Nonsurgical Tissue Repositioning: Analysis of Long-Term Results and Patient Satisfaction From 100 Absorbable Suture Suspension Cases.

BACKGROUND: Absorbable suspension sutures are the only nonsurgical modality approved for tissue repositioning. OBJECTIVES: To quantitate patient perceptions of treatment at 24 months and determine the impact of age and prior surgical procedures on perceptions of efficacy, treatment longevity, and overall satisfaction. In addition, the authors sought to describe the impact of treatment with absorbable suspension sutures on the likelihood a patient will undergo future surgical procedures. METHODS: The first 100 treated patients who underwent treatment with absorbable suspension sutures, by the senior author, were critically evaluated. Subjects completed surveys 24 months following initial treatment. RESULTS: Of the initial 100 patients, complete records were available for 80 patients (age 39-86). Eighteen (22.5%) received a second treatment with absorbable suspension sutures and average time to second treatment was 23.4 months (range 13-37 months). Overall satisfaction was affected by age, 100% of patients ≤ 50 vs. 60% of patients > 50 (P = 0.026). Prior surgery appeared to be a factor in patient perception of efficacy: 82.6% of patients with no prior surgery indicated that absorbable suspension sutures were effective vs. 45.5% of patients with a prior surgical procedure (P = 0.0286). Just under one third of pretreatment surgical patients underwent surgery following treatment while 25% of surgery naïve patients went on to have surgery. Importantly, satisfaction with the initial procedure does not preclude later surgery. CONCLUSIONS: Treatment with absorbable suspension sutures is associated with high satisfaction through 24 months and does deter patients from surgery. The combination of lift and volumization results in 4-dimensional rejuvenation that includes rejuvenation of dynamic expression.

Practical Guidance for Optimizing Patient Comfort During Microfocused Ultrasound with Visualization and Improving Patient Satisfaction.

BACKGROUND: Microfocused ultrasound with visualization (MFU-V; Ultherapy®) is an effective method for correction of skin laxity through lifting and tightening skin on the face, neck, and décolleté as well as on other parts of the body such as the knees, arms, and abdomen. In addition to being a noninvasive modality for tissue tightening, MFU-V has a biological effect on tissue, rejuvenating the skin through stimulation of elastogenesis and neocollagenesis. MFU-V is also commonly combined with other interventions such as fillers, neuromodulators, and absorbable suspension sutures. OBJECTIVES: The aim of this study was to share the extensive experience of the authors in optimizing comfort for their MFU-V patients in order to provide guidance to the broader community surrounding optimal patient comfort with this procedure. METHODS: The authors discuss their approaches to patient comfort and satisfaction. Elements of each approach include patient selection, pharmacologic and nonpharmacologic comfort measures, and how prioritization of patient comfort affects both their individual patients and practices. RESULTS: The authors share their approaches for optimizing patient comfort during the procedure and provide an overview of both pharmacologic and nonpharmacologic measures that can be adopted to support patient comfort and satisfaction. The similarities and differences of each approach are discussed. CONCLUSIONS: In addition to diligent patient selection, the authors find that attention to patient comfort is directly related to satisfaction and appears to be a primary factor in patients' decisions to return for additional treatments.

Advancing the Care of Post-Acne Scarring: Expert Insights Into New Treatment Options.

Most patients with acne have some degree of facial scarring even after their acne resolves, extending the period of psychosocial distress. Unfortunately, management of acne scars remains challenging. Many treatments for post-acne scarring including chemical peels, skin needling, laser resurfacing, surgical repair, subcision lifting, and punch elevation lifting, are limited by moderate and unpredictable results, significant morbidity, and substantial patient investments in time and money. The most recent addition to the armamentarium is tissue augmentation with soft tissue fillers, including a recently approved polymethylmethacrylate-collagen filler. Matching individual patient needs to the appropriate treatment is crucial. While many patients with acne scars have unrealistic expectations about treatment outcomes, open, honest, and realistic dialogue regarding their treatment options and concerns can facilitate realistic expectations. This article is based on a consensus discussion by the authors, who all have experience managing post-acne scarring, as well as the content of a series of live CME-accredited symposia in connection with major dermatology meetings.

J Drugs Dermatol. 2016;15(5):518-525.

Facial Aesthetic Surgery: The Safe Use of Oral Sedation in an Office-Based Facility.

