Front Matter| Volume 5, ISSUE 1, Pvii-xiv, May 2022

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        Editorial Board, iii
        Contributors, v

        Introduction,  xv

        By Gregory H. Branham, Jeffrey S. Dover, Shilpi Khetarpal, Smita R. Ramanadham, and Allan E. Wulc

        Preface:  xvii

        By Jeffrey S. Dover

        A Multimodal Approach to Melasma,  1

        By Kourtney Pony and Kiyanna Williams
        Melasma is a dermatologic disorder with a female predominance that most commonly presents in sun-exposed areas. It is estimated to affect approximately 5 to 6 million people within the United States. The current recommended treatment approach to melasma is multifactorial with strict photoprotection being an essential component of every treatment approach. First-line treatment options include topical therapies, such as hydroquinone and tranexamic acid. Second-line treatment options include oral therapies, retinoids, chemical peels, microneedling, and laser therapies. Multiple studies have shown optimal results with combination therapy.
         Background,  1
         Clinical Approach,  1
        Nonprocedural treatments,  1
        Procedural treatments,  3
         Summary,  5
         Clinical Care Points,  5

        Platelet-Rich Fibrin,  9

        By Taryn Murray and Shilpi Khetarpal
        Platelets contain growth factors that stimulate synthesis of new collagen, elastin, glycosaminoglycans, and vasculature. Autologous platelet concentrates have many uses in aesthetic medicine including hair restoration, skin rejuvenation, scar revision, fat grafting, and dermal augmentation, with immense potential for additional applications. Historically, platelet-rich plasma was the most commonly used autologous platelet concentrate. Platelet-rich fibrin, a second-generation autologous platelet concentrate, has emerged as the preferred therapy given it is less expensive, easier to produce, and yields comparable to superior results.
         Introduction,  9
        Mechanism of Action,  9
        Platelet-Rich Plasma: First-Generation Autologous Platelet Concentrate,  10
        Platelet-Rich Fibrin: Second-Generation Autologous Platelet Concentrate,  10
         Procedural technique,  10
        Preoperative Planning,  10
        Absolute Contraindications (Adapted from Harmon and Colleagues),  10
        Relative Contraindications,  11
        Preparation,  11
        Postprocedural Care,  11
        Rehabilitation and Recovery,  11
         Clinical results in the literature,  11
        Skin Rejuvenation,  11
        Natural Filler,  11
        Androgenetic Alopecia,  11
        Fat Grafting,  14
         Potential complications/risks/benefits/limits,  14
         Summary,  14
         Clinics care points,  15
         Disclosure,  15

        Radiofrequency Microneedling,  17

        By Marcus G. Tan, Shilpi Khetarpal, and Jeffrey S. Dover
        Radiofrequency microneedling (RFMN) creates tiny skin perforations and delivers thermal energy to underlying tissues to cause dermal coagulation, collagen remodeling, and neoelastogenesis, via a wound-healing response. The skin perforations also improve transcutaneous absorption of topical products and transcutaneous elimination of skin debris. There is high-quality evidence supporting its use for skin rejuvenation, acne vulgaris, acne scars, and axillary hyperhidrosis (AH). RFMN can be a safe option with lower risk of postinflammatory dyspigmentation, especially in those with darker skin phototypes. RFMN can be safely combined with other therapeutic modalities to augment clinical outcomes.
         Introduction:,  17
         Radiofrequency,  18
         Mechanism of skin tightening and rejuvenation in radiofrequency microneedling,  19
         Wound healing response,  19
         Importance of epidermal protection,  19
        Pathogenesis of postinflammatory hyperpigmentation,  19
        Differences between radiofrequency microneedling and lasers,  19
         The evidence supporting radiofrequency microneedling,  20
        Skin rejuvenation,  20
        Acne vulgaris,  20
        Acne scars,  20
        Axillary hyperhidrosis,  21
         Striae distensae,  21
         Papulopustular rosacea,  22
         Male-pattern androgenetic alopecia,  22
         Cellulite,  22
         Melasma,  22
         Adverse events and complications,  22
        Patient selection,  22
        Pre- and post-treatment protocol,  23
        Limitations,  23
         Summary and conclusions,  23
         Clinics care points,  23

