Face lift dissections are believed to compromise skin flap circulation, leading to wound healing complications in some cases. A local anesthetic agent with epinephrine may be injected to reduce bleeding. Limited information is available regarding the appropriate dose and efficacy. Hematomas have been attributed to rebound bleeding.
Laser fluorescence imaging is the most advanced method available to evaluate skin perfusion. This method has been used to quantitate blood supply during free-tissue transfers,1 breast reconstruction,2–5 and abdominoplasty.6–8 To the author’s knowledge, this technology has not been applied to face lifts.
This study was undertaken to evaluate (1) the degree of vascular compromise associated with a face lift dissection, if any, and (2) the effect of 2 concentrations of epinephrine on vascularity.
PATIENTS AND METHODS
Patients
Nine consecutive patients undergoing face lifts performed by the author were asked to participate in the study. The only inclusion criteria were face lift surgery and patient consent. There were no exclusion criteria. All patients consented (inclusion rate, 100%). Institutional review board approval was obtained from Chesapeake Institutional Review Board Services, accredited by the Association for the Accreditation of Human Research Protection Programs.
Local Anesthesia and Epinephrine Doses
The author’s usual face lift local anesthetic solution combines 50 mL of 0.5% bupivacaine with 1:200,000 epinephrine, 50 mL of 1% lidocaine with 1:100,000 epinephrine, and 100 mL of normal saline (total volume, 200 mL) for a final epinephrine concentration of 1:300,000.9 For study purposes, another solution was prepared, containing the same local anesthetic concentrations but an epinephrine concentration of 1:800,000 (Fig. 1) and a third solution containing no epinephrine. These epinephrine concentrations were chosen based on existing clinical10 and experimental data11 documenting efficacy in concentrations as dilute as 1:800,000. The first patient in the series received the 1:300,000 concentration of epinephrine. The second patient received the more dilute 1:800,000 concentration (See Video, Supplemental Digital Content 1, which demonstrates the local anesthetic injections, https://links.lww.com/PRSGO/A123), and the third patient received no epinephrine. The sequence was repeated chronologically by the date of surgery. The mean volume of local anesthetic solution was 74 mL per side (range, 60–85 mL), with no significant difference in volumes among the 3 patient groups.
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Fig. 1: The local anesthetic solution combines one 50-mL bottle of 0.5% bupivacaine with 1:200,000 epinephrine and one 50-mL bottle of 1% lidocaine without epinephrine with equal parts of saline. The final concentration of epinephrine is 1:800,000. In patients receiving no epinephrine, a bottle of 0.25% bupivacaine without epinephrine is used instead. In patients receiving the full 1:300,000 concentration of epinephrine, a bottle of 1% lidocaine with 1:100,000 epinephrine is substituted.
Surgery
All procedures were performed at a state-licensed ambulatory surgery center under total intravenous anesthesia using a laryngeal mask airway. No inhalational agent was given. No intraoperative hypotension or routine preoperative antihypertensive agent was administered, apart from any blood pressure medication taken regularly by the patient. All patients were treated with sequential compression devices. No patient received chemoprophylaxis. All patients underwent Doppler ultrasound scans of the lower extremities before surgery, the day after surgery, and approximately 1 week after surgery.12 Surgical drains were removed the day after surgery. Head dressings were not used.
Three patients underwent simultaneous procedures on the breasts or body. In 8 patients, a submental lipectomy was performed (1 patient had a previous submental lipectomy). Eight patients underwent adjunctive facial procedures, including fat injection (n = 7), endoscopic forehead lift (n = 6), laser skin resurfacing (n = 5), upper blepharoplasties (n = 3), rhinoplasty (n = 3), chin augmentation (n = 1), and setback otoplasties (n = 1). Adjunctive facial procedures (with the exception of upper blepharoplasties and otoplasties) were performed after the final imaging video so as not to interfere with perfusion measurements.
