Safety and Efficacy of Non- and Minimally Irradiated Homologous Costal Cartilage in Primary and Revision Rhinoplasty.

Importance: Despite favorable results with conventionally irradiated homologous costal cartilage, there have been no clinical studies to date evaluating the utility of non- or minimally irradiated homologous costal cartilage (NIHCC) in rhinoplasty. Objective: To evaluate the safety and efficacy of NIHCC in primary and revision rhinoplasty. Design, Setting, and Participants: We conducted a retrospective medical record review of patients undergoing primary and revision rhinoplasty between January 2010 and December 2014. Twenty-six patients who underwent primary or revision rhinoplasty with NIHCC were identified. Patient follow-up ranged from 2 to 43.2 months (mean 15.9 months) at the study took place in a single-center private practice, and surgery was performed by the two senior authors. Twenty-seven consecutive patients who underwent primary or revision rhinoplasty for functional and/or cosmetic concerns with NIHCC were identified. One patient was excluded due to concomitant use of GORE-TEX, leaving 26 patients for retrospective review. Seven patients underwent primary rhinoplasty and 19 patients underwent revision rhinoplasty. Main Outcomes and Measures: The purpose of this study is to demonstrate whether non- or minimally irradiated homologous rib cartilage used for primary and revision rhinoplasty has acceptable rates of warping, resorption, and infection. Results: A total of 26 patients underwent surgery with NIHCC; 20 (77%) were women, and the average patient age was 42 years (median 45 years). A total of 100 NIHCC grafts were used. Seven patients underwent primary rhinoplasty and 19 (73%) patients underwent revision rhinoplasty. The total complication rate related to grafts was 3.6%, which included 2 cases of partial noninfective resorption of 77 palpable or superficial grafts (2.6%), 1 infection of 100 grafts (1.0%), and zero cases of graft mobility and warping. Conclusion and Relevance: Non- or minimally irradiated homologous costal cartilage is safe and effective for grafting in primary and revision rhinoplasty, with low rates of resorption, infection, mobility, and warping. Further larger studies will need to be conducted to determine whether or not the reduced radiation improves outcomes compared with traditionally radiated homologous cartilage.

Effects of Intravenous Tranexamic Acid During Rhytidectomy: A Randomized, Controlled, Double-Blind Pilot Study.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent shown to decrease intraoperative bleeding, reduce transfusions, and improve outcomes across multiple specialties. Within plastic surgery, initial reports are encouraging but formal studies are lacking. OBJECTIVES: The aim of this study was to determine whether intravenous (IV) TXA has any effect on intraoperative bleeding or postoperative sequelae in patients undergoing a deep-plane facelift. METHODS: This is a prospective, randomized, double-blind, case series in a private practice surgery center. The participants were 44 patients undergoing rhytidectomy with the senior authors (R.A.G. or M.J.G). The treatment group received a 1-g dose of IV TXA prior to skin incision and the same dose 4 hours later (vs saline). Bleeding was rated mild, moderate, or severe. Postoperative ecchymosis and edema were subjectively evaluated by patient and surgeon and scores were aggregated for analysis. RESULTS: The TXA group showed decreased intraoperative bleeding but this difference did not reach statistical significance. Postoperative ecchymosis/edema ratings were lower for patients who received TXA, including a statistically significant decrease in surgeon-rated bruising. TXA resulted in a statistically significant decrease in postoperative collections in this study and no major complications occurred. CONCLUSIONS: TXA is a safe, low-cost addition to any existing surgical protocol and may lead to fewer surgical sequelae and improved satisfaction. Although we did not observe a dramatically different intraoperative experience, postoperative bruising and collections were significantly reduced. TXA acid may have great value in the management of patients undergoing rhytidectomy and its use warrants further study.

Direct Excision of the Lower Eyelid: A Safe and Effective Method for Treating Dermatochalasis and Pigmentation.