        Thread Lifts--Theory, Technique, Results and Duration of Effect,  27

        Video content accompanies this article at
        Thread lifts, or suture suspension procedures, were first introduced in 1993 and have gone through numerous modifications and iterations, and their popularity has waxed and waned. Now, they are once again in vogue. The threads used in the U.S. with FDA clearance are primarily composed of absorbable PDO and PLLA/PGLA materials with variable configuration of barbs or cones. The barbs and cones allow for grip, suspension and lift of soft tissues. It is a quick office procedure with minimal downtime. Risks are generally self limited due to the absorbable nature of the products. Patient selection is important as results are modest and last approximately 1 to 2 years.
        By Usha Rajagopal
         Introduction,  27
        Suture classification by material,  28
         Mechanism of PDO thread lifting,  28
         Mechanism of action,  28
         PDO suture classification,  28
         Suture composition and placement,  28
         Patient selection and indications,  28
        Pre-procedure instructions,  28
         Complications,  34
         Results,  35
         Summary,  35
         Clinics care points,  35

        Nonsurgical Approaches to the Aging Neck,  37

        By Mathew N. Nicholas, Sara R. Hogan, Michael S. Kaminer, and Jeffrey S. Dover
        Nonsurgical neck rejuvenation treatments can create meaningful differences for patients while having less recovery time and risk of adverse effects when compared with surgical treatments. The choice of nonsurgical treatment should be tailored to the patient’s specific concerns, which can be categorized as (1) dyschromia, (2) horizontal neck lines, (3) platysmal banding, (4) skin laxity, and (5) submental fullness. The options for treatment are numerous and include cosmeceuticals; chemical peels; intense pulsed light; ablative and nonablative lasers; energy-based devices including microfocused ultrasound with visualization, monopolar capacitive-coupled radiofrequency, and radiofrequency microneedling; neuromodulators; fillers; deoxycholic acid; cryolipolysis; and laser lipolysis.
         Introduction: nature of the problem,  37
         Pretreatment planning,  37
         Dyschromia,  38
        Cosmeceuticals,  38
        Chemical peels,  38
        Lasers and energy-based devices,  38
         Horizontal or transverse neck lines,  38
        Neuromodulators,  39
        Fillers,  39
        Lasers and energy-based devices,  40
         Platysmal Banding,  40
        Neuromodulators,  40
         Skin Laxity,  41
        Dermal fillers,  41
        Lasers and energy-based devices,  43
         Submental fat and fullness,  47
        Deoxycholic acid,  47
        Cryolipolysis,  48
        Laser and energy-based devices,  48
         Summary,  48
         Disclosure,  48

        Isolated Deep Neck Lift in the Young Patient for Facial Reshaping,  53

        By Danielle Cooper and L. Mike Nayak
        This article discusses the use of isolated deep plane neck lifts in the young patient. Young patients typically do not require formal facelift procedures. However, some may present wanting improvement in cervicomental contours. In this patient population, the blunted cervicomental angle may not be solely due to excess supraplatysmal fat. A surgeon must be able to address the deeper underlying causes of a blunted contour. This article discusses patient selection and evaluation, pertinent anatomy, detailed surgical techniques, and common complications and management. The reader will have a detailed understanding of how to safely perform this procedure and achieve desired results.
         Introduction,  53
         Deep neck anatomy,  54
         Planning,  54
         Surgical procedure,  54
        Marking,  54
        Anesthesia,  54
        Procedure Details,  55
         Postoperative care considerations,  59
         Complications,  59
         Case presentations,  59
         Summary,  60
         Clinics care points,  60
         Disclosure,  60

        The Ultralift: Ultrasound and Energy-Based Facelifting,  63

        By Richard D. Gentile
        Energy-based facelifting or Tesla facelifting is a relatively new concept. In energy-based facelifting energy devices such as fiber lasers, radiofrequency, ultrasound, or plasma devices are used to elevate skin flaps or deep structures of face and neck to perform the surgery. The author has used energy-based devices to complete portions of facelifts since 2008, and the number of successful cases is in the thousands. The author describes the technique with the preferred energy-based devices noted.
         Aging demographics and facial rejuvenation procedures,  63
         Introduction to TESLA Rhytidectomy,  63
         Technology-tissue interaction mediating TESLA rhytidectomy,  64
        Collagen shrinkage, morphologic change,  64
        Hemostasis,  64
        Enhanced tissue dissection,  65
        Biochemical and thermal-mediated events,  66
        Late effects of thermal mediated fibrous-adipose tissue remodeling after thermal fibroliposculpture,  67
         Hybrid procedures the 5 approaches to combining energy devices with rhytidectomy and neck lift surgery(TESLA Facelift Classification,  69
         Hybrid and procedures,  69
        Hybrid and procedures,  69
        Device-only approaches ( TESLA rhytidectomy I),  69
         Nonexcisional and platysmal modifications (TESLA rhytidectomy II),  70
         Minimal excisional rhytidectomy with platysmal and SMAS modifications ( TESLA rhytidectomy III),  70
         Conventional excisional rhytidectomy face and neck ( TESLA rhytidectomy IV),  71
         Conventional rhytidectomy and full facial resurfacing ( TESLA rhytidectomy V),  73
         Patient safety and complications of thermoplastic rhytidectomy,  74
        Complications,  75
         Summary,  75
         Clinics care points,  76

