Bicoronal forehead lift

Although aesthetic surgery on the upper third of the face has received relatively little attention in recent literature, it is an extremely important component of facial aesthetic surgery and often yields results that are quite dramatic. Periorbital rejuvenation, either alone or in conjunction with other aesthetic surgical procedures, offers facial enhancement to younger patients. In addition, older patients may benefit from a forehead lift performed in conjunction with lower facial surgery. This benefit is derived because lower facial surgery may create facial disharmony by yielding a more youthful lower face while leaving a more mature upper face. In these cases a forehead lift serves to unify the patient's facial appearance. The coronal browlifting technique described here is a personal interpretation and modification of periorbital rejuvenation techniques. This approach represents an ideal aesthetic procedure: It is a technically straightforward operation that yields results which are predictable, natural appearing, and long lasting with minimal morbidity.     

Evaluation of facial skeletal aesthetics and surgical planning

Proper surgical planning for aesthetic facial skeletal surgery requires of the surgeon not only intimate knowledge of available techniques but also an understanding of how and when to apply those techniques. To this end, proper facial form analysis is essential. In this introduction we have attempted to describe the elements of such an analysis, realizing that much remains to be learned about how the bone and soft tissue interact. In many ways the soft tissue--bone relations remain the unexplored area in aesthetic skeletal surgery. The further delineation of these relations by the use of anthropometry, laser light scanning, ultrasound, CT, and MRI remains an open area for investigation. The potential is enormous for using these data to study how bone and soft-tissue relationships combine to create facial form and how this form changes with both surgery and normal aging.     

Three-dimensional facial contouring: utilizing upper-midface suspension technology and alloplastic augmentation

Facial aesthetic surgery procedures have evolved to the highest level possible, the three-dimensional restructuring of facial form. Repositioning of the deep soft tissue planes from the neck to the zygoma as well as subperiosteal, upper, and midface elevation have become commonplace. Alloplastic implant contouring is not only a useful adjunct, but it should be a fundamental tool used with the variety of new facial aesthetic techniques. It is now possible for the aesthetic surgeon to variously restore, rejuvenate, or enhance facial forms of either hereditary or aging origins. Infinite variations in facial contour are now possible. By using alloplastic techniques based on concepts of zonal anatomy and aesthetic deficiency typing, the bony and soft tissue contours of the face can be created or modified with a minimum of complications. The use of alloplastic implants on the "fourth skeletal plane" represents an optimum, significant, three-dimensional manipulation of both the soft tissues of the face and the skeletal anatomic elements of mass and volume.     

Use of expanded polytetrafluoroethylene in aesthetic surgery of the face

Aesthetic surgery procedures and materials available to improve the appearance of various subunits of the face have been evolving for the past several decades. Initially, techniques such as direct excision or placement of autogenous tissue grafts (e.g., fat, fascia, tendon, and dermal fat grafts) were used. Additional options became available with the development of silicone, injectable collagen, and ePTFE. These options for facial augmentation can be done rapidly in an office setting and as an outpatient. An important aspect of treatment is discussing clearly all pertinent options with the patient, and recommending the appropriate option based on the patient's anatomic findings and personal needs. For example, patients desiring lip augmentation but unsure about the result may be best treated with collagen injection, which gives temporary results and lets the patient consider a long-term result provided by ePTFE or autogenous grafts. Use of ePTFE in facial aesthetic surgery gradually has increased over the past two decades. Its use in augmentation of lips, nasolabial creases, and nose is becoming an important treatment modality for aesthetic surgeons.     

Aesthetic improvements in mid-lower face skeletal surgery

Current surgical techniques allow to correct congenital and acquired facial deformities as well as aesthetic deficiencies resulting from inadequate bone support with excellent functional and aesthetic results. Hard and overlying soft tissue being in a closer anatomic relationship, remarkable aesthetic improvements can be achieved through the three-dimensional shifting of skeletal sections. Hence, facial aesthetic plays such an increasingly critical role in the repair surgery of basal deformities and in the surgical correction of poor aesthetics associated with growth abnormalities as to possibly trespass plastic surgeons' scope of activity. After setting forth our diagnostic and therapeutic guidelines through some relevant clinical cases, the increasingly closer relation between aesthetics enhancement and purely functional surgery of facial muscular and bone structures will be emphasized. Finally, some of the possible treatments currently available will be outlined.     

Correcting the unfavorable outcomes following facelift surgery.