BACKGROUND: The desire for efficient and safe office-based facial plastic surgery procedures has continued to rise. Oral sedation is a safe and effective method to provide anesthesia for facial aesthetic surgery. OBJECTIVES: This study reviewed private practice anesthesia-related outcomes using oral sedation combined with local anesthesia for office-based facial aesthetic surgery procedures. METHODS: A retrospective chart review was performed on all patients who underwent office-based facial plastic surgery procedures from July 2008 to July 2014. Patient demographic data including age, gender, body mass index (BMI), past medical history, social history, surgical history, allergies, and medications were collected. Anesthesia-related data were also collected including: American Society of Anesthesia (ASA) class, type of procedure, medications administered, and major complications related to sedation were assessed. RESULTS: There were 199 patients (23 males and 176 females) who underwent 283 facial aesthetic surgical procedures. Mean age was 49.8 years (range, 29 to 80 years). There were 195 patients in ASA class I and 4 patients were in ASA class II. Patients underwent 44 upper blepharoplasty procedures, 35 lower blepharoplasty procedures, 5 browlifts, 43 upper blepharoplasty-browpexy, 46 facelifts, 38 neck lifts/lower facelifts, 54 fat grafting, 3 tip rhinoplasties, and 15 minor revision cases. During the study period, there were no major complications and no sedation issues. CONCLUSIONS: Facial aesthetic surgical procedures can be performed safely and comfortably in the office-based setting under oral sedation in appropriately selected patients. LEVEL OF EVIDENCE 4: Therapeutic.

A novel, multistep, combination facial rejuvenation procedure for treatment of the whole face with incobotulinumtoxinA, and two dermal fillers- calcium hydroxylapatite and a monophasic, polydensified hyaluronic acid filler.

Facial aging is a three-dimensional process, and facial rejuvenation procedures intended to reverse the effects of aging need to address this by combining products that relax hyperkinetic musculature, volumize/fill, and recontour/lift the whole face. In line with the desire of patients to achieve an overall youthful facial appearance, we report for the first time three cases where patients have been successfully treated across the whole face with a novel, three-step approach, layering incobotulinumtoxinA and two dermal fillers (calcium hydroxylapatite and a monophasic hyaluronic acid filler with CPM Technology) injected at three separate treatment visits. The results suggest that this layering approach based on an understanding of the underlying causes of facial aging, where different products are used in combination to treat the entire face, can enable patients to achieve the desired outcome of a return to the characteristics of a more youthful face.

Current aesthetic use of abobotulinumtoxinA in clinical practice: an evidence-based consensus review.

The amount and complexity of scientific and clinical evidence for aesthetic use of botulinum neurotoxin type A (BoNT-A) has expanded rapidly in recent years, especially for abobotulinumtoxinA, necessitating reassessment of current knowledge about aesthetic use of abobotulinumtoxinA and other BoNT-A preparations. A committee of 13 plastic surgeons, facial plastic surgeons, and dermatologists engaged in a live discussion of information from a systematic literature review and an Internet-based survey of their beliefs and practices. The committee achieved consensus on most issues. It was concluded that doses of different BoNT-A preparations cannot be interconverted with a fixed ratio. The size of the "field of effect" is difficult to measure, and comparisons between preparations have yielded equivocal results. Nonresponse due to neutralizing antibodies appears exceedingly rare with currently available BoNT-A preparations and of little concern clinically. BoNT-A dose, injection depth, and injection technique should be adjusted according to the anatomic area being treated and each patient's individual characteristics and goals. Aesthetic use of BoNT-A has a good safety profile. Most adverse events are minor and related to the trauma of injection, although special care is needed in certain anatomic areas. Detailed recommendations for treatment of different anatomic areas are presented. BoNT-A products are often used in conjunction with other treatment modalities (eg, fillers and resurfacing), but little agreement was reached on best practices. The findings reported in this consensus document may serve as a practical guide for aesthetic practitioners as they apply the latest knowledge about BoNT-A in providing their patients with optimal care.

The transconjunctival deep-plane midface lift: a 9-year experience working under the muscle.

