Sublabial Approach to Tip Rhinoplasty: A Cadaver Model.

OBJECTIVES: The main objective of this study was to investigate the utility of the sublabial approach in gaining proper exposure for tip rhinoplasty maneuvers in a cadaver model. Additional objectives included identifying types of grafts that can be placed sublabially and whether these methods can be translated successfully to human subjects. METHODS: Ten (N = 10) fresh-preserved cadavers were dissected at our academic institution from August 18, 2019 through February 5, 2020. Photographs of the cadavers were taken with permission from the anatomy laboratory manager using an iPhone 10 (Apple Inc., Cupertino, CA). Standard rhinoplasty views were taken of all ten cadavers. RESULTS: Grafts were harvested and designed from septal (80%), auricular (50%) and rib cartilage (40%). The division of depressor septi muscle was accomplished in all ten (100%) cadavers to address tip ptosis. Placement of the columellar strut and shield grafts resulted primarily in the improvement of nasal projection as well as rotation in all (100%) cadavers. Premaxillary augmentation was not always indicated but helped to improve an acute, retrodisplaced nasolabial angle in three (30%) cadavers. Lateral osteotomies via this approach addressed the nasal bony pyramid in all ten (100%) cadavers. The swinging door technique enabled correction of the caudal septum in six (60%) cadavers. CONCLUSIONS: Several rhinoplasty techniques can be successfully performed on cadavers via the sublabial approach and we hope this work can be translated to human subjects.

"Not Above, Not Below: Right in the Middle!"-Novel Filler Technique for Temporal Augmentation and Rejuvenation.

The temporal region is challenging to treat due to its thin skin, which has the propensity toward showing irregularities. The literature on temporal hollowing augmentation suggests placing the filler either into the subcutaneous space or within the temporalis muscle. However, these techniques have been based upon opinion rather than supporting anatomical and clinical data. We introduce a novel injection technique to avoid complications and achieve lasting results. This novel technique was confirmed with a cadaver model, in vivo model, and application to a human subject. The anatomical layers of the temporal region were highlighted: the skin, subcutaneous tissue, temporoparietal fascia (superficial temporal fascia), deep temporal fascia, superficial temporal fat pad, and temporalis muscle. Particular emphasis was placed on identifying the frontal branch of the superficial temporal artery to avoid vascular complications. We believe the potential space between the temporoparietal fascia and the deep temporalis fascia is the safest, most efficacious plane to inject the temporal region with a 27-gauge cannula. Our future goal is to recruit and present a larger series of patients receiving this injection.

Advanced Techniques for the Use of Neurotoxins in Non-Surgical Facial Rejuvenation.

BACKGROUND: Neurotoxins initially were used to treat hyperfunctional rhytids of the face, but now have been expanded to improve facial shaping, correct facial asymmetry and even improve skin texture and tone. METHODS: The clinical approach to non-surgical facial rejuvenation is approached into four anatomical regions: the upper face, midface, lower face and neck. RESULTS: The key muscles of the upper face include frontalis, orbicularis oculi, corrugator supercilii, procerus, depressor supercilii and temporalis. The muscles in the midface to be discussed include the levator labii superioris, levator labii superioris alaeque nasi, depressor anguli oris, depressor septi nasi and nasalis. Treatment of the lower face focuses on the orbicularis oris, mentalis, depressor anguli oris and masseter muscles. Finally, treatment of the neck region will be reviewed with emphasis on platysmal bands and necklace lines as well as the Nefertiti lift. CONCLUSIONS: Non-surgical facial rejuvenation using neurotoxins should be performed safely and effectively in order to avoid and treat complications. LEVEL OF EVIDENCE V: 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 .

Lip Augmentation.

This article examines 6 questions about lip augmentation answered by 3 experts in their field of facial plastic surgery. The topics covered include high-yield areas such as injection, surgical enhancement, rhytid resurfacing, implants, complications, and technique changes over the years. All the authors answered these questions in a "How I do it" manner to provide the reader with a true understanding of their thoughts and techniques. This article provides a practical resource to all physicians and practitioners performing lip augmentation on some of the most common questions and issues.

Three-dimensional Facial Anatomy: Structure and Function as It Relates to Injectable Neuromodulators and Soft Tissue Fillers.

BACKGROUND: The advent of new neuromodulators and soft-tissue fillers continues to expand the nonsurgical repertoire of the core cosmetic physician. METHODS: The authors review relevant facial anatomy as it relates to facial aging and the resultant structural changes that occur. These changes are important for the cosmetic physician to identify and understand in order to perform both safe and effective placement of neuromodulators and soft-tissue fillers. In this anatomic review, the authors review key structures that serve as landmarks for successful treatment using both neuromodulators and fillers. CONCLUSIONS: Knowledge of key facial anatomical structures allows the cosmetic physician to perform injection of neuromodulators and soft-tissue fillers in a reproducible manner to optimizing patient safety and results.