Although many deformities formerly observed after rhinoplasties are seen less because of more sophisticated techniques, the deformities that may occur after conventional facelifts seem to be growing by epidemic numbers because of the widespread and almost universal use of conventional facelift and blepharoplasty techniques. The unfortunate appearance of these patients is the fault neither of the surgeon nor of the patient, but frequently both get blamed. Throughout every step of the history of medicine there have been improvements made that cause the physician to abandon a technique or medications that clearly are shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. More sophisticated techniques like composite rhytidectomy have a steeper learning curve, take more time to perform, and require longer periods of convalescence for the patient. Many experts in aesthetic surgery continue to teach conventional techniques because the public does not seem to know the difference. Fashion magazine articles on aesthetic surgery promote simple and easy techniques without bothering to explain the unfortunate and minimal results that are obtained. The obligation of any surgeon doing aesthetic surgery is the same as any physician must have in any medical field. If any operation would give a patient a suboptimal or negative result, then attempts must be made to improve these techniques. Although traditional techniques will continue to be used, there are certain conclusions that can be made: 1. More people who have undergone plastic surgery are showing eventual signs of surgery that are neither attractive nor youthful. It is clear that results of conventional facelift techniques are not predictable and are often unfavorable. 2. Facelift deformities are not the fault of the surgeon but are natural byproducts of the techniques that are used. These techniques must be improved. 3. Composite rhytidectomy with orbital fat preservation as a primary procedure will create a harmonious facial rejuvenation that will disallow the appearance of unwanted deformities such as hollow eyes and the lateral sweep. 4. Composite rhytidectomy as a secondary procedure produces the most effective correction of the unintentional but unfavorable results that follow traditional rejuvenative surgery.     

Implants for male aesthetic surgery

Male aesthetic surgery is rapidly becoming more popular. Increasing emphasis is being placed on facial skeletal contour. Prominent cheek bone and jaw line structure are highly desirable male characteristics. Newer anatomic designs for malar and premandible implants now exist and can be utilized with minimal risk. Following zonal principles of facial skeletal anatomy greatly enhances precision and predictability of result and form.     

When osteotomies should be considered

Osteotomy at various levels of the facial skeleton is entirely justified in selected aesthetic surgical patients. By the very nature of aesthetic surgery, the morbidity potential associated with such osteotomies must be extremely low. Accordingly, osteotomy at the symphyseal level and the LeFort I level are the most commonly performed procedures in the aesthetic surgical patient. Aesthetic changes required in the vertical plane of space will require osteotomy, because these cannot be reliably and consistently achieved through changes in skeletal surface contour. Lastly, when the extent of change required is greater than what can be naturally achieved with surface augmentation, osteotomy must be considered. This last indication is frequently found in the aesthetic surgical patient presenting with a facial skeletal imbalance that has been previously treated with orthodontics to correct a skeletally based malocclusion. Recent technical advances have markedly reduced the associated morbidity of facial osteotomies and, therefore, have made this treatment option more acceptable to aesthetic surgical patients. Ceramic orthodontic brackets and surgical hooks and lingual orthodontic appliances have made presurgical orthodontic preparation more aesthetic and socially acceptable for LeFort I osteotomy patients. The use of rigid fixation, obviating the need for any postoperative intermaxillary fixation, has also made this treatment approach more appealing to aesthetic patients. Lastly, the efficacy of nonresorbable bone substitutes--in particular, porous, block hydroxyapatite--has, to a significant extent, obviated the need for harvesting autogenous bone grafts, further reducing surgical morbidity.     

颜面部外伤美容修复106例报告

目的：探讨颜面部外伤的美容修复方法。方法：采用美容外科原则和技术对106例颜面部外伤患者进行修复治疗,并进性临床疗效的评估。结果：1例血肿,105例一期愈合,外观及功能满意。结论：美容外科技术是颜面部外伤修复的有效手段。     

Mesenchymal stem cells: Aesthetic applications

Adult stem cells may have significant aesthetic surgery applications. Their replicative capacity and plasticity may be useful in engineering autologous grafts for soft tissue and facial skeletal augmentation. Another possibility is that increasing the concentration of mesenchymal stem cells in the facial soft tissue at regular intervals during adulthood will maintain volume and elasticity. (Aesthetic Surg J 2003;23:504-506.)     

Rhytidectomy and Parotidectomy Combined in the Same Patient

Until now, aesthetic goals in parotid surgery have seldom been addressed because oncologic concerns have largely overshadowed aesthetic issues for patients with parotid masses. Fortunately, the majority of parotid masses are benign pleomorphic adenomas that rarely recur, leaving a large group of patients healthy after their parotid surgery, with some desiring aesthetic improvement in their facial appearance. Traditional parotidectomy incisions leave a visible scar on the neck as well as a visible hollow in the retromandibular region, which can extend onto the cheek. A rhytidectomy approach to the parotid gland allows for a more concealed, aesthetically appealing scar while maintaining good visibility and access to the parotid gland. By performing bilateral sub-SMAS (superficial musculoaponeurotic system) rhytidectomy after a parotidectomy, facial symmetry and balance is enhanced, and these aesthetic deformities can be minimized. The SMAS flap can help to fill the hollow and form a tissue barrier over the resected gland to prevent gustatory sweating. Finally, the incision scarring is minimized with a rhytidectomy-type approach. Two cases are reported in which patients underwent both rhytidectomy and parotidectomy. In the one case, the procedures were performed in the same surgical setting. In the other case, they were performed in a delayed fashion. These cases exemplify the possibility of addressing facial aesthetic goals of rejuvenation in a patient requiring parotid resection.     

