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60. Wang Q, et al. Down-regulation of Sonic hedgehog signaling pathway activity is involved
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M. A. Timoshchuk and W. Zaid
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Update andAdvancements inFacial
Plastics
ParulSinha, BrianH.Cameron, andTangHo
Introduction
The eld of facial plastic and reconstructive surgery is witnessing a myriad of technological advances in both surgical and nonsurgical techniques. This chapter aims
to provide an overview of the recent innovations and practice trends for different
procedures within the facial plastic and reconstructive surgery specialty that aim to
improve care, quality of life, and patient satisfaction.
P. Sinha
Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology
Head and Neck Surgery, University of Texas Health Science Center in Houston,
Houston, TX, USA
e-mail: Parul.Sinha@uth.tmc.edu
B. H. Cameron
Department of Otorhinolaryngology-Head and Neck Surgery, University of Texas Health
Science Center in Houston, McGovern Medical School, Houston, TX, USA
e-mail: Brian.H.Cameron@uth.tmc.edu
T. Ho (*)
Department of Otorhinolaryngology-Head and Neck Surgery, University of Texas Health
Science Center in Houston, McGovern Medical School, Houston, TX, USA
Division of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology
Head and Neck Surgery, University of Texas Health Science Center in Houston,
Houston, TX, USA
e-mail: Tang.Ho@uth.tmc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and
Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_15
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P. Sinha et al.
Rhinoplasty andNasoseptal Reconstruction
Surgical rhinoplasty has remained as the preferred technique for improving nasal
form and function. However, nonsurgical rhinoplasty is gaining popularity for certain indications. Nonsurgical rhinoplasty allows facial plastic surgeons to address
selected nasal deformities in a relatively safe, less invasive manner in an ofce setting and allows for a faster recovery time [1]. The indications include camouaging
of the dorsal and nasal side wall imperfections, alteration of the nasal tip projection
or rotation, elongation of nasal length, augmentation of a deep radix (Fig.15.1),
lowering of alar rims for retraction, or correction of minor contour imperfections
following a previous rhinoplasty [2, 3]. The procedure is most commonly performed
with synthetic dermal llers such as hyaluronic acid. Autologous materials such as
fat, cartilage, and platelet-rich brin have also been used for augmentation of the
nasal soft tissue envelope [4]. Other nonsurgical rhinoplasty techniques use botulinum toxin either alone or in combination with ller injection to correct certain nasal
aesthetic deformities. It is used to target muscles at the base and sides of the nose,
Fig. 15.1 Nonsurgical rhinoplasty for dorsal augmentation of a deep radix using hyaluronic acid
llers in a 20-year-old female. Frontal view, (a) pre-injection, (b) post-injection. Left prole view,
(c) pre-injection, (d) post-injection
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mainly depressor nasi septi and levator labii superioris alaeque nasi, to improve
undesirable ala or upper lip appearances, that sometimes are more noticeable with
smile or articulation. Overactivity of the paired depressor nasi septi muscles at the
nasal base can cause rotation and the drooping of the nasal tip, while that of levator
labii superioris alaeque nasi can cause tip rotation and upper lip elevation. By reducing overactivity of these muscles, botox injections can improve the nasal tip projection in patients with tip ptosis [5] and improve the upper lip appearance in patients
with excess dental show. Caution is recommended with injection of the levator labii
superioris alaeque nasi in older patients as it can cause droopiness of the upper lip
ptosis further increasing the upper lip length.
In addition to nasal aesthetics, nonsurgical rhinoplasty technique also nds
application in improving nasal function [3]. Intranasal placement of llers at the
internal nasal valve or scroll area has been described as a nonsurgical technique to
correct nasal valve collapse and improve nasal airow. External placement at the
nasal sidewalls is also reported to improve nasal breathing by reducing dynamic
collapse of the nose. Similar to surgical rhinoplasty however, it is critical to discuss
and set realistic patient expectations and increased infection risk. Vascular necrosis
is one of the notable complications about which patients should always be counseled in addition to the need of revision and repeated procedures. Overall, good
patient satisfaction scores have been demonstrated with the nonsurgical rhinoplasty
techniques, but long-term results are lacking [5].