All patients were treated using the same face lift technique (See Video, Supplemental Digital Content 2, which demonstrates a face lift dissection. This video is available in the “Related Videos” section of the full-text article at http://www.PRSGO.com or available at https://links.lww.com/PRSGO/A124). The author uses no temporal incision, allowing skin redundancy to settle spontaneously and avoiding a temple scar. A subcutaneous dissection is used in the lateral neck (Fig. 2), with conservative liposuction over the lateral neck and sternocleidomastoid muscle. The author typically uses a “triple-vector platysmaplasty.” A deep-plane dissection is used to elevate the superficial musculoaponeurotic system (SMAS) and platysma (vertical, vector 1), with release of the retaining ligaments. The platysma is plicated laterally (oblique, vector 2). A submental incision is used to access the neck for anterior liposuction, interplatysmal fat resection, and a medial platysmaplasty (medial, vector 3).
Fig. 2: The face lift incision is marked. This incision “hugs” the tragus in front of the ear and courses on the back of the ear just above the postauricular crease (dotted line). The incision turns at a right angle and continues horizontally into the hairline. Liposuction is performed over the lateral neck (yellow). Liposuction preserves the filamentous connections between the muscle (platysma) and the skin, allowing the skin to move in unison with the muscle. The superficial musculoaponeurotic system (SMAS) and skin are elevated as one layer in the cheek (magenta). Skin undermining is minimized (green).
Perfusion Measurements
The SPY Elite Intraoperative Perfusion System (Novadaq, Bonita Springs, Fla.) was used to image each side of the face and neck at least 20 minutes after injection of the local anesthetic solution on that side and before the face lift dissection. Immediately after completion of the face lift on each side, the patient was reimaged. Each patient was imaged 4 times. A video was recorded immediately after the contrast agent, indocyanine green, was injected intravenously (2.5 mL, 6.25 mg) and flushed with 10 mL of normal saline. (See Video, Supplemental Digital Content 3, which demonstrates SPY laser fluorescence imaging videos before and after face lift. This video is available in the “Related Videos” section of the full-text article at http://www.PRSGO.com or available at https://links.lww.com/PRSGO/A125). Measurements were made at the same time, 120 seconds after the start of the video recording. The temple was selected as the reference site. This site was used because it was just outside the injected area, not dissected, and it was within the field of view. Relative values were tabulated using this reference point.
Statistics
Statistical analyses were performed using IBM SPSS for Macintosh version 22.0 (SPSS, IBM, Armonk, N.Y.). Paired t tests were used to compare measurements before and after the face lift. One-way analyses of variance were computed to compare the preoperative mean perfusion values across the 3 treatment groups. A P value < 0.05 was considered significant. A Pearson correlation was computed to determine the linear relation between epinephrine concentration and hematoma rate.
RESULTS
Patient data are provided in Table 1. Subjectively, the 3 patients who did not receive epinephrine appeared to have greater bleeding during the face lift dissection. Two of these women had extensive postoperative bruising (Fig. 3). Table 2 provides perfusion data, including both absolute and relative measurements. Individual and combined comparisons before and after the face lift showed no decrease in perfusion. Two of the individual site comparisons and the combined right face and neck measurements showed significantly (P < 0.05) greater absolute perfusion values after the dissection. An example of a patient who was not treated with epinephrine and her left face lift perfusion studies are provided in Figures 4–6.
Table 1: Patient Data
Table 2: SPY Laser Fluorescence Measurements and Absolute and Relative Values*
Fig. 3: This 54-year-old woman (A) underwent a deep-plane face lift, submental lipectomy, endoscopic forehead lift, rhinoplasty, and fat injection of the lips, cheeks, nasolabial creases, and glabella (total fat volume, 27 mL). Her anesthetic solution contained no epinephrine. She had extensive bruising of the face, neck, and chest 10 days after surgery (B). One month after surgery (C), bruising of the face and neck has cleared, but she still has bruising of the orbital rims. She had previous blepharoplasties performed by the author 9 years previously and had no unusual bruising after the previous surgery. The patient is wearing no makeup, except for permanent tattooing of her eyebrows that was present preoperatively.
Fig. 4: This 60-year-old woman underwent a deep-plane face lift, submental lipectomy, carbon dioxide laser skin resurfacing, fat injection of the cheeks, nasolabial creases, lips, and earlobes (total fat volume, 45 mL), setback otoplasties, and a left forehead scar revision. She is seen before (A) and 3.5 months after (B) surgery, with no makeup. This patient’s SPY images before and after her left face lift are provided in Figures 5 and 6.