Facial sculpting: Comprehensive approach for aesthetic correction of round face

Context:

Standards for an aesthetic face are dynamic. The current trend is towards a leaner looking face with preservation of the inverted triangle of youth. Procedures that have been reported to be employed for correction of a chubby face include buccal fat pad excision, facial liposuction and injection lipolysis. In addition to giving the face an aesthetic triangular cut, chin and malar augmentation may be performed. The rounded appearance at the angles may further be reduced by injection of Botulinum toxin into the masseter.

Materials and Methods:

Forty patients who presented to us for correction of chubby (round) faces were analysed and treated by facial sculpting surgery, which included at least two of the procedures in combination. The procedures included facial liposuction, buccal fat pad excision, chin augmentation, malar augmentation and injection lipolysis. All cases were followed-up for a minimum of 6 months after surgery.

Results:

Aesthetic expectations of the patients were met in 39 cases, one patient complained of facial asymmetry following facial liposuction and was subjected to a touch-up injection lipolysis.

Conclusions:

A combination of procedures is necessary to give the face an attractive contour. All the individual procedures have stood the test of time and are safe, proven and are put in mainstream. However, a thorough analysis of the face preoperatively and then subjecting the patient to a combination of these procedures in a single surgical sitting has yielded good results as seen in this study.KEY WORDS: Chubby face, facial restructuring, facial sculpting, round face     

Facial Self-Perception, Well-Being, and Aesthetic Surgery

BACKGROUND: It is controversial whether impaired well-being is associated with (a) an increased likelihood of having a negative body/facial image; or (b) dissatisfaction with the postoperative result following aesthetic surgery. We set out to improve current knowledge in this matter. METHODS: A total of 324 subjects (n = 162 females, n = 162 males, 18-30 years) were photographed, asked to complete the adjective mood scale and to rate 46 statements regarding their own appearance, and its impact on social functioning as well as their willingness to undergo aesthetic surgery on a visual analog scale. The photographs of these subjects were also assessed by 50 independent judges. RESULTS: Average self-awarded ratings of appearance were significantly more positive in subjects with normal as compared to those with impaired well-being (P = 0.014). Items regarding the impact of appearance on social functioning were answered significantly more negatively by subjects with impaired well-being as compared with those with the normal well-being (P = 0.001). Subjects with impaired well-being did not declare an increased willingness to undergo aesthetic surgery (P > 0.197). Assessment by the independent judges did not reveal differences in the average level of attractiveness of subjects with impaired well-being and those with normal well-being (P = 0.666). CONCLUSIONS: Impaired well-being is associated with impaired facial selfperception, independent of attractiveness. Willingness to undergo aesthetic surgery seems not to be affected by one's sense of well-being. In the subjects with impaired well-being who undergo aesthetic surgery, facial self-perception seems unlikely to be improved.     

Membranous bone healing and techniques in calvarial bone grafting

Membranous bone grafts have become an integral part of facial skeletal reconstruction. The convenience of harvesting the graft material from a single operative site was no doubt the reason for its initial utilization. In recent years membranous bone has been shown to be more resistive to resorption and perhaps even provide greater strength per unit volume than does its endochondral counterpart. These facts plus a relatively hidden, nonpainful donor site make membranous bone a desirable graft material. Grafts can be harvested in a variety of forms from dust to vascularized segments, totally dependent on the need. The various techniques of harvesting and methods of utilization are discussed. Rigid fixation has enhanced these techniques, and as the technical aspects improve, so do the results. The use of membranous bone has expanded from the field of congenital craniofacial surgery to the correction of traumatic facial deformities to purely aesthetic surgery. As more experience is gained, the utilization and indications for membranous bone grafting will continue to expand rapidly.     

