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CST Editorial Advisory Board
Tina Alster, M.D., is the founding director of
the Washington Institute of Dermatologic Laser
Surgery and clinical professor of dermatology at
Georgetown University. She is a world-renowned
lecturer and author on the subject of cosmetic
laser surgery.
Steven Fagien, M.D., F.A.C.S., is an
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surgeon with private practice in Boca Raton,
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and injectable agents for facial aesthetic
enhancement.
James Carraway, M.D., specializes in plastic and
reconstructive surgery and is professor, division
of plastic surgery, and chairman, division of
plastic surgery, at Eastern Virginia Medical
School.
David H. McDaniel, M.D., practices cosmetic
dermatology and directs the Institute of AntiAging Research in Virginia Beach, Va. He is
certified by the American Board of Dermatology
and serves as assistant professor of clinical
dermatology at Eastern Virginia Medical School,
as well as co-director of the Hampton University
Skin of Color Research Institute and adjunct
professor in the School of Science at Hampton
University.
Joe Niamtu III, D.M.D., F.A.A.C.S., is a boardcertified oral and maxillofacial surgeon with
a practice limited to facial cosmetic surgery in
Richmond, Va.
®
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EDITORIAL
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Academy of Cosmetic Surgery and is in private
practice in Sacramento, Calif. He completed
his surgical training at Johns Hopkins Medical
Institutions and has served in faculty positions at
Johns Hopkins and the University of California,
Davis.
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COSMETIC SURGERY TIMES
4
One size doesn’t fit all
Surgeons share their opinions about success with short-scar facelifts
Q: What percentage of the facelifts you
perform is traditional versus short-scar? Why?
Mike Nayak, M.D.
St. Louis
“As a facial plastic surgeon, facelifting is a
central part of my practice. When possible,
I — and patients — prefer the short-scar techniques. Short-scar techniques
generally utilize an anterior-only
incision, or, less commonly, a
posterior-only incision. While
shorter scars are appealing, the
limited incision lines themselves
limit the access to the face and
Dr. Nayak
neck and also limit skin-excision
options. Given these limitations, only about one
in five patients is a good candidate for a shortscar lift.
“In my practice, a good short-scar lift candidate
is a patient with excellent skin tone and elasticity
who needs limited improvement of the jawline
only, or a patient with excellent skin tone and
elasticity in need of improvement of the neck
only. The anterior-only short-scar technique
allows for thorough treatment of the jowls with
only modest neck improvement, and the posterior-only technique allows for excellent treatment of the neck with modest jowl improvement.
“Due to the shorter incisions, the vectors of
skin excision are limited, and I must rely on the
skin’s elasticity to accommodate the excess
in some dimensions. When elasticity is poor
or skin quality is crepey, a full anterior and
posterior incision approach allows for complete
redraping and tailoring of this skin. On occasion,
the degree of laxity and inelasticity is surprising
intraoperatively, and I obtain permission from all
of my short-scar facelift patients to convert to a
full-incision technique if necessary during the
surgery.
“Interestingly, as my practice develops, I find
myself utilizing the short-scar techniques
more infrequently. Well-healed incision lines
are generally not cosmetically objectionable,
and to achieve excellent redraping and incision approximation, it is often desirable to
make longer incisions to allow for appropriate
Burrow’s triangle tailoring. While these longer
incisions take longer to close, the access they
afford generally lends efficiency to the deeper
portions of the face- and necklift. Due to that
efficiency, I generally find that the longer-scar
approaches take me no longer to perform than
the short-scar techniques.
“On balance, I find the best feature of the shortscar techniques to be their patient appeal, and
it is for this reason I continue to offer them. In
the appropriate patient, a short-scar facelift can
create an amazing change, with less dissection
and less recovery.”
Brett Kotlus, M.D., M.S.
Shelby Township, Mich.
“It’s a familiar scenario when a prospective
patient interested in lower facial rejuvenation asks about a television
commercial touting a one-hour
facelift. These infomercials
feature powerful images with
smiling faces, but a mini-facelift
can only produce smile-worthy
results in a subgroup of patients.
Dr. Kotlus
“The term ‘mini’ evokes feelings of something safer, faster and (perhaps)
better. Most people find it hard to digest the
idea that they might require a full facelift. They
don’t see themselves as having aged. Youthful
times don’t seem that long ago. From the ego’s
perspective, a mini-procedure offers an acceptable compromise.
“Approximately 10 percent of my facelift
patients undergo a mini- or short-scar procedure. In my experience, the patient best-suited
for a mini- or short-scar lift exhibits mild-tomoderate aging signs along the mandibular
line with mild or absent platysmal laxity, and
lacks a ‘heavy neck.’ When I identify substantial
subplatysmal adiposity and central platysmal
bands, I recommend submentoplasty with a
corset technique. I don’t find that a short-scar
lift with a lateral platysmaplasty is as powerful
or sustainable in regard to cervicomental
contouring.
“While a shorter scar has a certain appeal,
implying less downtime and fewer reminders of
surgery once healing has taken place, in facelift
surgery, the incision should provide sufficient
access to the tissues that require manipulation.
The scar should also be long enough to allow for
skin redraping and closure without excessive
pleating. A patient with advanced aging signs
and profound skin redundancy may require a
longer scar than one with isolated early jowls.
“It is fortunate that natural anatomic creases
exist on the face, and when they are properly
utilized and respected, the remnants of facelift
incisions are not obvious, assuming optimal
wound-healing conditions are present. For
patients with long hair in particular, the retroauricular suclus and hairline are ideal locations to
disguise scars.
“While most of my patients require a full lift,
those who are short-scar candidates are generally quite pleased with the procedure, as they
do seem to experience less downtime.”
Joe Niamtu III, D.M.D.
Richmond, Va.
“Contemporary facelift surgery has its roots in
numerous procedures that have evolved over
the past century. Although
short-scar facelifts are all the
rage now, they are, in fact,
exactly the same as facelifts
performed in the 1920s. I
saw a TV commercial about a
‘revolutionary, new and easy
Dr. Niamtu
technique. Drive home from the
surgery, no anesthesia, no bandages, go back
to work in two days.’ I have an article from a
1927 French textbook that shows a short-scar
JUNE 2011
5
facelift with purse-string sutures! Sorry, not
new or revolutionary.
“I actually have a bone to pick with these ‘franchise facelifts,’ as I call them. My criticism is
not with the surgeons who perform them, as
they are probably competent surgeons, but I
think the marketing for many of these types of
lifts is misleading and preys on patients who
truly need a more comprehensive facelift but
are falsely led to believe that this century-old
facelift is some new ‘miracle’ technique. Like
many of my colleagues, I have seen many
unhappy patients who got this small lift when
in fact they needed a much larger lift. Now
they are left with bagging and sagging and no
recourse from the iron-clad small print of the
franchise. They are mad and embarrassed that
they were sold a bill of goods, did not do their
homework, still need a real facelift and are out
of thousands of hard-earned dollars.
“Having said this, I do feel that short-scar lifts
are appropriate for a very small percentage of
the population, and by that I mean patients
from 38 to 42 years of age and only if they have
minimal neck-skin redundancy. I think these
lifts do have a place for the most conservative
of aging. I do believe they improve the jowl, but
they are seriously lacking for the average aging
neck.
“I also think they are a fine lift for the novice
facelift surgeon who is learning facelift technique. The big problem is that many doctors
learn this type of lift and try to apply it as a sole
technique. If this is performed on the average
45-year-old, the result will suffer.
“I firmly believe that it is impossible to truly
and effectively address the ptotic and elastic
cervical and submental skin without a significant postauricular incision. I find it almost
humorous that many surgeons go so far out
of their way to try to find some technique to
avoid a 5 cm posterior-auricular scar that is
well hidden in the hairline. Most surgeons also
avoid platysmaplasty in this type of lift, and
again, I feel that this short changes the average
patient in terms of result and longevity. I also
believe this type of lift is popular because many
surgeons do not have the ability (in terms of
facility or anesthesia experience or support) to
perform sedation, and these small lifts can be
done with local anesthesia.
“I perform 60 to 80 facelifts a year, and of
these only one or two patients get short-scar
lifts. My reason is simple: The average patient
who has enough aging for a facelift will have
a much better result that lasts longer with
traditional pre- and postauricular incisions with
platysmaplasty and conventional SMASec-
tomy. Even patients with minimal neck skin
are left with unsightly skin bunching behind
the ears and mastoid region that takes many
months to dissipate.
Academy of Cosmetic Surgery. Dr. Nayak reports no relevant
financial interests.
“I am obviously opinionated on this subject,
but my opinions are based on a series of
almost 700 facelift procedures. If a patient is
going to put the time, effort and money into
a facelift, they might as well select one that
will do the most and last the
longest. To forego a traditional
lift to save several inches of
incision or shorten recovery
by five days is not a deal in my
mind when compared to the
more comprehensive result
they could have.
Joe Niamtu III, D.M.D., is a board-certified oral and maxillofacial surgeon who limits his practice to cosmetic facial
surgery. He is a fellow of the American Academy of Cosmetic
Surgery and author of the textbook Cosmetic Facial Surgery.
Dr. Niamtu reports no relevant financial interests.
“In reality, the best type
of facelift is the one that
produces safe and effective
results with happy patients.
This also depends on the type
of practice one has and the
age of their patients. Some
docs love these short-scar
lifts. They are contraindicated
on my average facelift patient
and I believe they are a bit
gimmicky.
“Having said that, it is up to
each surgeon to provide what
works best for them and their
patients. Just don’t promote
this technique as revolutionary or overhype what it
does, as it can come back
and bite you. If you promise
a maximum result with a tiny
lift and can’t deliver it, you will
drive patients away.
“Not every patient can have
a larger lift for numerous
reasons, such as health, cost
or recovery. Every patient,
however, is due the ethics of
full disclosure as to what each
type of lift will and won’t do.”
Doctors’ Bios:
L. Mike Nayak, M.D., is a clinical
assistant professor of facial plastic
and reconstructive surgery at Saint
Louis University Medical School and is
triple board-certified in otolaryngologyhead and neck surgery, facial plastic
surgery, and cosmetic surgery. He is
an active member of the American
Academy of Facial Plastic and Reconstructive Surgery and the American
Brett Kotlus, M.D., M.S., is fellowship-trained in oculofacial plastic and cosmetic surgery. He is in private practice
in Shelby Township, Mich. He is the author of Boost Your
Beauty. Dr. Kotlus reports no relevant financial interests.
American Board of
Cosmetic Surger
Surgery, Inc.
The only Board dev
devoted
exclusively to Cosmetic Surger
Surgery
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Hilton Chicago
Chicago,
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acilityAirport,
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tificateofofAdded
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osmeticSurgery
Surger
Sur
gerororFacial
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ation Deadline:
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COSMETIC SURGERY TIMES
6
Letters to
the Editor
QUESTIONING ‘BIG SUCCESS’
Dear Editor:
As a plastic surgeon who has performed liposuction for
30 years, I was concerned by Dr. Salas’ report in the April
2011 issue of Cosmetic Surgery Times (“Big success.”
Cosmetic Surgery Times 2011; 14(3)31-33). Multiple
problems are immediately apparent.
For obese patients (BMI greater than 35) who are not
suitable candidates for liposuction, most surgeons
recommend consultation with a nutritionist, and if
necessary a bariatric surgeon. Dr. Salas, however,
comments that he allows patients to opt for liposuction as a
method of surgical weight loss.
Dr. Salas has performed less than 200 cases, of which only
2.5 percent were “mega liposuction” (greater than
10,000 cc fat removal). Therefore, he is basing this article,
issues related to safety and outcomes on five patients.
Besides noting there is an anesthesiologist on hand, there
is no mention of the safety measures in the guidelines
established by the American Society of Plastic Surgeons
(ASPS). While there may not be the strict state-by-state
regulations on the amount of aspirate that is permissible to
be removed in Mexico that we have in the United States,
these recommendations were put forth to enhance patient
safety.
Patients with aspiration volumes greater than 5,000 cc
need continual monitoring. Additionally, the procedure
must be performed in an acute care hospital or accredited/
licensed facility, with admission to an overnight facility.
Monitoring of fluid shifts, electrolytes and blood loss
as well as fluid replacement are critical (Haeck PC,
Swanson JA, Gutowski KA, et al. Evidence-Based Patient
Safety Advisory: Liposuction. Plast Reconstr Surg.
2009;124(4S):28S-44S). There is no mention of the need
for prophylaxis of deep vein thrombosis either prior to or
after this surgery, which should be mandatory on these
high-risk patients.
Offering concomitant procedures with these long cases
would only increase complications and the length of
anesthesia. On less obese patients, it is reasonable to
perform liposuction in stages, greatly reducing the length
of operation, amount removed at each stage and resultant
complications.
Dr. Salas explained that the cannulae that are used are 4
cm, 5 cm and 6 cm. Even a 6 mm cannula is enormous
and rarely used. A cannula as large as 6 cm would produce
contour abnormalities. Lastly, the photographs are of poor
quality. Even though they are so small, they show multiple
contour abnormalities.
In summary, the procedure as described is medically
unsound, and results are aesthetically unacceptable. This
is an anecdotal article that is not worthy of publication and
risks prompting inexperienced practitioners to embark on a
road with potentially disastrous outcomes.
JOHN E. SHERMAN, M.D., F.A.C.S.
Tara L. Huston, M.D.