The subciliary and skin pinch approaches are the most widely accepted techniques for treating dermatochalasis of the lower eyelid. Direct excision (DE) is an accepted method for treating festoons; however, it is not a popular technique for the treatment of dermatochalasis and pigment of the lower lid. DE of the lower lid offers a safe and excellent aesthetic result for dermatochalasis and pigment of the lower lid, without causing lower lid malposition, which can occur with more traditional methods. In addition to being able to remove significantly more skin without risking lower lid malposition, this procedure allows for removal of the most pigmented and poorly textured skin overlying the nasojugal groove. It is an effective alternative to the conventional subciliary and skin pinch approaches.

Analysis of Facial Aesthetics as Applied to Injectables.

Understanding the role of volume loss in the aging face has resulted in a paradigm shift in facial rejuvenation techniques. Injectable materials for volume restoration are among the most widespread cosmetic procedures performed. A new approach to the aesthetics of facial aging is necessary to allow the greatest improvement from volumetric techniques while maintaining natural appearing results. Examining the face in terms of facial frames and facial shadows provides the fundamental basis for our injectable analysis.

Midface sculpting with autologous fat.

There is currently a major paradigm shift from excision-based surgery to strictly volume enhancement. Because there is still no perfect facial filler, development of synthetic facial injectables continue to advance at a remarkable pace. Each type of filler carries a specific characteristic that makes it more suitable for a certain clinical application. The continuing change in facial fillers offers the possibility for volume augmentation procedures with less downtime and without the need for harvesting fat. We predict that volume enhancement will continue to play an increasing role as both a complementary and as a stand-alone procedure in facial rejuvenation.

Volume rejuvenation of the facial upper third.

The next three articles in this issue take a unique approach to discussing volumetric restoration. Robert Glasgold has provided an assessment for each facial region and five different renowned authors (TK, SPS, RF, SML, and EFW) have been asked to speak on a particular volumetric product, of which they are considered an expert, as it applies to the different regions of the face. The articles are broken into the following: (1) upper third which corresponds to the upper eyelid, brow, temple, and forehead; (2) middle third which will cover lower eyelid, cheek, and perioral area; and (3) lower third which discusses the marionette, prejowl, and jawline. Our hope is that by placing differing opinions of experienced authors, organized by facial region together, the reader will have the opportunity to more readily compare the options. The contributing authors and their product area are as follows: Theda Kontis, MD-hyaluronic acid; Steve Smith, MD-calcium hydroxyl appetite; Rebecca Fitzgerald, MD-poly-L lactic acid; Sam Lam, MD-polymethyl methacrylate; and Edwin Williams, MD-Autologous Fat Transfer. If the author included general comments on the product, they are included in the article on the upper face only and are not repeated. Please note that other individuals may also have significantly assisted in the production of these articles, but those listed above are the senior authors.

Volume management of the middle third-lower orbit/midface.

This is the second of the three articles discussing volumetric rejuvenation of the face. The previous article, Volume Rejuvenation of the Facial Upper Third, focused on the upper one-third of the face while this article focuses on the middle one-third, primarily the lower eyelid, cheek, and perioral area. Again, the authors (RG, TK, SPS, RF, SL, and EFW) from the upper face article have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Volume rejuvenation of the lower third, perioral, and jawline.

This is the third and final article discussing volumetric rejuvenation of the face. The previous two articles, Rejuvenation of the Upper Third and Management of the Middle Third, focused on the upper two-thirds of the face while this article focuses on the lower face, including the marionette area, jawline, and neck. Again, the authors of the previous two articles have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Autologous fat grafting for midface rejuvenation.