Fig. 5: SPY laser fluorescence imaging of the patient seen in Figure 4 before the left face lift. This patient received no epinephrine in her local anesthetic solution. The measurement sites are labeled. The temple is used for reference. Areas of greater perfusion appear red.
Fig. 6: SPY laser fluorescence imaging of the patient seen in Figure 4 immediately after the left face lift. There is no significant change in her perfusion measurements.
Table 3 compares pre-face lift perfusion data for the 3 groups with different concentrations of epinephrine. For patients who did not receive epinephrine, the mean values for the combined right and left facial measurements were 103.4% and 100.8%, using the reference value of 100% assigned to the temple. For patients treated with 1:800,000 epinephrine (Figs. 7, 8), these combined values were 50.8% and 59.6%. For patients injected with an epinephrine concentration of 1:300,000 (Figs. 9, 10), the mean relative perfusion values were 52.3% and 51.6%. The differences in combined perfusion measurements did not reach statistical significance because of the small sample sizes. However, 4 of the individual site comparisons (2 absolute values and 2 relative values) were significant at P < 0.05, and one comparison of absolute values, the right submandibular site, was significant at P < 0.01.
Fig. 7: SPY laser fluorescence imaging of a 78-year-old woman before her left face lift. This patient received an injection of 1:800,000 epinephrine > 20 minutes before the image was recorded. This patient was also the subject of the supplemental file videos. Despite the dilute epinephrine concentration, its vasoconstrictive effect is visible.
Fig. 8: SPY laser fluorescence imaging of the same patient depicted in Figure 7 immediately after completion of her left face lift.
Fig. 9: SPY laser fluorescence imaging of a 59-year-old woman before her left face lift. This patient received an injection of 1:300,000 epinephrine > 20 minutes before the image was recorded. The dark blue area of the lateral cheek, jawline, lateral neck, and mastoid area demonstrates the vasoconstrictive effect of the epinephrine.
Fig. 10: SPY laser fluorescence imaging of the same patient depicted in Figure 9 after completion of her left face lift.
Table 3: SPY Laser Fluorescence Measurements Pre-face Lift, Epinephrine Effect, and Absolute and Relative Values*
Complications
There were 2 complications. One patient who received epinephrine 1:800,000 developed a hematoma of the right neck several hours after discharge requiring surgical evacuation. Another patient experienced weakness in the left buccal branch distribution that fully resolved within 1 month. There were no systemic complications. All ultrasound scans were negative.
DISCUSSION
Blood Flow after a Face Lift Dissection
The author expected a diminution in blood flow caused by the face lift dissection. However, the data did not support this hypothesis. All 4 combined absolute and relative postoperative perfusion measurements (right, 67.3% vs 60.5%; left, 74.7% vs 70.7%) were higher after surgery than before surgery, although not significantly (Table 2). There are several possible explanations. First, the dissection was subcutaneous over the lateral neck, but largely sub-SMAS in the face (Fig. 2). Second, the author uses hydrodissection13 in creating the subcutaneous tissue plane, which may be less traumatic to the skin flap.14 Third, lidocaine10,15–17 and bupivacaine18 produce local vasodilation, thought to be caused by a local chemical sympathectomy effect,17 which would not be balanced by the vasoconstrictive effect of epinephrine in the 3 patients who did not receive epinephrine. This vasodilation is overcome by epinephrine, producing net vasoconstriction,10,15–18 caused by the α-adrenergic effect of epinephrine on the smooth muscle of arterioles.15,19 The finding of excellent post-face lift flap perfusion is consistent with the author’s clinical experience of few cases of marginal skin loss.20
Epinephrine
In an effort to control for any possible confounders (eg, room temperature, ambient lighting, and neurohormonal factors), the perfusion of the temple was used for reference. The mean measurements representing the combined data relative to the temple showed perfusion levels decreased by almost half (Table 3). The combined perfusion measurements for the 2 epinephrine concentrations were surprisingly similar, attesting to the efficacy of the more dilute epinephrine concentration. Similarly, Dunlevy et al,10 in their study using a laser Doppler flowmeter, found that a 1:800,000 concentration of epinephrine reduced cutaneous blood flow approximately 50% in patients undergoing head and neck surgery. These investigators10 also found that a 1:400,000 concentration decreased blood flow about 60%, with no significant difference in blood flow comparing epinephrine concentrations of 1:200,000 and 1:400,000. In their study of albino rabbits, Siegel and Vistnes11 found no significant difference in hemostatic effect comparing epinephrine concentrations of 1:100,000, 1:400,000, and 1:800,000; a concentration of 1:1,600,000 was significantly less effective. Previous studies show that the reduction in blood flow reaches a plateau between 5 and 10 minutes after epinephrine injection,10,15,16,18,19 although the maximum effect requires 25 minutes.17
Today, plastic surgeons use a variety of epinephrine concentrations, from 1:160,000 to 1:4,000,00014,20–41 (Fig. 11). Because epinephrine can produce toxic local (eg, skin necrosis)10,16,18,19 and systemic side effects (eg, tachycardia, arrhythmias, and hypertension)10,15,18 from stimulation of α- and β-adrenergic receptors,10,19 the prudent surgeon will choose the most dilute solution that provides adequate vasoconstriction. The measurements in this study suggest that 1:300,000 and 1:800,000 epinephrine concentrations are both effective.