The eld of rhinoplasty is currently also seeing a re-emergence of the structural
preservation concept, originally described in the beginning of the twentieth century,
mainly for managing deformities of the nasal dorsum and the tip. The basic principles of preservation rhinoplasty advocate to elevate the nasal soft tissue envelope in
a subperichondrial–subperiosteal dissection with preservation of the nasal ligaments, minimize cartilage resection through reorientation, and maintain the patient’s
natural dorsum contours. When applied to dorsal hump deformities, the term “dorsal preservation rhinoplasty (DPR)” is used. The DPR technique includes preservation of the bony-cartilaginous dorsum without interrupting the osseocartilaginous
interface. In contrast to the conventional dorsal hump takedown with an osteotome
or a rasp, DPR emphasizes preservation of the dorsal conguration of the upper
lateral cartilage with its attachments. Application of the DPR technique is considered to preserve the nasal bridge, avoid creation of an open roof deformity, and
minimize time and effort to reconstruct the middle vault following hump reduction
[6]. Two methods, the “let down” and the “push down,” are described to address the
bony vault in dorsal preservation. The “let down” technique involves removal of a
bony strip at the nasofacial groove, and the “push down” involves sagittal osteotomies to overlap the bones. Transverse and radix osteotomies are used to mobilize
the nasal pyramid. Due to the need for precise alteration of the osseocartilaginous
vault without disruption of the keystone area, adoption of newer instrumentation
using ultrasonic piezo technology in combination with the DPR is another of the
recent trends. The piezoelectric instrument is used both to make precise osteotomies
and septal cartilage resection and to drill controlled holes for suture stabilization
between the bony dorsum and septum [7]. The potential complications of DPR
include residual/recurrent hump, saddling of the nasal dorsum, bony pyramid
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asymmetries, cerebrospinal uid leak, and radix step-off. Patient selection is key to
the use of this technique and conventional methods are still recommended for
patients with wide dorsum, low radix, and severely deviated dorsum along with
underlying septal deformity [6]. Knowledge of the preservation rhinoplasty techniques is a desirable element in the armamentarium of a rhinoplasty surgeon who
can combine it with the concepts of structural grafting to obtain the most favorable
and long- lasting aesthetic and functional outcomes while optimally maintaining
integrity of patient’s native tissue structure.
P. Sinha et al.
Upper Lip Lift
The shape, projection, and volume of upper lip are important features of the facial
aesthetics and symmetry and, thus, central to perception of youth and beauty.
Aging results in relative elongation of the philtrum and inversion of vermilion with
atrophy of the red lip. Wider and fuller lips in relation to the facial width with a
slightly convex prole and greater vermilion height are desirable upper lip attributes in females [8]. Due to its age- and gender-specic features, the upper lip lift
has gained popularity as a component of both facial rejuvenation and facial feminization processes. Nonsurgical upper lip augmentation to improve structure and
volume is achieved with injectable hyaluronic acid llers of smooth consistency. It
allows for immediate outcomes, no scarring, no need of postoperative recovery,
and reversibility. However, the effects usually last for 6–8months and repetitive
sessions are required. The risks of nonsurgical augmentation include the adverse
effects from llers such as asymmetry, bruising, swelling, herpes simplex virus
infections, and the rare event of vascular compromise that should be promptly
recognized and managed. Surgical upper lip augmentation involves two methods,
lip implantation and subnasal lip lift. Surgical lip implantation is an option to
increase volume in younger patients with a normal cutaneous upper lip length and
is most commonly performed with a soft, malleable, silicone implant that is available in 3-, 4-, and 5-mm diameters. The procedure is usually performed under local
anesthesia in which small incisions are placed at each of the commissures and a
submucosal pocket is developed at the wet and dry lip border to position the
implant. Surgical subnasal lip lift is usually employed in individuals with an elongated cutaneous lip associated with lip thinning. The goals of the lip lift are to
reduce the height of the cutaneous upper lip, increase the visible red vermilion, and
enhance projection with appropriate dental show and minimal scarring [9]. The
subnasal lip lift, also known as the “bull-horn/gull wing” lip lift (Fig.15.2), uses a
curved skin excision along the nasal sill and bilateral alar skin creases to remove
the upper lip skin, followed by skin and subcutaneous tissue advancement to reduce
the distance from the nasal base to the vermilion border [9]. The amount of skin
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279
abc
Fig. 15.2 (a) Preoperative image of a 29-year-old female with long philtral length and reduced
vermilion show. (b) Postoperative image after subnasal upper lip lift at 1week showing the “bullhorn” scar along the nasal base, reduced philtral length, and improved vermilion show. (c)
Postoperative image at 3months showed stable lip lift with well-concealed scar
excised varies but usually averages between 4 and 6mm of the skin. The scar usually is well concealed with meticulous incision planning and good dermal apposition. For individuals with an unsatisfactory visible scar persisting up to 6months,
adjunctive interventions of dermabrasion and laser therapy can be offered in addition to scar creams and silicone sheets. Over-resection with excessive dental show
or a “gummy smile” and under-corrections can result as complications of the surgical subnasal lip lift along with form asymmetry such as side-to-side height disparities of the cupid’s bow peak [9]. While under-correction and asymmetry can be
addressed with revision surgical lip lift, it is difcult to treat the deformities resulting from over-resection. Hence, accurate measurements and incision markings
before local anesthetic inltration are recommended to minimize these
complications.