        Neck Lift with Platysma Excision,  79

        By Angelo L. Cuzalina, Pasquale G. Tolomeo, and Victoria A. Mañón
        The face is one of the most aesthetically pleasing aspects of the human person and is the first area acknowledged by an individual. Society places a large emphasis on attractiveness and distinctiveness, pushing for the “younger” look. The aging face is based on multiple factors including skin laxity and excess, lipomatosis, rhytids, and loss of facial volume. For the skilled surgeon, the complete process for facial rejuvenation begins the moment one interacts with the patient and ends with addressing the facial unit and all its parts. Treating an isolated part of the facial subunits does an enormous disservice to the patient and produces an unaesthetic result. The goal of this article is to discuss surgical techniques of a neck lift with platysma excision–as well as its limitations–for the creation of an aesthetic face.
         Introduction,  79
         Anatomy,  79
        Facial layers,  79
        Superficial muscular aponeurotic system (SMAS),  81
        Platysma,  81
        Neurovascular anatomy,  81
        Submental/submandibular region and neck,  83
         Classifications,  84
         Limitations and contraindications,  84
        Surgical technique,  87
        Patient discussion,  88
        Prep and patient positioning,  88
         Complications,  94
         Summary,  96
         Clinics care points,  96
         Disclosure,  96

        Update on Expanded Use of Kybella,  99

        By Ryan C. Kelm and Omer Ibrahim
        Deoxycholic acid (DCA) is a novel injectable treatment option approved for the reduction of submental fat. The efficacy and side effect profile of DCA may be advantageous compared with those of more invasive options. This article discusses practical approaches for using DCA in the submental region with a focus on patient selection, pretreatment and posttreatment planning and evaluation, and proper injection technique. Current literature examining off-label indications for DCA is explored, including jowls, infraorbital fat, periaxillary fat, abdominal fat, lipomas, xanthelasma, piezogenic pedal papules, paradoxic hyperplasia of adipose tissue, and fibrofatty residue of involuted infantile hemangiomas.
         Introduction,  99
         Mechanism of action,  99
         Deoxycholic acid for submental fat reduction,  99
        REFINE clinical trials,  100
        Practical approaches for deoxycholic acid use in submental fat reduction,  100
        Safety and adverse events,  101
        Off-label fat contouring with deoxycholic acid,  103
        Jowls,  103
        Infraorbital fat,  103
        Periaxillary fat,  108
        Abdominal fat,  109
        Lipomas,  109
        Xanthelasma,  109
        Piezogenic pedal papules,  110
        Paradoxic hyperplasia of adipose tissue,  110
        Fibrofatty residue of involuted infantile hemangioma,  110
        Deoxycholic acid dilution,  110
         Summary,  110
         Clincs care points,  110
         Disclosure,  110

        Fat Transfer in Oculoplastic and Facial Surgery,  113

        By Francesco Bernardini and Brent Skippen
        Volume restoration of the face is regarded as a key step in facial rejuvenation and may be addressed with autologous fat transfer. Fat transfer indications and techniques in oculoplastic and facial surgery continue to evolve rapidly. Traditional autologous fat grafting is based on Coleman technique but recent focus has been on microfat grafting techniques. Superficial Enhanced Fluid Fat Injection (SEFFI) is a modern “microfat” technique, which has proven to be a safe and effective method for replacing volume loss and correcting skin atrophy of the entire face.
         Introduction,  113
         The evolution of fat transfer techniques in oculoplastic and facial surgery,  113
         Superficial enhanced fluid fat grafting,  114
        SEFFI: histologic evidence,  114
         SEFFI: fat preparation,  115
         SEFFI: fat injection,  116
         SEFFI: results,  116
         Discussion,  116
         Clinics care points,  118
         Disclosure,  118