The authors have been performing autologous fat grafting for facial rejuvenation for 15 years and the procedure has evolved significantly during this time. In the beginning, the authors were primarily transferring to nasolabial folds, lips, and cheeks and found that the only patients who were satisfied with the procedure were cheek patients. To this day, the authors maintain that for isolated filling of lips and nasolabial folds, off the- shelf fillers are a better alternative. The authors treat these areas, however, as part of a current philosophy of smaller volumes over larger areas. In the early 2000s, the understanding of the volumetric nature of the aging process began to gain traction and global volumetric treatment became the authors' standard therapy. During that time, the authors developed a technique that led to an algorithmic approach to the surgery that allowed standard reproducible results for all surgeons. With the greater adoption of volumetric rejuvenation, an era of "more volume is better" has been entered, which is producing unnatural results. The authors' theory of facial shadow patterns explains more precisely why volume leads to facial rejuvenation and the understanding necessary to produce subtle more natural results. Currently, the authors are interested in quantitatively documenting results and evolving autologous fat transfer to a more predictable procedure.

Long-term volumetric retention of autologous fat grafting processed with closed-membrane filtration.

BACKGROUND: Some practitioners have criticized the unpredictable retention associated with autologous fat transfer. Potential causes of variations in predictability include intrinsic (patient-related) or extrinsic factors, such as harvesting, processing, and graft-delivery technique. OBJECTIVES: The authors sought to determine the long-term retention of autologous fat graft processed with a closed-membrane filtration system, to compare this retention with centrifuge-processed fat, and to analyze factors that affect graft retention. METHODS: This was a prospective analysis of 26 female patients (representing 52 hemi-midfaces) who underwent autologous fat transfer to the midface via the closed-membrane filtration system. The Vectra 3D camera and software were employed for all photography, which was then analyzed to compare immediate preoperative images with long-term follow-up images (obtained at least 10 months postprocedure). The authors compared the findings with data from their previous study of centrifuge-processed fat grafts (historical controls). RESULTS: Mean values were as follows: age, 55 years; follow-up period, 17 months; amount of autologous fat injected, 8.88 mL; absolute volume augmentation measured at the last postoperative visit, 3.71 mL; and retention, 41.2%. Results of Welch's t test, in which the membrane-filtration data were compared with the previous centrifuge data (31.8% long-term retention), showed a significant difference (P=.03). Retention in this study was significantly higher in patients younger than 55 years (53.0% vs 31% for older patients; P=.001) and lower in patients who underwent rhytidectomy (23.8% vs 47.6% for nonrhytidectomy patients; P<.001). CONCLUSIONS: Autologous fat processed by closed-membrane filtration had a significantly higher long-term retention rate than did centrifuged-processed fat injected by the same surgeons. LEVEL OF EVIDENCE: 3.

3D photography in the objective analysis of volume augmentation including fat augmentation and dermal fillers.

The authors present quantitative and objective 3D data from their studies showing long-term results with facial volume augmentation. The first study analyzes fat grafting of the midface and the second study presents augmentation of the tear trough with hyaluronic filler. Surgeons using 3D quantitative analysis can learn the duration of results and the optimal amount to inject, as well as showing patients results that are not demonstrable with standard, 2D photography.

Fat harvesting techniques for facial fat transfer.

Fat grafting has become popular as a stand-alone technique or as part of a combined procedure for facial rejuvenation, as volume restoration has increasingly become recognized as an important component in overall facial aging. Many facial plastic surgeons who are experienced in operating only in the head and neck region are unaccustomed to working elsewhere in the body. Accordingly, this article sets out to detail the specific technique for safe and effective lipoharvesting for facial fat transfer. In addition, site-specific considerations for the lower abdomen, inner/anterior/outer thighs, triceps, inner knee, buttock, and lower back are also discussed.

Volumetric rejuvenation of the periorbital region.

Volumetric rejuvenation of the periorbital region is based on an analysis of the aesthetics of the attractive youthful eye contrasted with the typical characteristics of aging. Traditional rejuvenation techniques emphasized fat and skin removal leading to "done" appearing results. The incorporation of volume with these techniques based on the specific analysis of volume loss produces more natural appearing true rejuvenation.

Quantitative evaluation of volume augmentation in the tear trough with a hyaluronic Acid-based filler: a three-dimensional analysis.