Fig. 11: Illustration of hematoma rates and epinephrine concentrations in 20 recent face lift publications. Two studies with concentrations less than 1:1,000,000 (one was 1:2,000,000
30 and the other was 1:4,000,000
41) lie outside the graph parameters but are included in the calculations. There is no significant correlation between the epinephrine concentration and hematoma rate.
Blood Loss
Limited information is available regarding blood loss associated with a face lift. A surprisingly heavy blood loss is calculated from hematocrits when a face lift (including endoscopic forehead lifts) is performed at the time of body contouring surgery, approximately 500 mL.9 This nontrivial blood loss attests to the highly vascular nature of the face and the scalp. Hence, the need to minimize surgical blood loss and the role for vasoconstriction.
Hematomas
To gauge the frequency of hematomas, the author reviewed 40 face lift studies published in the plastic surgical literature in the last 15 years,14,20–58 including fluid collections treated with needle aspiration when they were reported. The mean hematoma rate was 3.8%. This rate is more than twice the frequency of this complication in a recent review59 that did not include hematomas treated with needle aspiration or seromas when these fluid collections were reported separately. The mean frequency of hematomas reported in the 6 prospective studies20,28,31,47,48,56 was 6.7%.
Rebound Bleeding
Approximately 86% of hematomas develop within 24 hours of surgery.27,60 Some plastic surgeons recommend against using epinephrine.25,32 The theory is that bleeding is suppressed during surgery but occurs postoperatively after the vasoconstrictive effect of the epinephrine wears off. However, there is no significant correlation between epinephrine concentration and reported hematoma rates (Fig. 11). Most surgeons take a “second look”61 for hemostasis after the face lift repair and before skin closure. Nevertheless, hematomas occur even in patients treated by experienced plastic surgeons paying meticulous attention to hemostasis.13
Perhaps unfairly, patients may judge the extent of bruising as an indication of the degree of surgical trauma. Without epinephrine, the local vasodilatory effect of lidocaine is unopposed,10,15–18 increasing bruising and delaying patient recovery (Fig. 3). Epinephrine also serves to reduce the rate of systemic absorption of local anesthetic agents, reducing the risk of systemic toxicity.9
Many plastic surgeons advocate close control of blood pressure during surgery and postoperatively, including the use of clonidine.14,25,27,34,38,58,62 Although avoidance of hypertension is always advisable,59 the value of intraoperative hypotension is less clear.53,60 Local vasoconstriction is preferred to systemic hypotension to reduce blood loss. Moreover, intraoperative hypotension might be expected to increase the risk of rebound bleeding after surgery. Feldman41 takes the opposite approach, administering intravenous ephedrine to elevate the patient’s blood pressure during surgery, “so that the final look for hemostasis is a reliable one.” However, vasoactive medications can interfere with the reliability of pulse, blood pressure, and respiratory rate when titrating propofol and fentanyl doses. To ensure the validity of these important clinical indicators, the author prefers normotensive anesthesia. When pain and a full bladder are ruled out as causes of intra- or postoperative hypertension, antihypertensives may occasionally be administered (eg, labetalol, esmolol, and hydralazine). The incidence of postoperative nausea and vomiting, which can raise the blood pressure, may be reduced by using a propofol infusion rather than anesthetic gas9,27 and by routinely administering antiemetics.9,34,58,59
Choice of Local Anesthesia
Most plastic surgeons use lidocaine for local anesthesia, usually in a concentration of 0.5% (range, 0.25–1%).14,20–24,26,27,30,31,33,36,38–40,60 Other investigators use bupivacaine either on its own29,35,63,64 or with lidocaine.14,20,25,28,31,62 Bupivacaine has a greater potency and duration of action than lidocaine.9 Its safety has been documented when administered into the subcutaneous tissue in dilute concentrations and when combined with lidocaine.9 Postoperative analgesia is helpful in reducing the need for analgesic medication in the immediate postoperative period. Narcotic analgesics are a common cause of nausea and vomiting; their use should be minimized.21 The longer duration of action of bupivacaine makes it frequently possible to evacuate a hematoma several hours after surgery without the need for a general anesthetic or additional local anesthesia. Hematomas are less onerous when they can be treated without a return trip to the operating room and without the need for another general anesthetic.