New York Presbyterian Hospital - Weill Cornell Medical Center
Department of Surgery, Division of Plastic Surgery, New York
Cosmetic Surgery Times’ Editorial Advisory
Board Member James Carraway, M.D.,
F.A.C.S., responds:
The series noted by Dr. Salas is a small number since there
were only five mega-liposuction cases. It was not stated
how many large-volume procedures less than 10,000 cc
but greater than 4,000 cc were performed. We need to look
carefully at the studies of everyone who does the largervolume procedures, with the goal of maintaining the best
safety possible.
Dr. George Commons wrote an article in the ASPS in July
2001 on large-volume liposuction with 631 cases, defining
large-volume aspirations as those exceeding 5,000 cc. Fifty
percent of these cases were more than 5,000 grams, and
15 percent were more than 10,000 grams. In his series,
complications were seen in four patients who developed
pulmonary edema and one who developed pneumonia
postoperatively. He notes that meticulous fluid balance
calculations are necessary to avoid volume problems,
particularly because he uses the super-wet technique of
fluid management. He noted that large-volume liposuction
can be a safe and effective procedure when patients are
selected carefully and monitored closely in the postoperative
period.
The bottom line with large-volume procedures is how much
attention was paid to the safety of the patient and how
any complications could be avoided. It is important that
before a surgeon undertakes larger-volume liposuction that
he review the literature and scan every possible series to
see what complications occurred. Deep vein thrombosis
prevention has gained more and more importance to us, not
only in liposuction but in other plastic surgery procedures.
As plastic surgeons, we must safeguard our patients under
every possible circumstance to achieve a low complication
rate, especially in these large-volume liposuction cases.
JAMES H. CARRAWAY, M.D., F.A.C.S.
Member, Editorial Advisory Board
Cosmetic Surgery Times
June 2011
7
r
perfection
rP
Pearls
a l for
o
Getty Images/Cultura/Henry Arden
Condition-specifi
c considerations critical
o
to achieving optimal facelifting results
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
C
ontrary to what one may hear, there is no such entity as a “one-sizefits-all facelift,” E. Gaylon McCollough, M.D., told surgeons attending
the 2011 annual meeting of the American Academy of Cosmetic
Surgery (AACS) in Phoenix.
The ideal facelift must to be tailored to the specific needs of the patient,
keeping in mind that early in one’s facelifting career, less can be more,
Dr. McCollough says.
Dr. McCollough
“To avoid ‘career-killer’ outcomes, it is better to aim
for consistent base hits rather than a few home runs
that are offset with an equal number of strikeouts,” Dr.
McCollough says. “Then, as experience mounts, surgeons
can progress toward more aggressive techniques. However,
the ideal facelift includes as much surgery as is necessary
to achieve a natural-appearing result … and no more.”
With that philosophy in mind, Dr. McCollough, founder of the McCollough
Institute for Appearance and Health in Gulf Shores, Ala., used
8
the time at the AACS meeting to present a series of tips for
� Pearls
continued
achieving predictably good results, minimizing
complications and avoiding the telltale signs of
surgery.
incision pLAceMent A high forehead
due to a raised hairline is one tip-off to a
previous facelift procedure. To avoid that
outcome, Dr. McCollough recommends making
a hairline-preserving, trichophytic incision.
Incisions are beveled so that hair grows through
— and therefore camoufiages — the scar.
Hairline-preserving, trichophytic incisions not
only preserve a natural appearance for the
patient after the original procedure; they also
set the stage for a better outcome after future
surgeries.
and so may be coming back for a second and
even third procedure over time. With each
successive incision placed behind the trichial
margin, the hairline will continue to move up.”
Cosmesis is improved using a technique
borrowed from hair transplantation that assures
hair growth through the scar postsurgery.
Starting 1 mm into the hairline, the incision
cuts across the follicles (not parallel to them)
follows along the hairline and is beveled at the
edges. Cutting in a slightly irregular fashion
by following the hairline instead of moving in a
straight line also helps to reduce scar visibility,
Dr. McCollough says.
The incision is closed using stainless steel
staples and by suturing between the staples
with 5-0 plain fast-absorbing catgut in order
to bring the skin edges
together and further
optimize scar cosmesis.
sMAs issues
During (left) and after forehead trichophytic incision. note the hair growing through the
scar postoperatively. (Photos credit: E. Gaylon McCollough, M.D.)
SMAS flap elevation (left) and SMAS flap suspension with upward and backward
vector (right).
Supporting the SMAS in
facelifting seems to have
come into vogue just a
few years ago, although
Dr. McCollough says it
has been his technique for
more than three decades.
More recently, his subSMAS dissection is more
extensive than before, yet
it may still be considered
conservative by surgeons
who routinely advocate
deep-plane facelifting
techniques with extensive
sub-SMAS dissection.
“My answer to the
question of how far to go
with the dissection is that
I follow the ‘coronary rule.’
That means I advance with
the dissection until I feel
my coronaries begin to
constrict, and then I stop,”
Dr. McCollough says.
excess skin removed from neck (left) with extended post-auricular incision.
Hairline closure (right) with stainless staples and 5-0 plain catgut.
“There are trade-offs to everything we do in
cosmetic surgery, and any incision placed
farther back into the scalp to lift the tissues
of the face and neck will raise the hairline,”
Dr. McCollough says. “Although the cosmetic
consequences may not be too signiflcant for
a primary surgery, we need to consider that
patients are having facelifts at an earlier age
“The purpose of the
dissection is to free
tissue, and so one only
needs to go far enough to see free mobility
of the muscular structures in the face and
neck. There is no reason to proceed with the
dissection until you see the facial nerve,” he
says.
cLosure considerAtions Dr.
McCollough says he has switched from using
permanent sutures for suspending SMAS to
absorbable Vicryl after encountering a patient
misdiagnosed with a parotid gland tumor
who was found only to have developed suture
granulomas. The tensile strength of Vicryl has
adequate longevity to allow for scar formation
at the SMAS to SMAS anastamosis in the
pre- and postauricular regions, and adverse
reactions to the material are rare, he says.
“If one has created a raw surface that helps the
fascial edges of SMAS to adhere, the tissues
only need to be held in place with sutures for
six weeks while scarring occurs,” he says.
The sutures are placed in the distal SMAS
fiap in an accordion fashion that, according
to results of a study conducted by Dr.
McCollough’s research fellow, holds with
greater strength than a simple suture. The
vector of lifting for the flrst suture runs from
the angle of the mandible to the inferior aspect
of the tragus and the second from the corner
of the mouth to the inferior tragus. Those two
sutures set the desired vectors of the facelift,
and further sutures are placed for support.
optiMiZing outcoMes A stretched,
windblown look above the mouth seen in some
facelift patients is the result of pulling the
midface tissues straight back. Procedures that
pull the tissues straight up instead can avoid
that appearance and will give good results in
the neck, but this leaves the cheek and midface undertreated.
With these limitations in mind, Dr. McCollough’s
technique is a compromise solution that pulls
both up and back. Achieving good results
in the neck also depends on extending the
postauricular incision down the posterior hairline
for a minimum of 6 cm, he says.
“Using a short-scar technique that does not
include an incision along the posterior hairline
behind the ear will result in up to 5 cm of skin
being left behind in the neck … on each side,
or a total of 10 cm total. Incorporating the
postauricular incision does not increase the
surgical time signiflcantly. When a trichophytic
incision is used the scar is acceptable, and
patients get the results they expect,” he says.
Eliminating prominent platysmal banding
requires either incising the muscle or suturing
the platysmal bands in the midline. Myotomy
or myectomy will provide some improvement,
but such excisional approaches simply relocate
the band and it will reappear in a few years,
Dr. McCollough says. The best results, he says,
are obtained by suturing the leading borders of
platysmal muscles together in the midline.
Getty Images/Photodisc/ pulp
COSMeTIC SuRGeRY TIMeS
8
June 2011
9
Suturing the platysmal bands in the midline
commits the surgeon to performing a side-toside dissection of the fiaps in order to avoid a
cobra deformity, he says.
crosshatching avoids creation of vertical ridges
and simultaneously undermines the skin fiap.
“The vascular and nerve supplies to the fiap
remain intact, but everything else is freed
and a raw surface exists that will facilitate
adherence between the elevated skin and its
underlying bed,” Dr. McCollough says.
resurfacing has not been deep enough, and the
patient will not get a good long-term result,”
Dr. McCollough says. �
Disclosures:
Dr. McCollough is a consultant for Sandstone Medical Technologies and has
written a post-resurfacing treatment manual for the company.
resurfAcing
considerAtions When
Preauricular SMAS excision.
patients have deep wrinkles in
addition to tissue laxity, fullface resurfacing is necessary
to address the textural
changes, and Dr. McCollough
says laser skin resurfacing is
an acceptable way to address
superflcial facial rhytids.
Lalonde Skin Hook
Forceps easily win the
“Rose Petal Test.”
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Adjunctive procedures In
dissecting the SMAS, Dr. McCollough carefully
excises the tissue en bloc and uses that strip
as needed for augmenting the lips, nasolabial
folds, glabellar folds and marionette lines. In
a patient who had a previous facelift, a strip
of scar tissue can also be excised from the
postauricular regions and used instead.
Dr. McCollough says the SMAS is an ideal
flller because the undersurface is a layer of the
patient’s own collagen, whereas scar is pure
collagen. He notes that he has had excellent
results using this technique for more than 12
years.
For deeper wrinkling, he
says he has been able to
obtain optimal results by
employing a combination
of a Baker’s chemical peel
and dermabrasion. Over
surgically undermined areas,
skin resurfacing is generally
recommended nine months
postfacelift, but regional
resurfacing (periorbital or
perioral) is often performed at
the time of facelifting.
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Before (left) and nine months after facelifting and full-face skin resurfacing.
Dr. McCollough also advocates for performing
liposuction in most facelift procedures,
particularly when fat is present in the jawline
and submental regions. His technique uses a 4
mm cannula with the standard tubing and wall
suction found in any operating room. Moving
the cannula in a variety of angles to achieve a
“After facial skin resurfacing,
patients will look like they’ve
been dragged along the ground
and had boiling water poured
on them, and the healing will
take a minimum of two weeks.
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Getty Images/Lifesize/Elizabeth Hachem
CosmetiC surgery times
10
Facelift
fancy
Surgeon’s proprietary technique
restores natural appearance
with minimal morbidity
Cheryl Guttman
Krader
S ENIOR S TAFF CORRESPONDENT
JuNe 2011
11
A
facelift approach based on tightening
of SMAS and skin of the face and neck
in multiple natural vectors is a safe and
reliable procedure that delivers excellent
aesthetic results quickly and with minimal
morbidity for patients seeking restoration
of a more youthful, rested appearance,
according to Mark Foglietti, D.O.
Speaking at the Art of Facial Surgery
workshop prior to the 2011 annual
scientific meeting of the American
Academy of Cosmetic Surgery,
Dr. Foglietti described his
trademarked “Foglietti Natural
Vector Facelift Technique” as a
better alternative to standard
facelift techniques.
In his procedure, the incisions
are completely hidden
behind the hairline or in
natural facial creases.
Patients experience
minimal to no pain and
minimal bruising, and
they can shower and
wash the hair after
48 hours and return
to work in 10 to 14
days. Most importantly,
the aesthetic outcome
is superior to that
of standard facelift
techniques that pull
the tissues up and
back, redirecting the
facial lines in unnatural
directions and causing
patients to look different, but
not better, Dr. Foglietti says.
“Although there has been interest
in minimally invasive facelift
procedures that involve short
operative times, short incisions
and just a few days of downtime,
achieving a natural appearance is the
patient’s main goal," says Dr. Foglietti,
clinical professor, department of plastic
surgery, Ohio University College of
Osteopathic Medicine, and director,
plastic surgery residency, South Pointe
Hospital, Cleveland Clinic Health
System, Cleveland. "My technique
produces a very natural result
using incisions that
are as long as
necessary, and
the postoperative
morbidity and
downtime are
minimal compared with standard facelift
techniques.”
In preoperative counseling, Dr. Foglietti
demonstrates results to patients by placing them
in a supine reclining position and asking them
to look in a handheld mirror with the chin up.
While the majority of patients agree that what
they see is what they are seeking, Dr. Foglietti
also points out how the nasolabial folds and
marionette lines will be diminished — but not
eliminated. If the patient desires, those issues
are addressed at a later procedure, usually using
a hyaluronic acid filler or autologous fat.
“
My technique produces
a very natural result using
incisions that are as
long as necessary, and the
postoperative morbidity and
downtime are minimal
compared with standard
facelift techniques.
Mark Foglietti, D.O.
Cleveland
”
surGIcAL DetAILs Dr. Foglietti performs
his facelift procedure using general anesthesia.
Although IV sedation and local anesthesia would
be feasible, use of general anesthesia lessens
the amount of infiltration fluid infused so that
there is less tissue distortion, and it allows the
procedure to be completed faster and with less
total anesthetic exposure so recovery is faster,
Dr. Foglietti says.
Always beginning on the submental neck,
Dr. Foglietti infiltrates with a 1:500,000
epinephrine-saline solution that
gives excellent vasoconstriction
as well as provides some
hydrodissection.
“The hydrodissection is
particularly helpful when
performing a secondary facelift
Dr. Foglietti
where there can be scarring
from the previous procedure.
Omitting lidocaine in the infiltration solution is
helpful for identifying where the facial nerve is
whenever I am cauterizing,” he says.