BACKGROUND: Despite the prevalent use of hyaluronic acid-based filling materials for facial soft-tissue augmentation and favorable reports of durability in the infraorbital region, no quantitative data exist on the long-term durability of these products following injection. This study represents the first attempt to use three-dimensional imaging to quantify augmentation achieved and duration of effect with one hyaluronic acid product in the tear trough. METHODS: The authors conducted a prospective, blinded case series in a clinical setting. One non-animal stabilized hyaluronic acid material was used to augment 20 tear troughs to address cosmetic deficiency in this region. Patients were followed long term with three-dimensional imaging. Posttreatment and pretreatment images were compared, volume change was calculated at each time point, and percentage change between immediate and long-term posttreatment was evaluated. All measurements and calculations were performed independent of the injector. RESULTS: Residual effect from the hyaluronic acid product was demonstrable on three-dimensional imaging in 100 percent of tear troughs augmented in this study at the final follow-up visit. Average follow-up was 14.4 months (range, 8.5 to 22.75 months). Average initial augmentation measured by three-dimensional imaging was 0.21 cc per site. Average maintenance of effect for patients at the final follow-up visit was 85 percent. CONCLUSIONS: The long-term durability of a small gel particle-based hyaluronic acid in the tear trough is substantiated for the first time in an objective, quantitative fashion using three-dimensional imaging for evaluation of volumetric facial rejuvenation. Three-dimensional photographic imaging offers clinicians a precise and expeditious method for quantitatively evaluating volumetric changes in the face, and represents a significant advance in technology for studying the effects of facial aging.

Complications following fat transfer.

Traditionally, strategies for facial rejuvenation have emphasized correction of tissue ptosis and laxity with suspensory and excisional techniques, such as face-lifting and blepharoplasty. Volume loss plays a significant role in facial aging and, until recently, had not received appropriate attention. Facial fat grafting to correct volume loss has become a crucial component of facial rejuvenation in the authors' respective practices.

Autologous fat grafting: long-term evidence of its efficacy in midfacial rejuvenation.

OBJECTIVE: To provide quantitative objective data demonstrating the longevity and amount of volume augmentation in the midface obtained with autologous fat grafting. METHODS: A prospective analysis of all patients who underwent autologous fat transfer to the midface region at our private practice and were followed up for at least 1 year. Three-dimensional imaging was performed with a Canfield Scientific Vectra camera and software, with quantitative volume measurements evaluating the amount of postoperative volume change. RESULTS: Thirty-three patients (66 hemiface-midface regions) were included in the study. The mean follow-up time was 16 months. The mean amount of autologous fat injected into each midface region was 10.1 mL. Overall, the mean absolute volume augmentation measured at their last postoperative visit was 3.3 mL (31.8% take). There was variability between patients in the volume amount and percentage that remained. Touch-up procedures were performed in 8 patients. CONCLUSIONS: To our knowledge, this study is the first clinical quantification of autologous fat transfer and/or grafting in the literature that provides definitive evidence on the amount as well as the resultant longevity in the midface. Autologous fat transfer to the midface has definite long-term volume augmentation results. On average, approximately 32% of the injected volume remains at 16 months. However, some variability exists in the percentage of volume that remains that may require a touch-up procedure.

Limitations, complications, and long-term sequelae of fat transfer.

Facial fat transfer has become one of the most potent methods for facial rejuvenation. The two notable problems that have limited its widespread acceptance are the perceived absorption and dissipation of the transplanted fat and the risk of difficult complications such as lumps and bulges along the periorbital expanse. This article discusses these concerns and the long-term sequelae, particularly derivative benefits beyond volume contour changes such as textural improvements in the skin, ongoing improvements in the appearance of the grafted fat after months to years, and other structural changes.

Volume restoration and facial aesthetics.

This article discusses the rationale for the use of volume restoration to restore natural, youthful contours to an aging face. Topics discussed include the discrepancy that can exist between patients' stated wishes and optimal results and the concepts of framing the eye, creating highlights, and restoring facial shape and volume.