Limitations of the Study
The sample size was small, comprising only 9 patients. It is not feasible to study a large number of patients because this sophisticated imaging technology is expensive and there is no third-party payer. The cost of each study was $1300, representing the cost of each dye kit, borne by the author. Nevertheless, in view of the higher (not lower) perfusion values after surgery, it is doubtful that a significant decrease in tissue perfusion would be detected if the sample sizes were larger. There is subjectivity in assigning measurement sites and variability of perfusion measurements, although this problem is largely mitigated by combining measurements. This study provides no information on smokers, male patients, other face lift techniques, or the duration of vasoconstriction.
Strengths of the Study
A novel imaging method provides data that were previously unavailable. Eighteen before-and-after perfusion studies were possible because the procedure is bilateral. Importantly, patients served as their own controls, avoiding confounders that can affect comparisons in different patients. The same surgeon used the same technique in this prospective study of consecutive patients with a 100% inclusion rate, avoiding selection bias and adding to the reliability of the conclusions.
CONCLUSIONS
A deep-plane face lift dissection does not decrease skin flap perfusion (See Video, Supplemental Digital Content 4, which demonstrates a comprehensive video showing patient interviews before and 24 hours after surgery, local anesthetic injection, face lift dissection, and SPY laser fluorescence imaging videos. This video is available in the “Related Videos” section of the full-text article at http://www.PRSGO.com or available at https://links.lww.com/PRSGO/A126). Both 1:300,000 epinephrine and 1:800,000 epinephrine concentrations are effective in producing intraoperative vasoconstriction.
Video: Graphic 1. See video, which demonstrates a local anesthetic injection. This video is available in the “Related Videos” section of the full-text article at
http://www.PRSGO.com or available at
https://links.lww.com/PRSGO/A123.
Graphic 2. See video, which demonstrates a face lift dissection. This video is available in the “Related Videos” section of the full-text article at
http://www.PRSGO.com or available at
https://links.lww.com/PRSGO/A124.
Graphic 3. See video, which demonstrates SPY laser fluorescence imaging videos before and after face lift. This video is available in the “Related Videos” section of the full-text article at
http://www.PRSGO.com or available at
https://links.lww.com/PRSGO/A125.
Graphic 4. See video, which demonstrates a comprehensive video showing patient interviews before and 24 hours after surgery, local anesthetic injection, face lift dissection, and SPY laser fluorescence imaging videos. This video is available in the “Related Videos” section of the Full-Text article at
http://www.PRSGO.com or available at
https://links.lww.com/PRSGO/A126.
ACKNOWLEDGMENTS
The author thanks Jane Zagorski, PhD, for statistical analysis, Sarah Maxwell, RN, for data collection, and Gwendolyn Godfrey for illustrations.