Next, Dr. Foglietti performs liposuction of the
submental area using a No. 3 cannula. The
pretunneling facilitates elevation of the skin and
subcutaneous flap off the platysma, while the
liposuction can remove a surprising amount of
fat, even in thin patients, Dr. Foglietti says.
Platysmaplasty is performed next using 3-0
Ethibond for suturing, following the neck
dissection, which is done in continuity with the
previously performed submental dissection.
The procedure continues with dissection of
the right side of the face and SMAS plication
through a preauricular incision. Dr. Foglietti says
he has training in facelifting with both SMAS
dissection and plication, but prefers plication
because it enables the appropriate vectors and
allows for better tension, especially if the tissue
is very thin.
The first suture is placed preauricular and used
to pull the SMAS as far lateral as possible. Then
the second throw is placed and cinched.
“If it can’t be cinched completely, a spanning
suture will suffice, but it is nice to have a suture
that will scar at the appropriate level,” Dr.
Foglietti says.
The next suture focuses on the supramandibular
vector to tighten the jowl area. Up to 3 cm or
4 cm proximal pull may be achieved, but the
suture may tear through subcutaneous tissue
and may have to be replaced one or more times.
“Novice surgeons especially are reluctant to go
too deep with the suture at first,” Dr. Foglietti
says.
The first skin flap is created in the temporal
region where excision of redundant skin and
tightening enhances the appearance of the
upper third of the face, even if the patient is
also having an endoscopic browlift. About
1.5 cm to 2.0 cm of skin can usually be excised,
“
I make sure there is a
good anterior vector, and I
am not concerned with
the need to repair
a dog ear.
Mark Foglietti, D.O.
Cleveland
”
and a tension suture of 2-0 Silk is placed.
Next, a tension suture of 2-0 Silk is placed in
the postauricular sulcus to pull the skin lateral
and superior, creating a vector across the
submental and submandibular region.
“Early in my career I wanted to limit the size
of this flap so that I would not have to extend
the postauricular scalp incision, but I think
the results in the neck suffered,” Dr. Foglietti
says. “Now, I make sure there is a good
12
CosmetiC surgery times
12
� Natural
continued
anterior vector, and I am not concerned with the
need to repair a dog ear.”
The next vector pulls in a diagonal direction to
the tragus. Here, the skin is pulled with minimal
Prolene. Chin augmentation, if performed, is
done last after changing gloves, re-prepping and
draping.
“A lot of patients are afraid to have a chin
implant, and I have to reassure them that a
small implant will enhance their appearance
and can wash their hair, even if they have had
a browlift, which makes them very happy,” Dr.
Foglietti says. “Removing the dressing also
allows patients to see if there are any potential
problems.”
“
The patients look pretty
good the flrst day postop
and very impressive at
one week, usually with just
some periorbital edema
lingering if they had
eyelid surgery.
Cleveland
”
Strenuous activity, including sex, is prohibited
for three to four weeks. Sutures are removed at
a one-week postop visit.
“The patients look pretty good the flrst day
postop and very impressive at one week, usually
with just some periorbital edema lingering if
they had eyelid surgery,” Dr. Foglietti says. �
A female patient before (left) and two months after Dr. Foglietti’s Natural Vector Facelift technique™. (Photos credit: Mark
Foglietti, D.O.)
tension and after the excess is cut, suturing with
5-0 Vicryl maintains the vector.
without an exaggerated or elongated chin,” Dr.
Foglietti says.
To maintain a natural earlobe position, a small
incision is made anterior to the earlobe, and the
earlobe is fiopped out without tension and the
skin trimmed conservatively.
To decrease seroma risk, small drains (7-fr
TLS) are placed on vacuum tube suction
in the preauricular region and exiting
the postauricular scalp. The drains are
sutured and removed the following
morning.
“
A lot of patients are afraid
to have a chin implant, and
I have to reassure them
that a small implant will
enhance their appearance
without an exaggerated
or elongated chin.
Mark Foglietti, D.O.
Cleveland
”
The flnal vector addresses the posterior lateral
neck. The skin is pulled upward behind the ear,
the redundant skin is excised, and suturing is
done with 4-0 Monocryl.
All scalp closures are performed with running
4-0 P Prolene and skin is closed with 6-0
A circumferential ACE wrap and Kerlix
bandage is placed over the dressings
and ice applied to reduce swelling while
patients are hospitalized overnight. By
itself, the facelift is completed in
about 2.5 hours.
PostoP course Dr. Foglietti
acknowledges that a hospital stay
may be more for his comfort than the
patient’s needs. Patients are seen early
the next morning and discharged after
having the drains removed and the face redressed. The dressing applies moderate tension
to the face and neck to prevent facial swelling
from reaching the submental and submandibular
areas and is worn for one week, although it can
be removed while showering and eating.
“Patients are allowed to shower at 48 hours
Getty Images/Lifesize/Elizabeth Hachem
Mark Foglietti, D.O.
Getty Images/Image Source
JUNE 2011
13
More than
lifting
SStudy shows ancillary procedures
make all the difference
in facial rejuvenation
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
W
hen patients say, “I want a facelift,” they usually mean,
“I want to look younger and more refreshed.” Southern
California cosmetic surgeon Ronald Strahan, M.D.,
relies increasingly less on facelifts alone to address that request
and instead grants his patients’ wish for rejuvenation with a
combination of procedures.
14
COSMETIC SURGERY TIMES
14
continued
“Most women who come in want a neck that
looks tight and feels tight, so I perform an
aggressive neck operation, and then the
position of the brow dictates if I do a small
incision forehead lift. Then I evaluate the
midface,” says Dr. Strahan, who started his
career as a board-certified otolaryngologist.
When evaluating a patient for rejuvenation
of the aging face, he examines all of the
characteristics and layers of the face. The
goal, he says, is to create facial harmony for
an age-appropriate appearance. As a result,
he relies more on the ancillary procedures of
blepharoplasty, rhinoplasty, skin resurfacing
and soft tissue expansion (STE) and less
on aggressive techniques of facelifting to
p
produce that result.
“I usually ask the patient for a picture
of when they were about 30 or 35 years
old, which is the age of optimal physical
appearance, and this gives me a clear idea of
their ideal version of themselves,” Dr. Strahan
says.
MIDFACE FINDINGS Today, Dr. Strahan
rarely performs a facelift operation alone
because of findings from his recent study that
suggest patients have a much higher degree
of satisfaction with the treatment of the aging
face when some additional change to the
midface is provided.
In a retrospective study conducted by Dr.
Strahan and his colleague, Catherine J.
Hwang, M.D., the charts of 430 of his facelift
patients who had at least 10 years’ followup
the results of
p were reviewed to compare
p
patients having SMAS techniques with
the results of patients having deep-plane
techniques.
As he expected, forehead and necklift
patient satisfaction was well over 90 percent;
however, the long-term satisfaction rate with
the facelift part of treatment of the aging
face was disappointing.
The revision rate two years postoperatively
was 13 percent for the SMAS technique
group and 8 percent for the deep-plane
technique group. At 10 years after surgery,
the patient satisfaction rate for both groups
had plummeted to 50 percent. Of those who
were dissatisfied, 80 percent were unhappy
specifically with the midface outcome.
“This shows that the forehead lift is a good
operation and the necklift is a good operation,
and no matter what technique is employed in
the midface, it’s really a mediocre operation,”
Dr. Strahan says.
“
With my previous more
aggressive facelift, the
patients had to disappear
from society for about three
weeks, whereas with fat
grafting the downtime
is seven to 10 days,
even with the harmonyproducing procedures of
blepharoplasty and rhinoplasty
at the same time.
Ronald Strahan, M.D.
Los Angeles
”
All of the patients evaluated also had
ancillary procedures. Most had either
blepharoplasty or rhinoplasty or soft tissue
expansion (STE) — either hard implants, fat
transfer or nonautologous injectable fillers, or
skin rejuvenation or a combination of those
procedures.
“Fortunately, I had enough data to go back
and cross-reference these cases to see if the
ancillary procedures affected the patient’s
perception of their overall experience,” Dr.
Strahan says.
Five years postoperatively, skin resurfacing
— except for deep phenol peels and deep
Getty Images/Digital Vision/Monica Rodriguez
Lifting
JUNE 2011
15
ablative laser treatments — made no
difference in patient satisfaction ratings.
Those who had deep phenol peels or deep
laser ablative treatments had an
80 percent satisfaction rating just for those
procedures. Patients who had the nonablative
laser procedures said they couldn’t tell the
difference after five years.
Dr. Strahan says the
subjective benchmarks of
cosmetic surgery make
evidence-based decisions
for the cosmetic surgeon
impossible, but that best
practices medicine can
certainly be employed.
Of those patients who had blepharoplasty,
90 percent were satisfied with that surgery’s
outcome, and of those who had rhinoplasty,
92 percent were satisfied with that surgery’s
outcome. Of the people who had STE,
80 percent were satisfied that they had had
that particular intervention.
With respect to Dr. Strahan’s next findings, it
is important to keep in mind that the facelift
satisfaction rating across the board was
50 percent 10 years after surgery.
“We found that if the patient had a
blepharoplasty with their facelift, it improved
their satisfaction perception rate to
65 percent,” Dr. Strahan says. “If they had
a rhinoplasty along with the lift, it improved
their perception that they had a good result
to 75 percent, and if they had STE along
with the lift, satisfaction rating 10 years out
was 80 percent. So having had something
done in the midface significantly improved
the patients’ perception of whether they were
satisfied or not.”
ANALYZING RESULTS Dr. Strahan says
he suspects that what’s behind this finding is
that “when people look at the result of their
facelift, they look at the triangle bordered and
described by the brows, the eyes, the nose
and upper lip and cheek. If they look at that
area and their eyes are youthful and their
nose is in harmony with other facial features
and their cheeks are full, they perceive an
excellent result,” he says.
The findings suggest that rejuvenation of the
face is less about facelift techniques and
more about addressing the eyelids, nose and
A 51-year-old patient before (left) and after having a small-incision forehead lift, a skin-fl ap facelift and a necklift with
platysmaplasties. She also had a lower transconjunctival blepharoplasty, rhinoplasty and fat transfer to the cheeks,
nasolabial grooves and mandible. (Photos credit: Ronald Strahan, M.D.)
soft tissue of the face. Of these interventions,
Dr. Strahan says he thinks corrective nasal
surgery is the most often overlooked.
“That’s where many of us are headed
— concentrating more on the ancillary
procedures and less on the more invasive
facelift techniques,” he says. Dr. Strahan
also says “facelifts — especially the deeper
techniques — have a long recovery time. So
at this point, for my patient population I am
more frequently employing the simple skinflap surgery rather than the SMAS and deepplane techniques, and almost everybody gets
STE of the face. I prefer hard implants and
patients prefer fat-transfer grafting.”
practice,” he says.
“I used to be a great champion of the deeper
techniques of facelifting surgery, but my
statistics show that the increased morbidity
and recovery time of these techniques is not
rewarded with better results,” he adds. “With
my previous more aggressive facelift, the
patients had to disappear from society for
about three weeks, whereas with fat grafting
the downtime is seven to 10 days, even
with the harmony-producing procedures of
blepharoplasty and rhinoplasty at the same
time. There are obvious exceptions to this
generalization, and the more advanced facialaging patient may require the more aggressive
techniques.”
FAT FACTS Dr. Strahan says he prefers
hard implants because they provide an
immediate result that is permanent and feels
like bone. He says he is doing a lot more fat
transfers than hard implants, however, for
several reasons. Communicating with patients
about fat transfer is easier because they are
more amenable to a procedure that doesn’t
rely on more incisions or insertion of an
artificial material.
Dr. Strahan stresses that for any surgeon
who is doing a high volume of procedures,
it is important to evaluate outcomes and
patient satisfaction intermittently. He says
the subjective benchmarks of cosmetic
surgery make evidence-based decisions for
the cosmetic surgeon impossible, but that
best practices medicine can certainly be
employed.
“Fat transfers are perceived as safe because
it’s (the patients’) own tissue and there’s an
inexhaustible supply,” Dr. Strahan says. He
says he respects his patients’ choice of fat
grafting and concludes that in most cases,
it may be the best STE and the filler of the
future. “At least it seems that way in my
His study “highlighted that the success of
any state-of-the art program of treatment
of the aging face is favorably influenced by
the ancillary procedures of blepharoplasty,
rhinoplasty and soft-tissue expansion and
may be less dependant on the technique of
facelifting surgery,” Dr. Strahan says.
Getty Images/Vetta/Nabi Lukic
COSMETIC SURGERY TIMES
16
TRUE BLUE
Tried-and-true traditional facelift techniques stand the test of time
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
H
aving performed more than 5,000 facelifts in his 37-year
career, E. Gaylon McCollough, M.D., knows a thing or two about
facelift surgery. He says if there’s one thing he’d like the upand-comers to know, it’s this: There’s no such thing as a one-size-fitsall facelift.
He recommends steering clear of those corporate-sponsored facelift
courses and certification programs that use words such as “mini” and
“quick,” and instead focusing on learning the tried-and-true traditional
facelift technique that has stood the test of time.
Dr. McCollough
But even among experts, Dr. McCollough says, the term “traditional”
facelift leaves room for debate.