Injectable fillers for volume replacement in the aging face.

In recent years, there has been a better understanding of the aging process. In addition to changes occurring in the skin envelope, significant changes occur in the subcutaneous fat and craniofacial skeleton. This has led to a paradigm shift in the therapeutic approach to facial rejuvenation. Along with soft tissue repositioning, volumizing the aging face has been found to optimize the result and achieve a more natural appearance. Early in the aging process, when there has not been a significant change to the face requiring surgical intervention, fillers alone can provide minimally invasive facial rejuvenation through volumizing. Multiple injectable soft tissue fillers and biostimulators are currently available to provide facial volume such as hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, polymethyl methacrylate, and silicone. A discussion of the morphological changes seen in the aging face, the properties of these products, and key technical concepts will be highlighted to permit optimum results when performing facial volumizing of the upper, middle, and lower thirds of the face. These fillers can act as a dress rehearsal for these patients considering structural fat grafting.

Concurrent structural fat grafting and carbon dioxide laser resurfacing for perioral and lower face rejuvenation.

OBJECTIVE: To quantitatively evaluate a dual-modality treatment that combines autologous structural fat grafting and carbon dioxide (CO(2)) laser resurfacing for perioral and lower face rejuvenation. METHOD: Retrospective review of patients undergoing rejuvenation by a single surgeon between 2005 and 2009. A blinded expert rated photographs on three scales, each with a range of 1 (no abnormality) to 5 (severe abnormality): (i) perioral fine rhytids; (ii) deep folds; and (iii) pigmentary or cutaneous abnormalities. Within-subject comparisons were generated. Results were correlated with skin type (Fitzpatrick) and baseline photodamage (Glogau). A test for effect of adjunctive procedures was performed. RESULTS: Seventeen patients were included (all female, mean age 61 years). Significant postoperative improvement was noted for perioral fine rhytids (3.1 to 1.7, p < 0.0001); deep folds (3.4 to 2.0, p < 0.00001); and pigmentation (2.5 to 1.9, p = 0.02). Fitzpatrick skin type was inversely correlated with improvement in pigmentation scores (r = -0.78), while the Glogau score correlated with improvement of fine rhytids (r = 0.76). No significant effect of adjunctive procedures was found. No complications occurred, though fat grafts resorbed in one patient. CONCLUSIONS: Concurrent structural fat grafting and CO(2) resurfacing result in quantifiable improvement of perioral and lower face aesthetics in relation to baseline characteristics and independent of adjunctive surgical procedures.

Localization and histological characterization of injected hyaluronic acid in excised nasolabial fold tissue.

OBJECTIVE: To describe a technique for surgical correction of a prominent nasolabial fold (NLF) and use of the excised fold to assess the histology and localization of injected hyaluronic acid (HA) fillers. METHODS: Surgical correction was achieved by direct excision of the NLF, followed by advancement of the nasolabial fat compartment into the nasolabial crease. Excised tissue samples were injected with HA fillers (Restylane, Perlane, or layered Restylane/ Perlane), sectioned, and treated with histological stains. RESULTS: Surgical correction of NLF resulted in highly satisfactory results. HA localized primarily in the lower reticular dermis and subcutis of the excised NLF. Localization appeared similar regardless of the HA product employed. CONCLUSION: Direct excision of the NLF with advancement of the nasolabial fat compartment is a successful treatment for patients with deep NLF. HA injected into the excised tissue localized near the site of injection, emphasizing the importance of proper placement of HA fillers during soft tissue augmentation.

Injectable treatments for the aging face.

The use of injectable agents, specifically soft tissue fillers and botulinum toxin type A, has risen dramatically over recent years, due to the increased demand for minimally invasive techniques. In fact, today they represent the most commonly performed cosmetic procedures in the United States, with botulinum type A injections topping the list. In the treatment of the aging face, these agents, when used individually or in combination, can effectively decrease rhytids and restore lost volume. The result is a fuller, smoother, more youthful appearance. This article provides an overview of botulinum type A (Botox Cosmetic; Allergan, Inc., Irvine, CA) and the two injectable fillers most commonly used in our practice, namely hyaluronic acid (Restalyne; Medicis Aesthetics, Inc., Scottsdale, AZ) and human-derived collagen (Cosmoderm and Cosmoplast; Inamed Aesthetics, Inc., Santa Barbara, CA). Although we commonly use autologous fat as an injectable filler for facial-volume augmentation, its discussion is beyond the scope of this article. Conceptually, the aging face can be divided into upper, middle, and lower thirds. Using this framework, we will discuss our treatment strategies for addressing each facial region. General principles, preinjection evaluation, and specific approaches and techniques for each anatomic region will be discussed, with particular emphasis on the benefit of using dermal fillers in conjunction with botulinum toxin type A to achieve optimal aesthetic results for facial rejuvenation.