        Cannula Technique for Tear Trough and Under-eye Filler,  121

        By Brett Kotlus
        Under-eye dark circles, bags, and volume loss are common aesthetic concerns that can develop with aging. Although surgical blepharoplasty can address these issues, there are many patients seeking a nonsurgical correction. Injectable fillers can improve several under-eye concerns in the appropriate set of circumstances. Hyaluronic gel is the preferred filler and when administered with a blunt-tipped cannula this procedure can be rewarding. Several factors should be considered to improve the safety and efficacy of this procedure including proper patient selection, choice of filler, and careful attention to technique.
        Video content accompanies this article at
         Introduction,  121
         Evaluation,  121
         Filler selection,  122
         Technique,  123
         Postprocedure care,  123
         Potential complications and management,  123
         Summary,  125
         Clinics care points,  125
         Disclosure,  125

        Lowering and Raising the Upper Eyelid Crease,  127

        By Kim Byung Gun
        Blepharoplasty is one of the most common plastic surgery procedures in the world but may cause unsatisfactory results due to the inadvertent creation of too high or too low an eyelid crease or due to asymmetry of the eyelid creases. Raising a low upper eyelid crease can be performed by excision of the skin superior to the crease or by higher fixation of upper eyelid crease. Lowering too high an upper eyelid, in contrast, requires the release of previous adhesions anterior to the levator muscle complex and tarso-dermal fixation at a lower level at the appropriate height. Prevention of readhesion is critical. Soft tissue support of the gliding zone between levator and orbicularis muscle can be created with fat grafting or fat injection, a fibromuscular flap or graft, a dermis fat graft, or a fascia fat graft to prevent readhesion and to increase the volume to correct any depression present in the upper eyelid sulcus. Correction of blepharoptosis or eyelid retraction can be performed simultaneous to lid crease adjustment and may be mandatory in order to produce a satisfactory result.
         Introduction,  127
         Raising the upper eyelid crease,  127
        Causes of too low eyelid crease,  127
        Prevention of Too Low Eyelid Crease,  127
         Treatment–raising a low upper eyelid crease,  128
         Lowering of the upper eyelid crease,  128
        Causes of a Too High Upper Eyelid Crease,  128
        Prevention of Too High Eyelid Crease,  129
        Treatmentâ Lowering of Upper Eyelid Crease,  129
        Single Incisional Approach Without Skin Resection,  129
         Discussion,  135
         Summary,  135
         Disclosure,  135

        Botulinum Toxin Brow Elevation and Shaping,  137

        By Kenneth D. Steinsapir and Samantha Steinsapir
        Cosmetic botulinum toxin treatment is a significant advancement in minimally invasive cosmetic service that fundamentally changed how cosmetic treatment is performed. Rapidly after its introduction as a cosmetic service, clinicians understood that treatment affected the shape and position of the eyebrows. This was recognized as an important aspect of treatment. Thirty years later there is no agreement of how best to alter brow shape. The Microdroplet Lift paradigm presents a significant alternative method for shaping the eyebrows without forehead paralysis, which is customarily associated with botulinum toxin forehead treatment.
        Video content accompanies this article at
         Introduction,  137
         Facial expression, emotion, and botulinum toxin,  138
         Eyebrow elevation and shaping,  139
         The microdroplet lift,  141
         Summary,  143

        Update on Facial Noninvasive Skin Tightening,  145

        By Adam D. Miller and Arisa E. Ortiz
        Facial skin laxity is a common concern among patients seeking esthetic treatment. Although surgery remains the gold-standard therapy for improving laxity, the demand for noninvasive procedures with minimal downtime has increased drastically. Although tightening of the face through nonsurgical means has been historically challenging, new technology has provided safe and effective options for improving facial laxity. As the number of patients seeking these treatments continues to grow, it is likely that we will continue to see an evolution of this technology.
         Introduction,  145
         Changes contributing to skin laxity,  145
         General approach to noninvasive skin tightening,  145
         Resurfacing lasers,  146
        Overview,  146
        Ablative resurfacing lasers,  146
        Nonablative resurfacing lasers,  146
        Hybrid resurfacing lasers,  147
         Radiofrequency,  148
        Overview,  148
        Transcutaneous radiofrequency,  148
        Minimally invasive radiofrequency,  149
        Adverse effects and safety considerations,  149
         Ultrasound,  149
        Overview,  149
        Microfocused ultrasound with visualization,  150
        Synchronous ultrasound parallel beam,  152
        Adverse effects,  152
         Microcoring,  152
         Clinics care points,  152
         Disclosure,  153