“To me, a traditional facelift is when one makes an incision that
addresses all of the areas of the aging process; incorporates an
appropriate amount of liposuction to remove excessive fatty tissue in
JUNE 2011
17
the submental region and along the jawline;
and addresses sagging muscles in all areas of
the face — the neck, the cheeks, the brows
and the forehead. You have to do the deep
support first and then address the skin,” he
says.
Dr. McCollough says he’s encountered others
who define the traditional facelift as the
short-scar lift.
“They are not going behind the ear to address
the sagging tissues in the neck,” he says.
“Also, not everyone is addressing the muscles
in the appropriate way — some are simply
sewing fat to fat with sutures underneath,
while others are actually tightening the
muscles.”
presentations at national symposia about
these various new-and-improved facelift
options and there is a great deal of confusion
throughout the specialty. The patient pool
has widened and become more diverse since
facelifts first became commonplace and
popular.
Younger women — and plenty of men — of
a variety of ages are seeking facelifting
procedures to retain or restore a youthful
look, and there are an array of facelift options
to address this diverse population. That
doesn’t make the traditional facelift any less
effective for the patients to whom it was first
introduced, however, nor does it make it any
less of a viable option in today’s cosmetic
surgery practice, Dr. McCollough says.
is absolutely the wrong operation for that
patient because it only addresses part of the
problem, and even if it addresses all of the
elements it only addresses them in a minimal
fashion.”
CLASSIFIED INFORMATION While
Dr. McCollough remains committed to the
traditional lift that addresses all three
important aspects of facial aging, he
customizes the procedure to each patient
depending on how much help they need.
To that end, he has developed a classification
system that evaluates the extent of facial
aging, classifies it on a scale of 1 to 5,
and then determines the length of the
incision and the amount of undermining and
tightening, among other things.
BASIC TRAINING “Anatomy has
A 67-year-old patient before (left) and one year and three months after
undergoing facelift (temporal, cheek, neck) as well as upper and lower
blepharoplasty. Six months later she had full-face resurfacing using a
combination of chemical peel and dermabrasion. (Photos credit: E. Gaylon
McCollough, M.D., F.A.C.S.)
not changed since facelifting came
to be, so the tissues droop in the
same manner that they have always
drooped, and the same tissues
droop now that have always drooped
before,” Dr. McCollough says. “The
way to correct that is to address
all the different parts of the face
that are involved in sagging: the
musculature underneath and the
fascia that envelops the musculature
of the face and neck, as well as
addressing excessive fatty tissue
that sometimes produces bulges
along the jawline and under the chin
and contributes to the heaviness
of the face, thereby causing the
droopiness to occur. Then, of
course, you have the sagging skin —
those are all the components in the
aging face.”
Dr. McCollough says any procedure
that does not address all three
of those elements will provide
compromised results in comparison
to procedures that address all of
them. That’s the problem with the
commercialized facelift procedures
that are taught and marketed as onesize-fits-all surgery, he says.
“If you have a patient in his or her
late 30s or early 40s who has a very
minimal amount of sagging of the
skin but the muscles are still OK and there’s
not a lot of fatty tissue, then a mini-facelift
might be appropriate for that patient,” he
says. “On the other hand, if you have a
patient in his or her 70s where all of the
previously mentioned elements are involved
in drooping and sagging, then a mini-facelift
A 61-year-old female patient before (left) and six months after
undergoing facelift (temporal, cheek, neck with platysmaplasty) as well
as lower blepharoplasty and functional septorhinoplasty.
Whether short cuts are employed to reduce
surgical time, recovery time or something
else, Dr. McCollough says he suspects the
patient is ultimately short-changed with
suboptimal results.
Dr. McCollough says surgeons see
A “stage 1” rating represents patients who
need a less extensive amount of surgical
intervention, typically those in their 30s or
40s who are attempting to pre-empt the signs
of aging before they are obvious, whereas a
“stage 5” rating typically indicates that the
patient is in the 60 to 65 and older age range
and is in need of the maximum amount of
surgical intervention.
“You have to modify the operation to fit the
specific needs of the patient,” Dr. McCollough
says. “If you do a traditional extended or
maximally invasive facelift on all faces, you’re
going to do overkill on the younger patient
who just has early signs of aging, in the same
way that you would be underserving the older
patient with a minimally invasive procedure.”
When Dr. McCollough presents his views
about traditional facelifts to national
audiences of cosmetic surgeons, he often is
asked if he has considered using the shortscar lift. He says his answer is yes.
“Yes, absolutely if it’s a young patient who
just has some sagging in the cheeks, but if
the neck and forehead is OK, then an incision
that extends from the temple tuft of hair
down to the earlobe is all that needs to be
done,” he says. “But if the patient has a lot
of slack in the neck and all you do is shortscar lift, you can be sure that you are not
treating the neck adequately.”
CosmetiC surgery times
18
The
power
o
light
i
M
Minimally
invasive laser
technique works alone or in
combo with traditional facelifts
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
Getty Images/Vetta/Larysa Dodz
of
JuNe 2011
19
F
acelifting techniques have evolved over the
years and are trending toward minimally
invasive procedures with less downtime.
New and innovative approaches, such as the use
of laser-assisted incisional techniques, can be
used alone or in combination with traditional or
less-invasive short-scar facelifting techniques,
optimizing aesthetic outcomes.
“
The premise is that the
laser technology applied
to the undersurface of
the skin is easier and
gentler on the tissue when
compared to more invasive
surgical approaches.
Patrick McMenamin, M.D.
Sacramento, Calif.
”
“It is the early days for this novel and still
evolving laser-assisted facelifting technique;
however, in the right hands, the aesthetic
results achieved can be significant,” says
Patrick McMenamin, M.D., past president of the
American Academy of Cosmetic Surgery, who is
based in Sacramento, Calif.
Minimally invasive laser-based technologies
are coming of age and are now being used as a
minimally invasive surgical approach in cosmetic
surgery. The laser-assisted incisional technique
is quickly becoming more popular in cosmetic
surgery because the results achieved can
rival those achieved by more invasive surgical
approaches, and in some areas, even surpass
those cosmetic results achieved with traditional
approaches.
“Traditional and short-scar facelifts do not
always adequately address certain areas of the
face including the nasolabial folds, jowls, oral
commissure and lower part of the lip. The laserassisted technique can help lift and tighten
these areas for more pronounced cosmetic
outcomes,” Dr. McMenamin says.
HoW it’s Done Under tumescent
anesthesia, Dr. McMenamin typically will
make four small incisions — one behind each
earlobe and one at each lateral aspect of the
submental crease, just inside the inner cortex
of the mandible. Using a Blugerman rasp and
4 mm spatula, tunnels are created under the
skin throughout the lower two-thirds of the face
and neck. Specially designed cannulas are then
inserted through the incisions and laser energy
is applied within pre-marked multiple grids in
the target areas.
In the laser-assisted facelift procedure, Dr.
McMenamin uses Sciton’s JOULE with its
combined Nd:YAG 1,064 nm and 1,319 nm
wavelengths. Many different laser manufacturers
promote their technology and wavelengths used
as the best in terms of inducing controlled
trauma in the subcutaneous tissues. According
to Dr. McMenamin, no singular technology or
laser platform has yet scientifically proven its
technology to be optimal for this indication.
“Using the laser-assisted
technique, we can create trauma
under the skin similar to the way
you would in standard facelift
techniques. In my opinion, both
the mechanical and heat trauma
that we exact in the targeted
Dr. mcmenamin
tissues and the ensuing healing
ability of the body are what
is in part responsible for the
cosmetic outcomes achieved,” Dr. McMenamin
says.
Regardless of the laser technology used, it is
important to apply the laser energy and heat
the targeted subcutaneous tissues to a constant
temperature ranging between 40 and 42
degrees Celsius. This subcutaneous heating will
induce neocollagenesis and reorganization of the
architectural structure of the skin, which can
result in an aesthetically pleasing outcome.
“In essence, we are creating a traumatic wound,
and it is our knowledge of the body’s ability
to heal and how it is going to heal that can
potentially create positive aesthetic results,”
Dr. McMenamin says. “The premise is that the
laser technology applied to the undersurface
of the skin is easier and gentler on the tissue
when compared to more invasive surgical
approaches.”
traditional facelifting approaches. However,
depending on the degree of skin laxity, I believe
that this technique cannot achieve similar
A female patient before (left) and 12 months after laser
facelift, including one small incision behind each ear
lobule and one at each end of the submental crease. (Photos
credit: Patrick McMenamin, M.D.)
outcomes as traditional surgical techniques
unless one performs it in combination with
traditional surgical procedures.”
The facelifting technique chosen depends on
physician and patient preference of procedure,
as well as the degree of skin laxity and
amount of lifting required. Where only minimal
A female patient before (left) and four months after laser
facelift, including one small incision behind each ear
lobule with very limited submentoplasty. (Photos credit:
Patrick McMenamin, M.D.)
improvement of definition may be required
along the jawline and neck, Dr. Burke says he
may first use the laser-assisted technique and
then follow up with liposuction to remove the
excess fluid and liquefied fat that accumulates
as a result of the procedure. In those patients
in whom more lifting around the mid- to lower
face, jawline and neck is required, Dr. Burke
says he may combine this laser technique with
traditional facelifting procedures.
A female patient before (left) and nine months after laser
facelift, including one small incision behind each ear
lobule and one at each end of the submental crease. (Photos
credit: Patrick McMenamin, M.D.)
coUnt coMBo ProceDUres in
Robert H. Burke, M.D., F.A.C.S., of the Michigan
Center for Cosmetic Surgery, Ann Arbor, Mich.,
says, “There is an obvious trend towards
minimally invasive facelifting procedures. A
laser-assisted technique is less invasive than
“If there is significant skin and fascia laxity in
the mid-facial area, you either have to remove
skin and tighten fascia or you have to add
volume in order to take up that laxity in the
skin,” Dr. Burke says. “Depending on the degree
of aging, there may really be no way around a
traditional facelift or a short-scar surgery to get
significant aesthetic outcomes.”
20
CosmetiC surgery times
20
� Laser-assisted
continued
ProPer Patient selection The
laser-assisted technique can achieve good
cosmetic outcomes when chosen in the right
patient and when matched with the severity
of skin laxity seen in a given patient. Some
cosmetic patients may have lack of volume in
the face combined with skin and facial laxity.
Here, Dr. Burke says he may only perform
a fat transfer or use fillers such as Sculptra
(poly-L-lactic acid, Sanofi-Aventis) or one of
the hyaluronic acid fillers to restore the volume
loss. However, some patients may benefit most
from the combination of a filler technique with
the laser-assisted technique and/or a more
traditional surgical lift — again, depending
on the degree of correction and improvement
needed.
“
I choose my lifting
techniques based on the
patient’s needs, the degree
of skin laxity they have
and the time frame that
they will want the results.
Hyaluronic acid fillers can
be ideal for a ‘quick fix’
if the patient wants fast
results and does not have
the time for the downtime
associated with other, more
invasive, techniques.
Robert H. Burke, M.D., F.A.C.S.
Ann Arbor, Mich.
A 69-year-old female patient before (left) and at age 70, 13-and-a-half months postop. the patient received smartlipo
(Cynosure) of the neck and as assistance for the face with facelift. (Photos credit: Robert H. Burke, M.D., F.A.C.S.)
”
“I choose my lifting techniques based on the
patient’s needs, the degree of skin laxity they
have and the time frame that they will want the
results,” Dr. Burke says. “Hyaluronic acid fillers
can be ideal for a ‘quick fix’ if the patient wants
fast results and does not have the time for the
downtime associated with other, more invasive,
techniques.”
Using the laser-assisted incisional technique,
the wounding process initiated from heating
the tissues can result in a more enhanced
contraction and tightening of the tissues. The
subtle nuances and parameters involved in this
process remain unknown, however, and need to
be scientifically elucidated and defined.
“There is a definite induction process in terms
of applying thermal energy under the skin
using the laser technique, and we are wounding
the targeted tissues in a different manner
than we would with the mechanical wounding
process during traditional facelift surgery,” Dr.
McMenamin says. “Using this laser approach
alone or in combination with standard surgical
approaches can achieve good results. However,
there is still much to be learned with the laserassisted technique.”
Disclosures:
A 25-year-old female patient before (left) and three weeks after receiving a smartlipo (Cynosure) minimally invasive necklift,
performed with the smartlipo device only. (Photos credit: Robert H. Burke, M.D., F.A.C.S.)
Dr. McMenamin is a member of the advisory board, a consultant,
an investigator, a speaker, and receives honoraria from Sciton. The
Michigan Center for Cosmetic Surgery is a Cynosure Corporation
Center of Excellence and a clinical resource center. Dr. Burke trains
surgeons on the use of this technology.
June 2011
21
Facelift
face-off
Surgeons compare traditional
d
l with less invasive lifting
l
techniques
h
Getty Images/Comstock Images
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
T
oday, there are varying facelifting procedures and techniques used, all of which have
evolved since their dawn in aesthetic surgery more than a century ago. These can
range from more invasive traditional facelifting techniques to less invasive short-scar
techniques, and though there is no consensus as to which technique is the best approach,
the keys to a successful procedure remain careful patient selection, as well as techniques
22
COSMeTIC SuRGeRY TIMeS
22
� Face-off
continued
that work for a particular surgeon.
“There are many different lifting techniques
used to improve lower face and neck aging.
I believe that the best facelift technique is
the one that works well in the hands of the
specific surgeon, provides good results with
low complications, and, most importantly,
happy patients,” says Joe Niamtu III, D.M.D.,
a board-certified oral and maxillofacial
surgeon with a private practice limited to
cosmetic facial surgery in Richmond, Va.