BACKGROUND: Rejuvenation of the midface with a natural-looking, safe, and long-lasting result is a challenge in aesthetic surgery. The ideal approach should be easy to perform, with minimal risk and significant benefit. The combination of transconjunctival exposure and preservation of the periosteum may result in lower morbidity than traditional midface rejuvenation. OBJECTIVES: The authors present their 9-year experience with the transconjunctival deep-plane midface lift (TDML) and discuss the benefits and limitations of this procedure relative to traditional approaches. METHODS: A retrospective review (2000-2009) was conducted of 124 consecutive patients treated by the same surgeon (JWF) with the TDML approach. The technique combines transconjunctival and preperiosteal dissection under direct vision. Collected data included patient demographics, operative technique, concomitant procedures, and postoperative results. Complications and revisions were reviewed to assess safety and long-term efficacy. RESULTS: Patients included 97 women and 27 men, with a minimum of 13 months of postoperative follow-up (median, 56 months). The mean operating time for upper blepharoplasty with TDML was less than 150 minutes. No significant complications occurred. One patient required reexcision of redundant lower eyelid skin, and another patient underwent secondary excision via traditional midface lift. CONCLUSIONS: The TDML procedure is safe and effective. The technique is readily applicable and more "forgiving" than the traditional midface lift. With proper patient selection, the limited soft-tissue dissection reduces surgical morbidity. Patients with excessive skin redundancy or festoons should be treated with more traditional techniques.

Rejuvenation of the african american periorbital area: dynamic considerations.

The rejuvenation of the African American periorbit is rooted in select modifications of traditional techniques. The African American patient presents with dynamic considerations and needs. Whereas this subset is at risk for pigmentation and scar concerns, the natural resistance to actinic damage makes rejuvenation efforts rewarding. We will review the composite that makes up the periorbit, the brow, upper eyelid, lower eyelid/lateral canthus, and the midface unique. Specific indications and presurgical and postsurgical considerations will be presented in addition to technical considerations to manage periorbital aging that spares the skin. Common pitfalls and succinct ways to avoid them without compromising on the ultimate end result will be presented. Ultimately, periorbital rejuvenation can be done completely without jeopardizing one's ethnic identity.

Periorbital aging and ethnic considerations: a focus on the lateral canthal complex.

BACKGROUND: There is a general perception that skin from various ethnic groups possesses different properties that may affect barrier function, responsiveness to topical agents, sebum production, chemical sensitivities, and aging changes. The first noticeable signs of facial aging are frequently localized to the upper face, brow, and eyes. The authors postulate that a greater relative descent of the lateral canthal complex in African Americans contributes to periorbital aging more so than in Caucasians. METHODS: The photographic archives of the senior plastic surgeon (J.W.F.) were reviewed. Two hundred ninety-six cases met inclusion criteria. Lateral canthal angles were measured, and the angle assigned to each patient was an average of the right and left lateral canthal angles. RESULTS: Statistically significant intrarace differences were found for the lateral canthal angle. The median lateral canthal angle for African American patients decreased from 3.00 degrees for those aged 45 years or younger to 1.15 degrees for African American patients older than 45 years (p = 0.03). The median lateral canthal angle for Caucasian patients decreased from 2.30 degrees for those aged 45 years or younger to 1.30 degrees for Caucasian patients older than 45 years (p = 0.00). When the data were age-matched, with 25 subjects in each group, the differences increased. CONCLUSIONS: In comparing young and aged cohorts, African American women demonstrate a more dramatic attenuation of the lateral canthal complex than their Caucasian counterparts. It appears that the lateral canthal complex has been underappreciated, and it is a vital component to periorbital rejuvenation.

Modern endovascular and aesthetic surgery techniques to treat arteriovenous malformations of the scalp: case illustration.

BACKGROUND: Arteriovenous malformations of the scalp consist of abnormally connecting arterial feeding vessels and draining veins, devoid of a normal capillary bed within the subcutaneous fatty layer of the scalp. We present a case of a left temporal scalp AVM treated for aesthetic and pain-related concerns. A multidisciplinary approach combining endovascular AVM embolization and AVM excision with local flap reconstruction was chosen. CASE DESCRIPTION: The patient presented with a progressive painful pulsatile mass in the left temporal region. On examination, there was no evidence of any facial nerve compromise or any other neurologic deficits. Computed tomographic angiography revealed a 6-mm lesion located totally within the scalp and not associated with bone or periosteum. A recommendation was made to proceed with preoperative embolization to facilitate surgical resection. The AVM was occluded endovascularly using multiple detachable platinum coils, and the patient was neurologically intact. The following day, the patient was taken to the operating room. By that time, the mass was minimally pulsatile. The AVM was resected en bloc, and a 3-layered intermediate closure of the 5.5-cm defect was then performed. The procedure was well tolerated, and the patient had an uneventful postoperative course. CONCLUSIONS: Scalp AVMs are interesting lesions with heterogeneous anatomical features. Treatment can be optimized in a multidisciplinary environment, using a prescribed treatment algorithm to minimize the size of soft/hard tissue defect and enhance cosmesis. Careful selection of therapeutic modalities based on AVM anatomy and aesthetic concerns can lead to safe and durable results with high patient satisfaction rates.