REFERENCES
1. Pestana IA, Coan B, Erdmann D, et al. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg. 2009;123:1239–1244
2. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg. 2010;125:1065–1073
3. Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial. Plast Reconstr Surg. 2012;129:778e–788e
4. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg. 2012;129:1043–1048
5. Kanuri A, Liu AS, Guo L. Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction. Plast Reconstr Surg. 2014;133:448e–454e
6. Mayr M, Holm C, Höfter E, et al. Effects of aesthetic abdominoplasty on abdominal wall perfusion: a quantitative evaluation. Plast Reconstr Surg. 2004;114:1586–1594
7. Roostaeian J, Harris R, Farkas JP, et al. Comparison of limited-undermining lipoabdominoplasty and traditional abdominoplasty using laser fluorescence imaging. Aesthet Surg J. 2014;34:741–747
8. Swanson E. Comparison of limited and full dissection abdominoplasty using laser fluorescence imaging to evaluate perfusion of the abdominal skin. Plast Reconstr Surg. 2015;136:31e–43e
9. Swanson E. Prospective study of lidocaine, bupivacaine and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702–722 discussion 723–725.
10. Dunlevy TM, O’Malley TP, Postma GN. Optimal concentration of epinephrine for vasoconstriction in neck surgery. Laryngoscope. 1996;106:1412–1414
11. Siegel RJ, Vistnes LM. Epinephrine requirements for effective hemostasis in local anesthetics. Surg Forum. 1972;23:514–516
12. Swanson E. Ultrasound screening for deep venous thrombosis detection: a prospective evaluation of 200 plastic surgery outpatients. Plast Reconstr Surg Glob Open. 2015;3:e332
13. Brody GS. The tumescent technique for face lift. Plast Reconstr Surg. 1994;94:407
14. Jones BM, Grover R. Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg. 2004;113:398–403
15. O’Malley TP, Postma GN, Holtel M, et al. Effect of local epinephrine on cutaneous bloodflow in the human neck. Laryngoscope. 1995;105:140–143
16. Ghali S, Knox KR, Verbesey J, et al. Effects of lidocaine and epinephrine on cutaneous blood flow. J Plast Reconstr Aesthet Surg. 2008;61:1226–1231
17. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg. 2013;131:811–814
18. Millay DJ, Larrabee WF Jr, Carpenter RL. Vasoconstrictors in facial plastic surgery. Arch Otolaryngol Head Neck Surg. 1991;117:160–163
19. Larrabee WF Jr, Lanier BJ, Miekle D. Effect of epinephrine on local cutaneous blood flow. Head Neck Surg. 1987;9:287–289
20. Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834
21. Imber G, Silich RC. Limited-incision face lift technique. Aesthet Surg J. 2001;21:216–226
22. Marchac D, Brady JA, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg. 2001;109:2539–2551 discussion 2552–2554.
23. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109:2074–2086
24. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Rejuvenation of the midface by elevating the malar fat pad: review of technique, cases, and complications. Plast Reconstr Surg. 2002;110:1526–1536 discussion 1537–1540.
25. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg. 2004;113:381–387 discussion 388–390.
26. Ullmann Y, Levy Y. Superextended facelift: our experience with 3,580 patients. Ann Plast Surg. 2004;52:8–14
27. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985 discussion 1986–1987.
28. Jones BM, Grover R, Hamilton S. The efficacy of surgical drainage in cervicofacial rhytidectomy: a prospective, randomized, controlled trial. Plast Reconstr Surg. 2007;120:263–270
29. Waterhouse N, Vesely M, Bulstrode NW. Modified lateral SMASectomy. Plast Reconstr Surg. 2007;119:1021–1026 discussion 1027–1028.
30. Fuente del Campo A. Update on minimally invasive face lift technique. Aesthet Surg J. 2008;28:51–61
31. Citarella ER, Sterodimas A, Condé-Green A. Endoscopically assisted limited-incision rhytidectomy: a 10-year prospective study. J Plast Reconstr Aesthet Surg. 2010;63:1842–1848
32. Firmin FO, Marchac AC, Lotz NC. Use of the harmonic blade in face lifting: a report based on 420 operations. Plast Reconstr Surg. 2009;124:245–255
33. van der Lei B, Cromheecke M, Hofer SO. The purse-string reinforced SMASectomy short scar facelift. Aesthet Surg J. 2009;29:180–188
34. Beer GM, Goldscheider E, Weber A, et al. Prevention of acute hematoma after face-lifts. Aesthetic Plast Surg. 2010;34:502–507
35. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800
36. Cárdenas-Camarena L, Encinas-Brambila J, Guerrero MT. Cervicofacial rhytidoplasty: more does not mean better. Aesthetic Plast Surg. 2011;35:650–656
37. Castello MF, Lazzeri D, Silvestri A, et al. Modified superficial musculoaponeurotic system face-lift: a review of 327 consecutive procedures and a patient satisfaction assessment. Aesthetic Plast Surg. 2011;35:147–155
38. Pitanguy I, Machado BH. Facial rejuvenation surgery: a retrospective study of 8788 cases. Aesthet Surg J. 2012;32:393–412
39. Rosenfield LK. The pinch rhytidectomy: a safe, effective, “low SMAS” variation on the theme. Aesthet Surg J. 2014;34:825–840
40. Ryu MH, Moon VA. High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients. Aesthet Surg J. 2015;35:1–8
41. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014;134:1173–1183
42. Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg. 2000;105:267–285 discussion 286–289.