Aesthetic surgeons remain at odds as to
which facelifting technique is best and
which can achieve superior aesthetic
outcomes. Though specific
techniques may vary, a more
invasive traditional facelift
procedure will typically involve
pre- and postauricular
incisions, platysmaplasty
and SMAS treatment.
the ShortScar FaceLIFt
Minimally invasive,
so-called “shortscar,” techniques
may consist of only a
preauricular incision
that terminates at the
mastoid region with
no posterior auricular
and scalp incision.
These lifts are also
usually performed without
midline platysmaplasty
and frequently utilize
variations of pursestring sutures.
Here, an accurate
assessment of the
degree of lifting
needed in an
individual
patient may
ultimately
direct the surgeon in
choosing the appropriate
technique.
“I personally do not
favor minimally invasive
facelifts,” Dr. Niamtu
says. “It is not that I never
do a short-scar facelift,
but my parameters are
only for young individuals
with minimal aging,
meaning those patients with early jowling and
almost minimal neck laxity. However, even
younger patients may require a larger, more
comprehensive lift.”
During short-scar facelift surgery, Dr. Niamtu
says he may even switch to a traditional lift
and perform a conventional
pre- and postauricular
procedure.
“I have changed to the larger
lift in mid-surgery numerous
times and have been glad I
did, as even patients that did
Dr. niamtu
not exhibit significant neck
laxity actually had impressive skin excess
as evidenced when the posterior auricular
incision was completed,” Dr. Niamtu says.
The face of each individual patient may age
in a different way. The spectrum of an aging
face can range from a mere sagging of the
tissues to more deflation where the fat and
sub-tissues melt away.
cuStoMIZINg couNtS While a
short-scar facelift is in essence less invasive,
proponents of this technique often choose this
approach because they believe it can better
address the individual aspects of the aging
face.
“If you only use the traditional, more invasive
facelift technique, you end up treating all
of your patients the same way, regardless
of their differing degrees
of facial aging,” says Alexis
Verpaele, M.D., F.C.C.P., a
plastic surgeon at the Coupure
Center for Plastic Surgery,
Gent, Belgium. “In contrast, a
short-scar technique is better
Dr. Verpaele
catered to the individual aging
characteristics of the face and
can more optimally correct the sagging or
laxity in the neck, lower jowl area, mid-face
and temple areas.”
Dr. Verpaele is co-designer of the MACS
(minimal access cranial suspension) shortscar technique, which remains the basis of all
of his facelifting procedures. This approach
is not a limited technique with limited
possibilities, however, and depending on the
type of individual facial aging and degree of
lifting needed, Dr. Verpaele may add smaller
procedures to his MACS lift.
“If you have a patient with a lot of loose
skin at the neck, I may have to add a small
incision under the chin in order to release
and more optimally redrape that skin and
the platysma when necessary. By combining
smaller techniques, you can better tailor your
treatment to the needs of your patient,” Dr.
Verpaele says.
One of the major advantages of a shortscar technique such as the MACS lift is
that this approach will more often result in
more natural-looking surgical outcomes due
to the vector used when lifting the tissues.
The vector used in traditional lifts is usually
oblique towards the back, which may help in
flattening out wrinkles but may also tend to
flatten the face and can often result in what
people call a “frozen-looking” face.
According to Dr. Verpaele, the faces of
patients receiving a MACS lift will typically
age better and more naturally due to the
vertical pulling of the skin, as opposed to
the oblique pulling of the skin performed in
traditional lifts. Facial aging continues, and
the forces of gravity will further pull the skin
down vertically.
In patients who received a traditional lift,
this vertical dropping of their skin over
time may sometimes result in a curtain-like
appearance of the skin over their cheeks.
Short-scar techniques will work against these
gravitational forces as they pull the skin in
the opposite direction of the gravitational pull
and more often result in more natural-looking
aesthetic outcomes.
“It is true that the vector used
in short-scar techniques is
more optimal, as the curtainlike effect can be better
avoided over time. That’s why
we usually try to lift the tissues
a bit more vertically when
Dr. Cuzalina
performing traditional facelifts.
However, the surgeon still has
to drape the skin where it will look best,”
says Angelo Cuzalina, M.D., D.D.S., president,
American Academy of Cosmetic Surgery, who
has a private practice in Tulsa, Okla.
“It is important to match the technique to
the patient’s needs and in practice, the ideal
redraping of the skin will lie between the
vertical and oblique line,” he says.
According to Dr. Cuzalina, it is difficult to say
which procedure is optimal for all patients,
and the choice of technique will depend on
what the surgeon is trying to lift and what
the patient wants. Though the short-scar
technique may be ideal for patients requiring
more of a lifting effect of the mid-face and
June 2011
23
some jowls, Dr. Cuzalina says many of his
patients ask for a lifting of their neck and jowl
regions, and here, a more traditional approach
may be the technique of choice.
“In my experience, you need a longer incision
including both pre- and postauricular incisions
in order to achieve a maximum lift in patients
A 43-year-old patient who had complained of laxity in the
neck, jowling and a “sad” appearance, before (left) and 10
months after surgery. Surgery involved a MACS-lift through
a short incision at the anterior border of the ear, with no
scar behind the ear. Lipofilling was used to restore the
volume in the midface and upper eyelids, to enhance the
chin and to fill some wrinkles in the upper lip. (Photos credit:
Alexis Verpaele, M.D.)
procedures in addition to the short scar
may be required. This approach, however,
is still more optimal than performing larger
traditional facelift procedures, which require
more downtime as well as general anesthesia.
In contrast, short-scar techniques can be
performed with local anesthesia, which
can not only increase the potential patient
A female patient before (left) and after undergoing
comprehensive cosmetic facial rejuvenation with
simultaneous facelift, four quadrant blepharoplasty, cheek
implants and full-face CO 2 laser resurfacing. (Photos credit:
Joe Niamtu III, D.M.D., F.A.A.C.S.)
population for the procedure, but also
circumvent any potential contraindications
regarding general anesthesia.
who have significant sagging in their neck and
jowl regions. I will also perform short-scar
lifts, but reserve them for those patients who
are specifically looking for a little more of a
mid-facelift,” Dr. Cuzalina says.
Dr. Niamtu says, “My biggest problem
with short-scar facelifts is the lack of a
postauricular incision that extends into the
scalp. To me, this is the most important
vector to truly manage significant cervical
and submental skin laxity. Any sacrifice in
A patient before (left) and after undergoing comprehensive
cosmetic facial rejuvenation with simultaneous facelift,
browlift, four quadrant blepharoplasty, cheek implants,
chin implant and full-face CO 2 laser resurfacing. (Photos
credit: Joe Niamtu III, D.M.D., F.A.A.C.S.)
facelift surgery,
and according to
Dr. Niamtu, some
practitioners may
not be trained
in larger lifting
procedures and
therefore may feel
more comfortable
with the smaller variety
of lift. Additionally,
some surgeons may
not have the ability
or the facilities to
utilize IV anesthesia
or general
anesthesia, not
required for
the short-scar
technique.
“One of the
reasons for the
increased popularity
of these lifts is the
significant media hype
that is so pervasive in our
society today,” Dr. Niamtu
says. “Many consumers
equate new with better,
which is simply not the case.
I believe that these smaller
lifts are overrated and too often
performed on patients that
should have had a larger lift.”
According to Dr. Niamtu, short-scar lifts are
appropriate on some patients, but at the same
time, they do not comprehensively address
the average facelift patient (ages 40 and
older). Some patients receiving a short-scar
facelift may feel betrayed because they were
promised a maximum result with minimum
surgery and they still have laxity following the
procedure. While many surgeons have become
much more conservative in their approach to
facelift surgery, Dr. Niamtu has become more
aggressive.
A 47-year-old patient before (left) and six weeks
after a long-flap lower facelift, submentoplasty and
blepharoplasties. The patient had a musculofascial
deep-flap elevation off the parotid along with open
submentoplasty involving direct excision of deep,
subplatysmal fat along with platysmal back cutting,
undermining and anterior plication. (Photos credit: Angelo
Cuzalina, M.D., D.D.S.)
this vector will affect the surgeon’s ability to
tighten the neck.”
Short-Scar Surge Short-scar
Older patients who have more significant
sagging skin may require more lifting, and
according to Dr. Verpaele, smaller additional
facelifts have become very popular in
cosmetic surgery and are fashionable for a
variety of reasons. Many different specialties
now perform cosmetic facial surgery, including
“In the end, surgeons should choose facelift
technique that works well in their hands and
makes their patients happy. If their smaller
procedure works better in their hands and
they can achieve lasting results with happy
patients, then we are all winners,” Dr. Niamtu
says.
Disclosures:
Drs. Cuzalina and Niamtu report no relevant financial interests. Dr.
Verpaele receives royalties for books he co-authored, titled The MACSlift Short Scar Rhytidectomy and Short Scar Facelift: Operative Strategies
and Techniques.
COSMETIC SURGERY TIMES
24
Illuminating
c
combo
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
P
reliminary results from a prospective study indicate that a noincision, dual-laser facelift procedure can be a viable option
for properly chosen patients interested in a minimally invasive
alternative to a traditional surgical facelift.
Getty Images/Vetta/Sandy Jones
The procedure combines laser lipolysis of the lower face and neck with
fractional CO 2 laser resurfacing and was developed by Carey Nease,
M.D., to satisfy patient demands for a procedure that would provide
good cosmetic results with less downtime than a traditional facelift
and no visible scars. Dr. Nease is a fellowship-trained, board-certified
JUNE 2011
25
cosmetic surgeon in private practice with
offices in Chattanooga, Tenn., and Calhoun,
Ga.
“Dr. Nease was looking to meet the needs
of patients who did not want a traditional
facelift either because of the downtime, the
cost, or because they were
not emotionally or clinically
ready for it,” says Vincent
Gardner, M.D., who conducted
the research as a cosmetic
surgery fellow. The fellowship
training program is approved
Dr. Nease
by the American Academy of
Cosmetic Surgery (AACS) and
is under the direction of Dr. Nease. “Having
achieved good outcomes using laser lipolysis
to contour the neck and jowls and with the
fractional CO 2 laser for facial skin resurfacing
and tightening, he decided to investigate
combining the two technologies.”
Preliminary results from a
prospective study indicate
that a no-incision, duallaser facelift procedure
can be a viable option for
properly chosen patients
interested in a minimally
invasive alternative to a
traditional surgical facelift.
Times interview a few months after the
meeting, however, Dr. Nease says as more
patients reached the six-month visit, the
overall results improved. Based on follow-up
from about 20 patients, three-fourths were
satisfied or highly satisfied, he says.
Post-treatment sequelae included some
minor bruising and swelling from injection
of the tumescent solution. Downtime for the
majority of patients was only four to five days,
however, and there have been no significant
complications, although one dissatisfied
patient went on to a traditional facelift prior
to six months of follow-up.
PATIENT SELECTION The availability of
more patient data is also allowing insight as
to who are the best candidates for the duallaser facelift, Dr. Nease says.
“It appears this procedure is best for women
and men in their 40s who have very mild
skin laxity with mild jowling and mild-tomoderate excess fat deposits in the neck
and submental region. In fact, a significant
proportion of such patients we treated felt
the procedure made them look five years
younger, and several considered themselves
looking five to 10 years younger. That is an
impressive result for a one-hour procedure
with such reasonable downtime,” Dr. Nease
says. “However, for older individuals, above
50, who have more skin laxity, the laser
treatment itself does not seem to provide
sufficient tightening, and these patients were
less satisfied with their cosmetic outcome.”
PROCEDURE DETAILS The duallaser facelift is performed using modified
tumescent anesthetic solution and light
intravenous sedation and is completed in
less than 60 minutes. Its efficacy and safety
are being evaluated in a study that enrolled
27 nonsmoking patients ages 40 to 55 with
Fitzpatrick skin types I-III who had no prior
surgical procedures to the neck, jowls or facial
skin.
TECHNIQUE DEFINED The laser lipolysis
is performed using the Smartlipo MPX
platform (Cynosure). The settings include
total power of 12 watts with a 2-to-1 blend
of the 1,064 nm and 1,320 nm wavelengths.
The treatment endpoint is a skin-surface
temperature of 39 to 40 degrees Celsius for
the neck and 37 to 38 degrees Celsius for the
lower face and jowls, measured using infrared
transdermal thermography.
Final data collection was at six months, and
at the AACS meeting in January of this year,
Dr. Gardner reported results from the first 15
patients that showed that outcomes varied
but were generally positive. About two-thirds
of patients reported that they felt they looked
younger, but only about half thought the
procedure met their expectations and said they
would recommend it to friends. The remaining
patients were split about 2 to 1 between being
dissatisfied and neutral, Dr. Gardner says.
The Affirm fractional CO 2 laser (Cynosure)
is used for the resurfacing with settings
of 25 watts, 500 pitch, and a dwell time
of 1,500 milliseconds. After delivering a
full-face treatment with feathering along the
mandibular border and jawline, a second
pass is made on the cheeks, glabellar area,
nasolabial folds, marionette lines and perioral
region as indicated.
Providing an update in a Cosmetic Surgery
“Only the infraorbital region along the lower
bony rim was treated in the study, but outside
of the protocol, resurfacing is also performed
on the upper and lower eyelids,” Dr. Nease
says.