        Updates in Rhinoplasty,  157

        By Emily A. Spataro
        Using evidence-based measures to guide rhinoplasty surgical techniques and preoperative, perioperative, and postoperative care is increasing. The clinical practice guidelines (CPG) for rhinoplasty published in 2017 exemplify this shift in the rhinoplasty literature. The goal of the rhinoplasty CPG was to develop consensus statements based on the best available evidence to optimize patient safety and surgical outcomes, while minimizing harm or unnecessary variations in care. Importantly, the CPG highlights major gaps in the literature, calling for research in these areas to expand the current recommendations.
         Introduction,  157
         Updates in preoperative management,  158
         Updates in perioperative management,  160
         Updates in postoperative management,  161
         Summary,  162
         Clinics care points,  162
         Disclosure,  163

        Powered and Piezoelectric Rhinoplasty Techniques,  165

        By Aisling S. Last, Sam P. Most, and Emily A. Spataro
        Power-assisted rhinoplasty relies on motor-driven tools to shape and cut the nasal bones, and specifically, piezoelectric devices use ultrasonic frequency vibration to perform these bony modifications while minimizing damage to the surrounding soft tissue or cartilage. Primary uses of these techniques include reducing bony dorsal humps, addressing bony asymmetries, and performing osteotomies. Compared with manual techniques, powered rhinoplasty allows for more precise and atraumatic cutting or rasping of the bone. Piezoelectric instruments are emerging as more favored, as their atraumatic handling of surrounding tissue allows for expanded applications compared to powered techniques, such as complete exposure of the nasal vault to perform lateral and complete osteotomies under direct visualization, precise ostectomy, sculpting of mobilized nasal bones, which also facilitated the resurgence of dorsal preservation rhinoplasty techniques.
         Introduction,  165
         Powered rhinoplasty techniques,  166
         Uses,  166
         Advantages,  166
         Disadvantages,  166
         Piezoelectric rhinoplasty techniques,  166
         Uses,  167
        Dorsal hump reduction,  167
        Osteotomies,  167
        Rhinosculpture,  168
        Septoplasty,  168
        Other uses,  168
         Advantages,  169
         Disadvantages,  169
         Summary,  169
         Clinics care points,  169
         Disclosure,  170

        Current Updates in Otoplasty,  171

        By Eric Y. Du, Frank Simo, and Collin L. Chen
        Otoplasty is a common surgical technique performed to correct prominauris. Although hundreds of techniques have been developed, the open otoplasty is the most utilized. Recent trends have moved toward less invasive options, including nonsurgical and incisionless otoplasty. Patient satisfaction is the ultimate end point for judgment of a successful outcome of otoplasty. Consistent results involve emphasis on preoperative analysis, intraoperative adjustments, and good patient follow-up and communication. Complications are relatively rare and range from those in the immediate postoperative period (ie, hematoma, infection) to esthetic complications apparent after healing is complete.
         Introduction,  171
         Surgical technique,  171
        Preoperative Planning,  171
        Surgical Prep and Patient Positioning,  173
        Procedural Approach,  173
        Immediate Postprocedural Care and Recovery,  176
        Clinical Results,  176
        Potential Risks and Complications,  177
        Management,  178
         Summary,  179
         Clinics care points,  179

        Correction of Ear Lobe Deformities,  181

        By Sarah Benyo, Kasra Ziai, Jessyka G. Lighthall, and Scott Walen
        Earlobe deformities can result from congenital or acquired causes. Congenital deformations can present as earlobe clefts, skin tags, or duplicate earlobes, and acquired deformities may be due to surgical resection or trauma. Restoring the normal dimensions and mass of the earlobe, ensuring that the free margin is smooth, and restoring natural continuity of the lobe with the face constitute the key elements of earlobe reconstruction. Operative techniques include local tissue advancement flaps, rotational flaps, and chondrocutaneous flaps. In this chapter, the authors provide a comprehensive review of the operative planning, intraoperative techniques, and postoperative care of patients with earlobe deformities.
         Introduction,  181
         Surgical technique,  182
        Preoperative Planning,  182
        Prep and Patient Positioning,  182
        Procedural Approaches,  182
        Postoperative Considerations,  193
         Clinical results in the literature,  194
         Summary,  194
         Clinics care points,  194
         Disclosure,  194