treatment options. OBJECTIVE: The objective of the study was to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. METHODS: Patients were treated with a single treatment of PrecisionTX™ 1440-nm wavelength laser on their necks. Baseline and posttreatment photographs were taken and evaluated by 3 blinded reviewers using the Cervicomental Angle Scale (CAS). RESULTS: Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.07. Patients, 23/25 (92%), showed at least a 1 score improvement. CONCLUSIONS: This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction.

Use of a controlled subdermal radio frequency thermistor for treating the aging neck: Consensus recommendations.

INTRODUCTION: A new temperature-controlled device has been used as a percutaneous radio frequency probe to treat lax submental and other facial areas. It has significant advantages over other esthetic devices as it provides the dual benefit of fat lipolysis and skin tightening. Our goal here is to present consensus recommendations for treating the aging neck. METHODS: A panel of 11 expert physicians convened in Dallas, Texas, on October 15, 2016 to arrive at a consensus on the best current practice for submental skin tightening and contour improvement. Prior to the meeting, a comprehensive review of the literature was performed and a survey was sent to esthetic dermatologists and plastic surgeons who were queried about various aspects of neck rejuvenation. RESULTS: The literature search revealed 10 different technologies for neck rejuvenation evaluated in double-blind (n = 2) and single-blind (n = 1) clinical trials and other clinical evaluations (n = 21). The survey was sent via an email to 1248 individuals and was completed by 92 respondents. Review of the data and discussion by meeting attendees generated eight consensus recommendations. DISCUSSION: Subdermal monopolar radio frequency represents an effective means for disrupting fat volume and skin tightening of the face, neck, and jawline. For suitable patients, this treatment can be used to achieve significant esthetic improvements.

Laser Resurfacing: Full Field and Fractional.

Laser resurfacing is a very popular procedure worldwide. Full field and fractional lasers are used in many aesthetic practices. There have been significant advances in laser resurfacing in the past few years, which make patient treatments more efficacious and with less downtime. Erbium and carbon dioxide and ablative, nonablative, and hybrid fractional lasers are all extremely effective and popular tools that have a place in plastic surgery and dermatology offices.

Intense Pulsed Light Therapy for Skin Rejuvenation.

Intense pulsed light (IPL), also known as pulsed light and broad band light, is a nonlaser light source used to treat a variety of vascular and pigmented lesions, photo damage, active acne, and unwanted hair. Current IPL systems are much improved from older-generation devices with better calibration, integrated cooling, and improved tuning. These devices are extremely popular because of their versatility and are often the first devices recommended and purchased in many offices.

Subsurface Laser and Radiofrequency for Face and Body Rejuvenation.

Minimally invasive devices are a departure from standard laser therapies, because energy is delivered directly below the skin through a 1-mm incision. Lasers can affect such tissues as fat for enhanced disruption, coagulation of small blood vessels, and skin tightening at the right temperatures. Minimally invasive radiofrequency devices can tighten skin but can also improve neck muscle laxity. These devices can achieve results not possible with traditional external devices and, because the skin is not penetrated with energy, a much improved healing profile is seen as well.

A Multicenter Study for Cellulite Treatment Using a 1440-nm Nd:YAG Wavelength Laser with Side-Firing Fiber.

BACKGROUND: Treatment of cellulite using a 1440-nm YAG wavelength laser with side-firing fiber has proven safe and effective, lasting at least 6 months. OBJECTIVES: The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite for at least 1 year. METHODS: Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Adverse events (AE) were recorded throughout the study. Twelve month data were analyzed and compared to 6 month data. RESULTS: Evaluators chose baseline photographs 97% on average from 6 (-1, +2) months and 91% from the 12 (-3, +2) months posttreatment photographs. At 6 (-1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (-3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale. CONCLUSIONS: A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. LEVEL OF EVIDENCE 2: Therapeutic.

Noninvasive and minimally invasive techniques in body contouring.

Major surgical body contouring procedures have several inherent drawbacks, including hospitalization, anesthetic use, pain, swelling, and prolonged recovery. It is for these reasons that body contouring through noninvasive and minimally invasive methods has become one of the most alluring areas in aesthetic surgery. Patient expectations and demands have driven the field toward safer, less-invasive procedures with less discomfort, fewer complications, and a shorter recovery. In this article, the current minimally invasive and noninvasive modalities for body contouring are reviewed.

Gold Nanoparticle-assisted Selective Photothermolysis of Adipose Tissue (NanoLipo).

BACKGROUND: Conventional suction-assisted lipectomy (SAL) often results in contour irregularity. Selective photothermal heating of adipose tissue by polymer-coated gold nanorods energized by an external near-infrared exposure at 800 nm is introduced in this work to facilitate fat removal. METHODS: The effects of NanoLipo were examined in food-grade porcine abdominal tissue (skin, fat, and fascia) by histology. The efficacy of NanoLipo was compared with that of conventional SAL in vivo in Yucatan mini pigs by quantification of removed subcutaneous tissue and fatty acids and ultrasound measurement of adipose layer thickness. RESULTS: NanoLipo led to the appearance of disruptions in adipose tissue that were not apparent in control groups in ex vivo samples. NanoLipo allowed removal of more subcutaneous tissue (~33% vs ~25% of removed material, P < 0.05) and approximately twice as much free fatty acids (~60% vs ~30% of removed tissue, P < 0.05) in comparison with conventional SAL. Most importantly, NanoLipo led to a greater decrease in adipose layer thickness at 1 month post surgery (P < 0.001). CONCLUSIONS: NanoLipo facilitates removal of a greater quantity of fat and requires less suction time (4 vs 10 minutes) than conventional SAL. As the safety of poly(ethylene-glycol)-coated gold nanorods is well-established, a clinical trial is currently being organized.

The aging neck: a diagnostic approach to surgical and nonsurgical options.

BACKGROUND: The neck is a prominent indicator of aging. Loss of subcutaneous fat, prominence of platysmal banding, jowling along the mandibular border, and excessive skin laxity due to loss of collagen and elastin are common conditions that are treated. Laser technology provides additional benefits when treating the first two anatomical layers of the neck. METHODS: A 7-category classification system of anatomic skin layers of the lower face was developed. Based on the classifications treatments include the use of laser, ultrasonic technology, and toxins. RESULTS: A classification system offering surgical and nonsurgical treatments including a 1440-nm laser fiber with a specifically designed tip to allow targeted energy delivery managed through a thermal sensing device. CONCLUSIONS: Treatment options correlate with the presence and severity of conditions. Categories 1 and 2 have only a fat excess condition. Laser application alone, without skin intervention, is utilized. The amount of fat with subsequent aspiration follows guidelines of categories 2 through 5. The 1440-nm laser helps in all treatments. The surgeon may elect to address skin tightening with surgical tightening in categories 6 and 7. Modalities such as toxins and focused ultrasound can be used to address muscle laxity.