“
It appears this procedure
is best for women and men
in their 40s who have
very mild skin laxity with
mild jowling and mild-tomoderate excess fat
deposits in the neck and
submental region.
Carey Nease, M.D.
Chattanooga, Tenn.
”
Outcomes assessments were based on
comparisons of baseline and post-treatment
photographs by two independent cosmetic
surgeons and each patient. The photographs
were taken from five different views under
standardized lighting conditions, and there
was good correlation between the patient and
physician ratings of change. Patients also
completed a six-item survey.
At press time, Dr. Nease was completing
analyses of the data and will be submitting a
manuscript for publication. Continued followup will be needed, however, to assess the
longevity of the results, he says.
“With the earliest enrolled patients now
at about 15 months post-treatment and a
number reaching the one-year time point, no
one has undergone an additional procedure
except for the single patient who went on to a
traditional facelift,” Dr. Nease says.
“I suspect we will have to wait for two to three
years of follow-up to know how durable the
outcomes are. Certainly, patients who need
a touch-up for improving tone, texture or sun
damage could undergo another fractional CO 2
laser resurfacing after one or two years,” he
says. “Whether recurrent laxity in the neck and
jowls could be adequately addressed
with repeat laser lipolysis or would
require an invasive surgical
procedure is something we
will determine with time.”
Disclosures:
Dr. Nease is a paid speaker
for Cynosure, but he received
no financial support for the
study. Dr. Gardner reports no
relevant financial interests.
COSMETIC SURGERY TIMES
26
Global
view
Australian cosmetic surgeon offers
international perspective on facelifting
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
T
Getty Images/Comstock Images
o Australian plastic surgeon Bryan C. Mendelson, M.D., a facelift isn’t
just a facelift; it’s a social equalizer of sorts. In a discussion about what’s
new and noteworthy regarding the surgery’s evolution, Dr. Mendelson
says, “We are entering a major sociologic change where facial rejuvenation is no
longer limited to the wealthy few, but to the masses worldwide — they will be
united by the ability to conceal aging.”
He is known globally for his Melbourne cosmetic surgery practice, the Centre
for Facial Plastic Surgery. According to Dr. Mendelson, “The world of facelifts
is going through an extraordinary phase, as there is progress occurring on
several different fronts simultaneously. First, the leading surgeons are now
performing absolutely beautiful surgery. The exact aesthetic objective varies
in different parts of the world and even in different parts of the same country,
such as the difference in styles between cutting-edge Los Angeles and the more
conservative New England,” he says.
What Dr. Mendelson says he finds particularly significant in today’s facelifting
landscape is that the best surgeons are able to obtain for their patients a
JUNE 2011
27
refreshed appearance, so that they do not look as
though they have had surgery.
“Patients benefit from the evolution of our
techniques, which have largely resulted from
an improved understanding of facial anatomy,
as well as from the finesse of their surgeons,”
he says. “It is impressive that a person’s
appearance can benefit so much while (the
surgery is) completely undetectable.”
Dr. Mendelson says that after proper internal
support surgery, the rate of future aging is slowed.
“There have not been any scientific studies to
verify this, but this associated benefit is obvious
to surgeons who operate at this level,” he says.
“Accordingly, when looking naturally youthful is
the objective, then slowing the rate of aging of the
face is the best way, and therefore, the choice of
technique becomes significant.”
‘LESSER’ LESSONS The second area of
advance, Dr. Mendelson says, is in minimally
invasive, or as he refers to it, ‘lesser’ facelifts.
“Their attraction is the convenience they provide
for the patients who are willing to sacrifice the
ultimate result because that is a lesser priority,”
he says. “The reality is that a large proportion
of surgeons are being forced by the marketplace
into performing these lesser facelifts, and
in general the patients attain sufficient
improvement and do not realize the difference
from the best facelifts. The lesser benefit of
these facelifts is enhanced by complementary
procedures performed at the time, specifically
augmenting facial volume using either fat
injections or synthetic fillers.”
Dr. Mendelson says the third area of advancement
is in avoidance of surgery altogether. “The
nonsurgical alternatives for rejuvenating the
face by enhancing facial volume, mainly
with fillers, with or without skin tightening is
growing in popularity,” he says. “Not only is
there a worldwide trend for people to have
facial rejuvenation using fillers, but they are
commencing this at an increasingly younger age,
when the earliest traces of aging first appear.”
Dr. Mendelson says fillers work well, but are
expensive in the long term. “The consumer reality
is that people are motivated by a desire to avoid
surgery and are willing to pay more for less in order
to have the result now. The potential problem is
in the nature of the aging process, as it continues
unabated with exponential, not linear, progression,
while all along the filler is concealing it,” he says.
“Eventually, there is the requirement for more and
more filler volume, for a less and less natural look.”
On the up side, he says, “Continuous improvement
in fillers is inevitable from the companies who
stand to make fortunes out of having the preferred
product used worldwide.”
ANATOMICAL INSIGHTS Dr. Mendelson’s
beliefs are based on his anecdotal and clinical
practice observations as well as years of research
into facial anatomy. “It is natural for a plastic
surgeon to want to better understand the process
of facial aging in order to define a better surgical
approach,” he says. “Unfortunately, so far the
available information has not been of sufficient
quality to be useful, other than suggesting the
direction of future research.”
premasseter, with almost no bruising on the face,”
he says. “This approach to facelifting is relatively
new and important in that it delivers at last the
long-awaited goal, which is retoning the area where
most of the aging occurs on the inner part of the
cheek, without paying the price for dissecting this
far forward from the ear. Excellent correction is
obtained, yet with low risk and minimal bruising.”
“
Not only is there a
worldwide trend for people
to have facial rejuvenation
using fillers, but they are
commencing this at an
increasingly younger age,
when the earliest traces
of aging first appear.
Bryan C. Mendelson, M.D.
Melbourne, Australia
”
In the 1990s and early 2000s, useful anatomical
advances were related to understanding the SMAS,
Dr. Mendelson says. Since then, anatomical
research has focused on the structure beneath this
support layer.
“Tightening the SMAS support layer enables an
indirect retoning of the skin and most importantly
a recontouring of the shape of the face,” he says.
“The earlier research on the layer under the
SMAS related to the location and character of the
retaining ligaments of the face, and this has been a
consideration over the past 20 years.
“Now, we are in the era in which the facial spaces
in between the ligaments are being defined,”
he says. “For surgeons, these spaces are like
steppingstones across a stream in that they are
safe spaces, meaning that they do not contain
vessels or nerves. Accordingly, when the surgeon
operates through the spaces there is no bleeding or
resultant postoperative bruising.”
He says it is the understanding of where the facialnerve branches travel relative to the spaces and
ligaments that determines the ability to operate
safely in this “steppingstone” area.
“The benefit of having this is that a comprehensive
facelift can be performed on the mid-cheek
and lower face through the series of adjacent
spaces, the prezygomatic and upper- and lower-
The position of the facial ligaments is depicted in red;
soft-tissue spaces are depicted in blue. (Image credit: Dr.
Levent Efe, CMI©)
SKELETAL AGING Another area of important
research, according to Dr. Mendelson, is the
effect of skeletal aging of the face. “Despite the
consequences that changes of the facial skeleton
can have, the topic was essentially overlooked for
decades,” he says. “Only now is it realized that
there is considerable resorption of the skeleton
underlying the mid-cheek, and this contributes
enormously to the pattern of aging changes in the
mid-cheek, particularly the tear-trough deformity
and the heaviness of the nasolabial folds. When
these changes of the skeleton are corrected, there
is less need to tighten lax soft tissue.”
Correcting the resorption of the maxilla using
hydroxyapatite granules is a crucial development.
“The ability to alter the facial skeleton, as in
correction of the aging of the medial maxilla, led to
a fundamental reconsideration on aging of the face
— that people age according to the structure of their
facial skeleton,” Dr. Mendelson says. “Accordingly,
when correcting premature soft-tissue changes that
are secondary to changes in the facial skeleton, it
is a logical extension to correct this area of skeletal
weakness at the same time as the soft tissues
are being corrected. Not only does this structural
correction slow the rate of future aging, but it
enhances a person’s appearance in the direction of
freshness rather than looking artificial.”
For more information:
www.bmendelson.com.au
28
Y SCO
G
R
U
S
ETIC
M
COSMETIC SURGERY TIMES
S
Plumping
pup
Getty Images/Lena Clara
Facelift, fat injection combo
b
provides best results, surgeon says
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
F
or almost a century, plastic surgeons have believed that lifting and
tightening could fix all of the problems associated with the aging face.
That turned out to be a tall tale, according to San Francisco plastic
surgeon Timothy Marten, M.D.
“Now we know that we cannot lift our way out of all of the problems
seen on the aging face,” says Dr. Marten, who was one of the first
plastic surgeons to champion the use of facial fat injections in facelift
patients more than 15 years ago. “Experience has shown that patients
with significant facial atrophy and age-related hollowing from facial fat
loss will generally achieve suboptimal improvement from surgical lifts
alone.”
Surgeons now recognize that the face ages in three ways: The surface of the
JUNE 2011
29
skin ages, facial features sag and skin becomes
loose, and the face undergoes a process of
atrophy, and shrinks and becomes hollow.
“Now people seek me out because I do both
procedures at once,” he says.
FAT ON THE FOREFRONT Dr. Marten
“Traditional facelifts just treated the laxity and
looseness; they didn’t address atrophy,” Dr.
Marten says. “Fat grafting is really our first good
tool to address that shrinkage.”
says even after fat injections began to gain
acceptance, for the most part, surgeons were
doing either facelifts or fat injections. There were
only a few, he says, who were doing both.
Dr. Marten says that while a surgeon can insert
a cheek implant or use nonautologous fillers to
restore cheek volume and make the face look
fuller, these will typically not create the soft,
natural, feminine, healthy appearance that fat
does.
“I realized a long time ago that this was an
important tool to make my facelifts look better.
Many of my colleagues doubted this, however,
and would say, ‘It doesn’t work,’ or ‘It creates a
lot of swelling,’ or ‘The face will look too fat,’ and
these sorts of comments made a lot of patients
have second thoughts, but we’re over that hurdle
now,” Dr. Marten says. “Patients know it works,
they know they want it and they have ‘filler
burnout’ and want a more sustained improvement
that requires less maintenance. I think that’s why
it’s taking off.”
Ultimately, Dr. Marten says, neither facelifts nor
fat injections alone produce results that are as
satisfactory as those attained with a combination
of the two.
TURNING BACK TIME Despite the
fact that facial fat injections still have critics
whose primary objection to the technique is its
purported inconsistent “take,” Dr. Marten says
there is an expanding body of evidence that the
technique produces a predicable and sustained
improvement that has resulted in the procedure
becoming increasingly attractive to surgeons as
well as patients.
“It has caught fire. Just a few years ago, surgeons
didn’t believe in this, and now it has a major
following,” Dr. Marten says. “A decade ago, if
I told a patient who wanted a facelift that she
needed some fat in her face, she didn’t really
understand that. She would say, ‘Doctor, I’m
already too fat. I don’t want to look fatter.’
Gradually, patients began to learn about atrophy
as a part of the aging process. They read
about it in magazines, and they experienced
the improvement they could get with artificial
injectable fillers.”
Before patients understood and accepted the use
of fat injections as a means of obtaining a more
youthful appearance, Dr. Marten says he would
perform the facelift first and evaluate the patient
later to determine whether they could benefit
from and agree to a follow-up treatment with fat
injections. Once patients came to understand the
treatment and its benefits, however, Dr. Marten
began receiving requests to have the facelift
and fat injections done together to minimize
downtime.
“When patients started letting me do that, I
was stunned at how much better the facelifts
were,” Dr. Marten says. This, he says, may be
due in part to a not-yet-clearly defined “stemcell effect” that results in fat injections actually
inducing improvement in facial tissue quality.
Now, he says, even surgeons whose reputations
were built upon quick-recovery, limited facelifts
have seen the light and are adding fat to their
facelifts.
Dr. Marten says he believes surgeons who do not
add fat injections to their facelift armamentarium
will fall behind and be unable to compete with
their colleagues who are using them.
“For 50 years, surgeons have been debating
the best way to do a facelift, asking, ‘Where
should we put the incisions; should we do a
composite of lamellar dissection; how should we
utilize the SMAS; should we lift the periosteum;
should we do a mid-facelift or a ‘suture lift’? I
think fat injections have made these questions
moot points. Fat injections have now become
so important that what kind of facelift one does
doesn’t matter as much,” Dr. Marten says.
“Surgeons are seeing the near-sighted arguments
against fat injections for what they are and are
looking at the face more comprehensively and
in a new way. They’re not just fat grafting a few
areas; they are fat grafting the whole face to
attain comprehensive improvement,” he says.
Dr. Marten suggests that fat injections should be
used to restore pan-facial fullness because as
the patient ages, “To a certain extent the whole
face is collapsing upon itself. Really stunning
results unlike any we could obtain before” come
when fat is added all over to restore the padding
that was present in the patient’s 20s and 30s,
he says. “In the past, we performed liposuction
on the face, taking away that padding, and we
made men and women look harder and arguably
older; it was the wrong thing to do in the majority
of cases.”