Surgical treatment of forehead and glabellar wrinkles]

Many surgeons concerned with aging in the jowl and neck often overlook more objectionable changes in the upper face. These changes produce not only an old or aged appearance but inappropriate expressions as well. This paper outlines the elements of aging in the upper face and details the planning and execution of the foreheadplasty. Topics discussed include inappropriate facial expressions, upper facial aesthetics, incisions for bald or balding men and techniques for minimizing scars. For many years the evolution and application of techniques for rejuvenation of the upper face lagged behind that of procedures used to correct aging in the cheek and neck. Men were generally overlooked as candidates for foreheadplasties by surgeons who believed these procedures not to be possible on bald or balding scalps. In addition, patients were frequently disappointed after surgery due to objectionable secondary deformities. These include bizarre expressions from over-resection of forehead muscles, contour irregularities following imprecise muscle sculpturing, inappropriate appearances due to eyebrow malpositioning and aesthetic imbalances resulting from hairline shifting. For these and other reasons some surgeons deemed the procedure to be of questionable value. The author would like to share current concepts and new techniques which have overcome these problems and delivered satisfaction and happiness to many patients.     

Hemiface Rhytidectomy

In the current study, skin flaps raised in the subcutaneous plane were applied for 22 patients who underwent reconstruction for unilateral upper facial skin defects after skin tumor surgery. The defect was reconstructed with flaps designed via procedures similar to classic rhytidectomy techniques using periauricular and temporal skin incisions. Objective assessment of the aesthetic result was possible by comparison with the healthy contralateral side of the face. Immediate postoperative evaluation confirmed facial asymmetry due to unilateral skin tension. High patient acceptance of the procedure, uneventful flap healing, and good aesthetic results were achieved, with almost complete restoration of facial symmetry 1 year postoperatively. In conclusion, unilateral rhytidectomy without plication or resection of the subcutaneous musculoaponeurotic system (SMAS) is an ideal application of aesthetic surgical techniques for the reconstruction of unilateral skin defects.     

Alloplastic facial contouring: Surgery of the fourth plane

Plastic surgeons are now better prepared to fulfill the primary goal of facial aesthetic surgery. By manipulating and combining the various new techniques, they can restore, rejuvenate, or enhance facial form and affect aging changes. Infinite variations in facial contour can now be achieved with alloplastic facial implants. By using techniques based on the concepts of zonal anatomy, the facial skeleton can be augmented with a minimum of complications. Alloplastic onlay techniques significantly improve facial contour to correct both hereditary deficiencies in youth as well as aging changes. The use of implants in the fourth skeletal plane, as defined by the author, represents the newest favorable manipulation of volume.     

Preoperative assessment of the aging patient

The issues related to preoperative evaluation and facial analysis for patients undergoing facial rejuvenation procedures are discussed in this article. A key component of the preoperative evaluation begins with a thorough understanding of the patient's concerns and desires for improvements. Other components of the evaluation should include a detailed assessment of the patient's medical and psychiatric history, informed consent, and photographic documentation. Additionally, we discuss facial changes associated with aging, paying special attention to some of the differences that occur between male and female patients. Different aesthetic scales and their applications in facial plastic surgery are also presented. Finally, we consider the process of facial analysis in the context of common facial plastic procedures including rhytidectomy, blepharoplasty, browlift, and minimally invasive techniques.     

Full Face Rejuvenation in Three Dimensions: A ``Face-Lifting' for the New Millennium

Traditional facial rejuvenation techniques address the face by lifting the soft tissues in one or two dimensions. The face is a tri-dimensional structure and aging occurs in three dimensions, therefore, facial rejuvenation should be done in three dimensions. Sagging of facial soft tissues occurs inferiorly and inferomedially. The ideal reorientation during rejuvenation is in the opposite direction: vertically and supero-laterally. Two other elements not routinely addressed by traditional rejuvenative operations are reduction of skeletal framework and atrophy of soft tissues, particularly subcutaneous fat layer. These are the third dimension of facial aging. By principle, any technique that unfolds, pulls, or lifts produces a flattening effect of the structure being treated. They may give a false impression of augmentation if these tissues are advanced over bony prominences. These stretched out tissues also have a tendency to recoil. For that reason, the author suggests use of structures or methods less susceptible to a stretch relaxation or recoil. A prerequisite to 3-D facial rejuvenation is to perform a 2-D-(bi-dimensional) lift. A third dimension is integrated into it. There are four methods to provide the third dimension: (1) augmentation of the skeletal framework; (2) augmentation of subcutaneous layer with fat injection; (3) imbrication of soft tissues; (4) mobilization and repositioning of fat pockets as pedicle flaps. These methods are not exclusive to each other. One, a few, or all methods could be integrated according to the patient's needs and aesthetic goals. Tridimensional changes in facial rejuvenation can be assessed by a standard photographic comparison, using tools for in-vivo measurements or 3-D digital imaging. 3-D facial rejuvenation is an advanced concept in our pursuit to provide superior results with the more aesthetic, natural, and harmonious youthful look to our patients.