43. Yaremchuk MJ. Subperiosteal and full-thickness skin rhytidectomy. Plast Reconstr Surg. 2001;107:1045–1058
44. Oliver DW, Hamilton SA, Figle AA, et al. A prospective, randomized, double-blind trial of the use of fibrin sealant for face lifts. Plast Reconstr Surg. 2001;108:2101–2105 discussion 2106–2107.
45. Saylan Z. Purse string-formed plication of the SMAS with fixation to the zygomatic bone. Plast Reconstr Surg. 2002;110:667–671 discussion 672–673.
46. Ellenbogen R, Youn A, Yamini D, et al. The volumetric face lift. Aesthet Surg J. 2004;24:514–522
47. Marchac D, Greensmith AL. Early postoperative efficacy of fibrin glue in face lifts: a prospective randomized trial. Plast Reconstr Surg. 2005;115:911–916 discussion 917–918.
48. Kamer FM, Nguyen DB. Experience with fibrin glue in rhytidectomy. Plast Reconstr Surg. 2007;120:1045–1051 discussion 1052.
49. Lindsey JT. Five-year retrospective review of the extended SMAS: critical landmarks and technical refinements. Ann Plast Surg. 2009;62:492–496
50. Mustoe TA, Rawlani V, Zimmerman H. Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection. Plast Reconstr Surg. 2011;127:357–370
51. Mottura AA. SPA face lift: SMAS plication-anchoring. Aesthetic Plast Surg. 2011;35:511–515
52. Martén E, Langevin CJ, Kaswan S, et al. The safety of rhytidectomy in the elderly. Plast Reconstr Surg. 2011;127:2455–2463
53. Abboushi N, Yezhelyev M, Symbas J, et al. Facelift complications and the risk of venous thromboembolism: a single center’s experience. Aesthet Surg J. 2012;32:413–420
54. Cabas Neto J, Rodriguez Fernandez DE, Boles MM. A new technique of external quilting sutures: their importance in preventing hematomas in cervicofacial rhytidectomies. Plast Reconstr Surg. 2013;131:121e
55. Ozturk CN, Huettner F, Ozturk C, et al. Outcomes assessment of combination face lift and perioral phenol-croton oil peel. Plast Reconstr Surg. 2013;132:743e–753e
56. Hester TR Jr, Shire JR, Nguyen DB, et al. Randomized, controlled, phase 3 study to evaluate the safety and efficacy of fibrin sealant VH S/D 4 s-apr (Artiss) to improve tissue adherence in subjects undergoing rhytidectomy. Aesthet Surg J. 2013;33:487–496
57. Mast BA. Advantages and limitations of the MACS lift for facial rejuvenation. Ann Plast Surg. 2014;72:S139–S143
58. Ramanadham SR, Costa CR, Narasimhan K, et al. Refining the anesthesia management of the face-lift patient: lessons learned from 1089 consecutive face lifts. Plast Reconstr Surg. 2015;135:723–730
59. Mustoe TA, Park E. Evidence-based medicine: face lift. Plast Reconstr Surg. 2014;133:1206–1213
60. Rees TD, Barone CM, Valauri FA, et al. Hematomas requiring surgical evacuation following face lift surgery. Plast Reconstr Surg. 1994;93:1185–1190
61. Baker TJ, Gordon HL. Complications of rhytidectomy. Plast Reconstr Surg. 1967;40:31–39
62. Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg. 2001;54:481–486
63. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg. 1998;101:494–503
64. Schnur PL, Weinzweig J. A second look at the second-look technique in face lifts. Plast Reconstr Surg. 1995;96:1724–1726