In a textbook description of when it is best to
inject fat when it is being done in combination
with a facelift, Dr. Marten writes, “It is most
expedient to inject fat at the beginning of the
procedure before the facelift itself has been
started. The reasons for this include the fact that
it is easier to harvest the fat at the beginning of
the procedure before the face has been prepped
or draped and when the patient is typically in a
deeper plane of anesthesia. In the beginning of
the procedure, the tissue planes of the face have
also not been opened, the face is not swollen,
and preoperatively made pen marks and facial
landmarks are easier to identify. Finally, surgical
principles suggest that it is also likely best to
inject the fat before the start of the facelift
procedure if fat has been harvested at the
beginning of the case to limit the time the graft is
out of the body.”1
Dr. Marten says that until now, surgeons “were
merely working as tailors, but now we have
moved into the third dimension and are working
more as sculptors, and our patients are benefiting
significantly from this transition.
“Fat grafting requires the surgeon to have an
artistic sensibility and see the big picture,
and that artistic vision supersedes technique
in importance,” he says. This does not come
naturally to most surgeons, Dr. Marten says.
A 75-year-old patient before (left) and one year and seven
months after facelift and fat injections. A total of 90 cc of
fat was injected. (Photos credit: Timothy Marten, M.D.)
“I’m waiting for some really artistic people in
our specialty to get their hands on this tool,” Dr.
Marten says. “I think they will take it to the next
level.”
References:
FAT’S CHANCE The good news, according
to Dr. Marten, is that facial fat injections are not
only catching on, they are moving the evolution of
facelifts forward.
1
. The Art of Aesthetic Surgery: Principles and Techniques, 2nd Edition.
2008 Edited by Foad Nahai M.D, Simultaneous Facelift and Facial Fat
Grafting, p. 1621, Timothy J Marten, M.D., F.A.C.S., Quality Medical
Publishing Inc.
COSMETIC SURGERY TIMES
30
Eye-opener
Bioabsorbable fixation device
enables minimally invasive browpexy
Cheryl Guttman Krader
Getty Images/Image Source
S ENIOR S TAFF CORRESPONDENT
N
onendoscopic, transblepharoplasty brow suspension using a
bioabsorbable fixation device (Endotine TransBleph, Coapt
Systems) provides safe, reliable and stable results for patients
interested in minimally invasive forehead rejuvenation, according to
Mohan Thomas, M.D., D.D.S.
The procedure is performed through a small upper blepharoplasty
incision. After subperiosteal dissection, the device is
fixed within the frontal bone just above the supraorbital
rim. Subcutaneous tissue beneath the lateral brow is
engaged onto the device’s hooks to achieve secure and
even suspension.
Dr. Thomas’ experience using the bioabsorbable fixation
device includes a series of 50 patients, and he reports
they were universally satisfied with the aesthetic results.
The average brow elevation achieved was 2.2 mm, the benefit was
maintained in follow-up ranging from 8 to 15 months and there were
few minor complications such as bruising and swelling for more than 10
days.
Dr. Thomas
“There are multiple techniques for browlifting and forehead rejuvenation,
and all can claim good results with minimal complications,” says Dr.
Thomas, a cosmetic surgeon in private practice in Mumbai, India.
JUNE 2011
31
“However, traditional and subcutaneous
lifts result in long scars, while endoscopic
procedures involve a learning curve and
require special equipment.”
“The latter drawbacks are avoided in
browlifting with this bioabsorbable
fi xation device, and the procedure is also
relatively easy to learn and allows for good
intraoperative control of brow position,” he
says. “However, it is not a panacea or the
end-all procedure. There is an added cost for
using the device, a small learning curve with
a chance of causing injury to the supraorbital
nerve for first-time users, and compared with
my own percutaneous suture suspension
browlift, the surgical time is longer.”
The patients in Dr. Thomas’s series ranged
intraoperatively. The second patient required
a second procedure that was performed using
the same implant. A transient decrease in
forehead sensation lasting three to four weeks
occurred in four patients.
hole or by suturing the device to the adjacent
periosteum on either side,” he says.
SURGICAL TECHNIQUE The fi xation
device is intended to be placed just lateral to
the mid-pupillary line, and the exact position
is marked preoperatively while the patient is
in a sitting position. The upper-lid incision
is undermined to the inferior border of the
orbital rim, and subperiosteal dissection is
then performed to release the brow.
“
Using the disposable drill bit provided with
the device, an anchoring hole is created in
the frontal bone, and then the fixation device
is placed using its own insertion tool. To
Once the device is placed, the periosteum is
elevated to achieve the desired brow position
and anchored to the device using digital
There are multiple
techniques for browlifting and
forehead rejuvenation and
all can claim good results
with minimal complications.
However, traditional
and subcutaneous lifts
result in long scars, while
endoscopic procedures
involve a learning curve and
require special equipment.
Mohan Thomas, M.D., D.D.S.
Mumbai, India
”
pressure to secure the tissue onto the contact
hooks. Tissue elevation can be adjusted
intraoperatively, but the achieved height and
symmetry are best judged by viewing the
surgical field from a short distance away, Dr.
Thomas says.
A 45-year-old patient, concerned with "tired-looking" eyes, before (left) and one year after Endotine browlift and upper
blepharoplasty.
Once the tissue position is verified, the
blepharoplasty incision is closed. Dr. Thomas
says, however, he first secures the periosteum
by placing Prolene sutures laterally and
medially between the implant and periosteum
as a precautionary measure.
“The sutures represent a belt-and-suspenders
approach for fixing the brow tissue just in
case the device pops out,” he says.
A 60-year-old patient before (left) and one year after Endotine browlift and upper blepharoplasty. (Photos credit: Mohan
Although the device should maintain its
position when correctly placed, the forehead
is taped over the device with a positioning
bandage for one week to prevent any
movement and shifting.
Thomas, M.D., D.D.S.)
Disclosures:
in age from 26 to 65 years and included 16
males. Complications encountered included
implant palpability in five patients. The
affected individuals had very thin tissue
overlying the implant and the palpability
resolved within four to six months as the
device was absorbed.
Slippage of the implant occurred in two
patients. In one case, the hole was slightly too
wide and the implant had to be repositioned
ensure solid fixation, the surgeon must take
care to enter the bony plane with the drill at
a 90-degree angle and avoid using too much
torque when inserting the fixation device, Dr.
Thomas says.
“The fixation device is self-sinking and will
advance to the proper depth when inserted.
However, the hole must be properly sized.
If the device pops out when placed, the
procedure can be rescued by drilling a second
Dr. Thomas reports no relevant financial interests.
COSMETIC SURGERY TIMES
32
Building
Getty Images/Vetta/Wolfgang Lienbacher
G
blocks
Attention to architectural changes — not surface changes
— key to successful rejuvenation
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
S
ensitivity to the architectural changes
that define the aging face underscores
the importance of jowl development and
establishes correction of this feature as a primary
target in surgical rejuvenation, according to J.
William Little, M.D., who spoke at the American
Society of Plastic Surgeons’ Plastic Surgery 2010
conference.
In a two-part course on sculptural rejuvenation of
the aging face, neck, eyes and mouth, Dr. Little
emphasized that the focus of surgery to restore
a more youthful appearance should be on facial
shape or architecture more than on changes in
the facial surface (folds, texture or pigmentation).
He emphasized that shape reversal is the most
important aspect of facial aging, typically manifested
as a change from what artists might call an “inverted
cone of youth” to an upright cone, or gourd-like,
shape.
Since jowl formation and descent are the main
culprits in causing this shift in facial architecture,
a surgical technique that concentrates directly on
eliminating the jowls while restoring fullness to the
cheek area is a logical approach to rejuvenation, says
Dr. Little, clinical professor of surgery, department
of plastic surgery, Georgetown University School of
Medicine, Washington.
Dr. Little
D
Dr
Plastic surgeons have generally embraced this
concept since the mid-1990s, as evidenced by
the introduction of a variety of mid-face lifting
techniques at that time. While Dr. Little was among
those who developed such a subperiosteal midfacelift (combining it with a simple subcutaneous
plication in the superficial plane) and published on
JUNE 2011
33
“The correct mid-facelift presents sculptural
benefits, of course. However, subcutaneous
plication addresses the fatty excess of the
lower face (jowls) by re-suspending the
tissues directly to fill the accompanying
submalar deficiency or hollow,” Dr. Little
says. “This becomes a simple manipulation
that produces superior results, especially in
correcting the jowl and its bitterness and
the labiomandibular folds that so often prove
recalcitrant to facelifting.”
Since jowl formation and
descent are the main culprits
in causing this shift
in facial architecture, a
surgical technique that
concentrates directly on
eliminating the jowls
while restoring fullness
to the cheek area is a
logical approach to
rejuvenation, says Dr. Little.
Dr. Little calls the simplified procedure an
XJ lift — or external jowl lift — emphasizing
that the jowl is manipulated from its outer or
subcutaneous aspect, as opposed to the inner
or SMAS aspect.
HOW IT’S DONE In performing the
surgery, Dr. Little employs a limited facelift
incision that follows the subsideburn
hairline into a standard, hidden tragal crest
preauricular component, culminating in
a retroauricular section that remains and
ends within the sulcus, without posterior or
inferior extension (ever). He continues by
undermining the skin beyond the jowl to the
oral commissure, thereby freeing the jowl for
easy re-suspension.
“Such undermining also provides access for
occasional further reduction of the jowl by
direct scissors sculpture, as well as routine
division of depressor anguli oris (as suggested
by LeLouarn), which further aids in correction
of the bitterness and labiomandibular folds,”
Dr. Little says.
Once the undermining is completed, the jowl fat
over the premasseter space is lifted vertically
and sutured to the submalar fat along an inked
line that joins the alar base to the lobular base
using 5-0 Vicryl. Good results are maintained
long-term without using heavier or permanent
suture material and without solid fixation
to deeper structures because the surgical
manipulations occur at a superficial level, just
beneath the skin, and because the fat is moved
only a short distance, little more than an inch,
Dr. Little says.
“The corset-style or mid-line platysmaplasty
remains the gold standard for neck rejuvenation,
while the vertical Labbé suture is still a
technique in evolution. However, on an
anatomical basis I believe that ultimately the
Labbé philosophy presents the correct vector,”
he says. “My developing experience with vertical
platysmaplasty, especially when combined
with medial platysma suspension by way of
subcutaneous plication, suggests this to be a
powerful approach to neck rejuvenation without
need for submental access.”
“The recent description of the premasseter
space (by Mendelson and colleagues) as a
bursa-like area devoid of restraining elements
or vital structures explains how the jowl
forms so readily and universally during aging
and why simple subcutaneous plication with
a delicate suture can reverse it,” he says.
“Because the fat lifts easily and is moved
only a short distance, there is no strong
counterforce acting against it postoperatively.
Therefore, there is also no need to use heavier
suture material with deeper fixation.”
The subcutaneous plication
procedure brings a secondary
benefit by improving
neck contour because
the fat of the lower face
and jowl is intimately
connected to the underlying
SMAS or platysma.
He says, however, in patients with volumetric
excess in the neck associated with subplatysmal
fat, enlarged submaxillary glands or prominent
anterior digastric muscles, open access
will continue to be required to achieve
optimal results in the heavy neck with poor
cervicomental angle.
A 63-year-old patient before (left) and 10 months after
subcutaneous placation (XJ lift) to the face, liposuction
(only) to the neck, and structural fat grafting to the lids and
lips, but not the face. (Photos credit: J. William Little, M.D.)
SCULPTURING THE NECK The
subcutaneous plication procedure brings a
secondary benefit by improving neck contour
because the fat of the lower face and jowl is
intimately connected to the underlying SMAS
or platysma. Consequently, the upward fat
plication also produces suspension of the
medial fallen neck muscle. As a result, open
neck surgery through a submental incision can
often be avoided.
Dr. Little says he adds a
modified Labbé suture
for posterior platysma
suspension, which further
contributes to overall neck
correction, especially when
combined with undermining
of the neck skin beyond
any existing muscle band,
which may then be divided or
resected, as indicated.
PATIENT CONSULTATION As part of the
preoperative consultation for facial sculptural
rejuvenation, Dr. Little says he requires early,
non-smiling photographs taken during the
patient’s 20s or 30s. These images aid in
surgical planning and help patients to better
understand the architectural effects of aging
over their own lifetimes.
The oblique or three-quarter photographic pose
remains the best for architectural analysis of the
face; following well-done sculptural rejuvenation,
its postoperative component should document
restoration of an inverted-cone-of-youth
architecture, with elimination of the excess of
the jowl region and concomitant
filling and blending of the submalar
deficiency, Dr. Little says.
Getty Images/Photographer’s Choice RF/ Gregor Schuster
this technique, he has since abandoned the
deep or mid-facial component, concentrating
instead on the “old-fashioned” subcutaneous
plication — but now with added structural fat
grafting.
COSMETIC SURGERY TIMES
34
B O D Y
B R E A S T
F A C E
Lowdown
on LIPO
Comparative study highlights pros, cons
of liposuction methods
Cheryl Guttman Krader
Getty Images/Digital Vision/Michael Poehlman
S ENIOR S TAFF CORRESPONDENT
JUNE 2011
35
NATIONAL REPORT — Results of a
prospective, single-surgeon
study comparing three different
liposuction methods indicate an
ultrasound-assisted technique
offers superior efficacy relative to
both suction-assisted liposuction
(SAL) and waterjet-assisted
liposuction (WAL). Ultrasoundassisted liposuction (UAL) was
also associated with minimal
intra- and postoperative morbidity,
but is accompanied by some tradeoffs that include longer procedure
time and increased expense of the
ultrasound equipment, says Robert
J. Troell, M.D.
Dr. Troell evaluated the three
techniques in consecutive groups of
50 patients each and analyzed multiple
intra- and postprocedural endpoints.
All of the cases were performed using
the manufacturers’ specifications and
recommendations for equipment use and
under local anesthesia with oral sedation (~95
percent) or IV sedation (~5 percent). For all
three methods, patients had liposuction at an
average of three anatomical sites.
“Safety is key when performing liposuction, no
matter what technique is used. Therefore, the vast
majority of my cases are performed with just local
anesthesia and oral sedation, and all candidates
undergo a comprehensive preoperative evaluation
for medical clearance,” Dr. Troell says.
SAL (Medco) was performed using a superwet
technique (1 cc infiltration fluid per estimated 1 cc
of fat removed) with a standard cannula (Medco),
not microcannulas. The UAL cases were done using
a third-generation 36,000 Hz ultrasound platform
(VASER, Sound Surgical Technologies) and a solid
probe. WAL (Body-Jet, Human Med) was performed
using 2.5 mm and 3.5 mm infiltration cannulas and
3 mm to 5 mm suction cannulas.
Dr. Troell prepares his tumescent solution for SAL
and UAL procedures using 75 mL to 100 mL of
lidocaine 1 percent, one ampule (1 mg) epinephrine,
and 10 cc to 15 cc 8.4 percent sodium bicarbonate.
Since twice as much fluid is used for infiltration
when performing WAL, the tumescent solution is
prepared using 25 to 50 percent less lidocaine.
then the infiltration and suction can be done
simultaneously,” Dr. Troell says. “However, I learned
to use just a minimal amount of infiltration initially
because the power of the water action is reduced if
too much fluid is infused.”
UAL extracted about 10 to 15 percent more fat
than SAL, and SAL extracted about 10 to 15
percent more fat than WAL. With its extra step of
applying ultrasonic energy, UAL was associated
with the longest procedural time, while WAL was
the shortest, since suction and infiltration are
performed together.
Discomfort during the infiltration phase was
greatest in the WAL group and similar with
SAL and UAL, which Dr. Troell attributes to the
larger cannulas used for WAL versus the other
techniques (2.5 mm or 3.5 mm versus 1.8
mm). After the procedure, patients who had SAL
appeared to have the most discomfort, as they
used narcotics for one to four days postoperatively
compared with just one or two days of use by
patients in the UAL and WAL groups. SAL also
The revision rate was similarly low for all three
groups, and there were no serious complications.
UAL resulted in the greatest amount of fat
removal and highest patient satisfaction, and
it ranked favorably relative to WAL and SAL in
evaluations of intraoperative and postoperative
discomfort and postoperative bruising.
“Since liposuction was introduced by Giorgio
Fischer, M.D., in the mid-1970s, surgeons have
investigated the technique in a never-ending
quest for excellence and optimization. This study
was designed on that principle to determine the
advantages and disadvantages of each of the
three techniques and identify the best method for
body sculpting,” says Dr. Troell, a board-certified
facial plastic and reconstructive surgeon in private
practice in Las Vegas and Laguna Beach, Calif.
“Outcomes were favorable for all three techniques.
Importantly, however, the UAL patients were most
happy with their results, probably because UAL
removed the most fat and has enhanced skin
tightening, and also because there is less chance of
indentations when performing UAL compared with
SAL using standard cannulas,” he says.
STUDY METHODS The patients enrolled
in the study ranged in age from 18 to 65 years.
About 80 percent of the procedures were primary
liposuction and the rest were revisions. With a few
exceptions, the patients were ASA class 1 or 2.
A 30-year-old patient before (left) and nine months after VASER Liposuction and buttock fat grafting. (Photos credit: Robert
Troell, M.D.)
Patients receive a maximum lidocaine dose of 45
mg/kg, although the dose is reduced taking into
account potential drug interactions and other risk
factors for lidocaine toxicity.
Dr. Troell says he treats all of his liposuction
and fat-grafting patients with a seven-day
perioperative course of antibiotic prophylaxis
using oral cephalexin and clindamycin.
“The need for antibiotic prophylaxis in liposuction
is yet to be proven, but I have never had a single
infection utilizing this regime,” he says.
STUDY OUTCOMES The volume of infused
tumescent solution was greatest with WAL, which
required about twice as much fluid as either of the
other two techniques. Infiltration time was about
twice as long for SAL and UAL compared with
WAL, however.
“When performing WAL, the surgeon has to
infuse some anesthetic solution initially, but
resulted in the most ecchymosis, while bruising
was least after WAL.
“WAL and UAL use less traumatic methods to
remove fat than simple suction power. With WAL,
water under pressure separates the fat cells without
injuring vasculature or muscles and then the fat is
suctioned out,” he says. “Similarly, UAL liquefies
fat without injuring other tissue because the
cavitation energy creates expanding air bubbles that
get in between fat cells but not muscles or vessels.”
Dr. Troell says that while all of the SAL procedures
were performed using just a standard cannula,
he sometimes also uses the Mangubat FastLipo Cannula (IMI Beauty and Sound Surgical
Technologies).
“Using the Mangubat dissector enables removal of
more fat more quickly, but it also results in more
bruising,” Dr. Troell says.
Disclosures:
Dr. Troell is a national trainer for Body-Jet and VASER technologies. He reports no other
relevant financial interests.
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COSMETIC
SURGERY
TIMES
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COSMETIC SURGERY TIMES
42
B O D Y
B R E A S T
F A C E
Fighting facial
lipodystrophy
Modified facelift procedure may provide
safer results than permanent injectable fillers
TORONTO — For treatment of facial lipodystrophy, a modified facelift procedure with
placement of polytetrafluoroethylene sheets (ePTFE; Gore-Tex, Gore) to replace
lost volume is a better alternative than augmentation with permanent injectable
fillers, according to Nancy Van Laeken, M.D., who spoke at Plastic Surgery 2010,
the joint annual meeting of the American Society of Plastic Surgeons and the
Canadian Society for Aesthetic Plastic Surgery.
Dr. Van Laeken based her remarks on experiences she has had throughout the
past seven years using different methods for treating facial lipodystrophy. She
told attendees that while she was initially satisfied with the results achieved
using polyalkylimide gel (Bio-Alcamid, Polymekon) and reported her positive
impressions at a scientific meeting based on early follow-up, some patients
who received that product subsequently presented with difficult-to-treat
complications. In contrast, Dr. Van Laeken said that both she and her patients
remain pleased with the efficacy and safety outcomes associated with the more
aggressive surgical approach during follow-up that extends now to seven years.
“When polyalkylimide gel was originally described and presented to us as a
biocompatible permanent filler, it seemed to be the perfect solution for treating
the problem of facial lipodystrophy, and findings from early follow-up were
consistent with that impression. However, beginning at about one year after
the procedure, some patients returned with complaints relating to the product
shifting and malpositioning, and we have seen infections as well,” says Dr. Van
Laeken, associate professor, division of plastic surgery, University of British
Columbia, Vancouver.
“Based on this new evidence, I felt obligated to publicly recant my previous
positive report. We know that ePTFE has an established safety record from a
long-standing history of use in a number of surgical specialties, and using it for
augmentation with facelifting has resulted in outcomes that are safe, durable and
associated with high patient satisfaction,” she says.
INVESTIGATING COMPLICATIONS Dr. Van Laeken says she had
treated about a dozen patients — mostly HIV-positive patients but also a few
who had lipodystrophy secondary to tumor treatments — with polyalkylimide
gel for facial lipodystrophy, and the patients who developed complications
associated with the filler were not limited to the HIV-positive population.
To better define the prevalence and features of the complications, she is
currently conducting a multipractice chart review that includes all of her
patients as well as those treated by several plastic surgery and dermatology
colleagues in Vancouver.
“In addition to reports of product migration and infection associated with
polyalkylimide gel injection for facial lipodystrophy and other facial defects,
information is also now emerging about similar events in Asia, where the
product is being used for breast augmentation,” Dr. Van Laeken says.
In her patient series, management of the complications proved to be
challenging. Some patients had to undergo surgical removal of the
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
migrated or contaminated product using a facelift technique to expose
the cheek plane and gain access to the material. In several patients, the
product had migrated into the oral mucosa and had to be removed by
direct excision through an intraoral approach, she says.
SAFER SURGERY Dr. Van Laeken’s approach for the modified facelift
technique with ePTFE sheets comes from her success performing the same
procedure in patients with facial paralysis, where the primary purpose
for laying the synthetic graft is to provide a static sling for supporting the
paralyzed tissue.
“Through doing that work in patients who had facial paralysis as a result
of a stroke or Bell’s palsy, I realized that the ePTFE sheets also filled up
hollowing that was present, and so I reasoned it might also work well as a
filler for the subcutaneous defect in patients with lipodystrophy,” she says.
In the procedure, the ePTFE sheets are inserted into the facial region in
areas of soft-tissue deficiency using a modified facelift approach. After
making the facelift incision, the plane is dissected similar to what one
would elevate for a traditional facelift, extending to the nasolabial fold
and up into the arch of the zygoma. The ePTFE is placed in the area,
sometimes using several layers to help fill the defects and including an
onlay into the temporal region.
The material is usually secured into position using interrupted 4-0 Vicryl
sutures to prevent movement during the healing process. Then the skin
is redraped over the ePTFE graft, and the redundant skin is resected and
inset as would be done for a traditional facelift.
Dr. Van Laeken acknowledges that a desire to avoid surgery in HIV-positive
patients was a primary motivation for using an injectable filler to treat
facial lipodystrophy. Although the surgical approach has proven to have
a more favorable benefit-to-risk ratio, patients are carefully selected for
surgery, and strict precautions are followed to prevent infection.
“Surgery is not undertaken as a unilateral decision, but rather in a team
approach that involves the input of the infectious disease specialist who
is managing the HIV disease,” she says. “White blood cell counts and
viral loads are checked prior to operating to make sure they are within an
acceptable range, all patients receive perioperative antibiotic prophylaxis,
and the procedure is performed in an operating room using sterile
technique.
“Fortunately, we have not seen any infections so far, but these are also very
motivated and conscientious patients who can be relied on to comply with
instructions and cautions for postoperative care,” she says.
Disclosures:
Dr. Van Laeken reports no relevant financial interests.
Invited Speakers
For more details please contact:
Pam Storey at (402) 697-6566 or
[email protected]
The 3rd Annual
UP TO
EARN A PRA
18 AM ORY
CATEG ITS ™
D
1 CRE
Cosmetic Surgery Forum 2011
Discussions in Dermatology
Live Demos/Case Discussions With a Multispecialty
Approach and Practice Management Sessions
• NEW! 1/2 Day MOC Board Review Course!
• Cosmeceuticals: What’s new? Top 10 list of cosmeceuticals!
• Cosmetic Surgery: What’s new? What should you avoid? What’s a
waste of money?
• New Frontiers: What’s the next ‘big thing’ in cosmetic surgery?
• Lasers and Hand-held Devices: How do you compete against Nordstroms?
• Lightening Skin: Is it safe and does it work? Can it be done without
hydroquinone?
• Mole Mapping Versus the Dermatogist: Are melanoma detection
devices a good idea?
• Electronic Medical Records: Costs, risks and implementation for
full service practices.
• Defending Your Reputation: Keeping your reputation intact in an
electronic world.
Heidi Waldorf, MD
Hema Sundaram, MD
Cory Maas, MD
Steven Dayan, MD
Vivian Bucay, MD
Ira Berman, MD
Mimi Cummings, MD
Bill Danby, MD
Haines Ely, MD
Curtis Samlaska, MD
Candace Spann, MD
Cheryl Burgess, MD
Manjula Jegasothy, MD
Jeanette Graf, MD
Mike Kluska, DO
Rhett Drugge, MD
Joseph Niamtu, MD
Adam Rotunda, MD
Jeanine Downie, MD
Julie Woodward, MD
Jason Michaels, MD
Joe Eastern, MD
Mitch Goldman, MD
Art Huntley, MD
Founder of Dermchat
and RxDerm
Invited Press
Paul Winnington
Editor, Practical Dermatology
Sharon Finch
Publisher, Cutis
Amy Stankiewicz
Managing Editor, Dermatology Times,
Cosmetic Surgery Times
Amy Pfeiffer
Editor, Skin and Allergy News
Eliza Drewa
Executive Editor, New You Magazine
Marcus Schmidt
VP of New Products &
Strategic Alliances, Infogroup
Rick Ehrlich
Group Publisher, Skin and Aging
Course Director
Joel Schlessinger MD, FAAD, FAACS
Past President, American Society of Cosmetic
Dermatology and Aesthetic Surgery
This meeting will be commercially supported by
unrestricted educational grants.
Jointly Sponsored by
CME Information
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical
Education (ACCME) through the joint sponsorship of the Dulaney Foundation, Practical Dermatology and Cosmetic Surgery Forum, LLC. The Dulaney
Foundation is accredited by the ACCME to provide continuing medical education for physicians. The Dulaney Foundation designates this live activity
for a maximum of 18 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the
activity.
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© 2011. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical, Ltd. ePrime, eMatrix,
elure, CO2RE, Sublative Rejuvenation and Syneron Advantage are trademarks of Syneron Medical, Ltd. and may be registered in
certain jurisdictions. Candela, the Candela logo and GentleLASE are registered trademarks of Candela Corporation. 01034