Some recent modications in techniques to the traditional surgical subnasal lip
lift include a deeper and more extensive release of the upper lip that may include
separation of the deeper attachments of the orbicularis oris and a more denitive
suspension with anchoring of the muscle edge at the premaxillary periosteum [10–
12]. These modications are considered to create longer-lasting results with a more
favorable concealment of the subnasal scar [12]. Other surgical options used for
upper lip augmentation include the use of autologous fat, sternocleidomastoid muscle, and dermal and fascia grafts mostly in individuals with baseline side-to-side
asymmetry in lip size who may benet from but are not interested in surgical lip
implantation. These surgical techniques can be associated with gradual resorption
with subsequent form asymmetry owing to differential resorption from side to
side [13].
In summary, the upper lip lift can be a signicant component of facial rejuvenation and feminization procedures. With a variety of surgical and nonsurgical options
available, satisfactory outcomes with minimal complications require appropriate
selection of patient and the technique. A meticulous preoperative planning and precise surgical technique are critical in patients undergoing surgical lip lift as some of
the changes can be irreversible.
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P. Sinha et al.
Blepharoplasty
Restoration of youthful eyelid aesthetics is one of the most commonly performed
procedures in patients seeking facial rejuvenation [14]. “Nonsurgical” blepharoplasty involving lasers and llers has been described to address aging of the periorbital tissues in selected patients [15]. Recently, another noninvasive device using
plasma technology has been reported to improve dermatochalasis and periorbital
rhytids by induction of new collagen formation through controlled thermal damage
[15]. Although acceptable outcomes can be achieved with nonsurgical measures,
surgical blepharoplasty remains the gold standard for addressing aesthetics of the
eyelids and the periorbita region.
Upper eyelid blepharoplasty addresses excessive skin and upper lid sulcus deation. Lower eyelid blepharoplasty focuses on the lower eyelid–malar complex
involving laxity of the eyelid skin, orbital septum, canthal tendons, and orbicularis
muscles that commonly manifest as pseudoherniation of fat, tear trough deformity,
malar festoons, etc. For both upper and lower eyelids, there has been a practice shift
toward tissue preservation and/or augmentation compared to the traditional techniques of aggressive skin, orbicularis, and fat excision [14]. For upper eyelid blepharoplasty, the surgical considerations are relatively consistent with some recent
trends that further rene the approach by favoring graded removal of the nasal fat
pad with preservation or repositioning of the central fat. These trends are supported
by studies that show the nasal fat compartment to become more prominent with age,
while the central compartment tends to involute [16]. These techniques are considered to optimally preserve the orbital volume and minimize iatrogenic hollowing of
the superior sulcus [16]. For lower eyelid blepharoplasty, the surgical considerations
can be more nuanced and complex in comparison to upper blepharoplasty as it
involves not only the rejuvenation of lower eyelid but also recreation of a youthful
lower eyelid–malar interface. The favored approach for lower eyelid blepharoplasty
remains largely surgeon-dependent. However, in addition to conservative skin and
fat excision with orbicularis preservation, the current trends favor enhancement of
eyelid volume with orbital and suborbicularis oculi fat (SOOF) repositioning and fat
transposition [16]. The preservation and transposition of fat are purported to restore
the volume loss associated with aging changes in the lower eyelid–malar area and
minimize the risk of lid retraction and iatrogenic enhancement of the tear trough
deformity. Mobilization of herniated fat pads (Fig. 15.3) to areas of depression
improves the periorbital volume [17]. Autogenous microfat grafting or use of autogenous dermis fat grafts are other options both to minimize post-blepharoplasty hollowing and to augment the lower eyelid–malar interface in patients who are not
candidates for traditional blepharoplasty. A recent survey among oculoplastic surgeons showed that a majority (80%) perform fat repositioning, and of those, about
70% perform it in the supraperiosteal plane [16]. In addition to fat repositioning,
there is a growing trend to routinely perform adjunctive procedures including lateral
canthoplasty or canthopexy at the time of blepharoplasty to minimize lower eyelid
malposition. In short, there may not be a single “one-size-ts-all” surgical approach
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Fig. 15.3 Images of a
75-year-old female with
bilateral lower eyelid fat
pseudoherniation and tear
trough deformity who
underwent lower eyelid
blepharoplasty with fat
transposition. (a)
Preoperative, (b)
postoperative
a
b
to blepharoplasty, but awareness of the surgical trends and customizing their application based on careful assessment of an individual’s features of excessive skin, fat
herniation, orbital vector, tear troughs, and malar festoons are essential to achieve
optimal outcomes for eyelids rejuvenation.
Facial Rejuvenation
As skin ages, a variety of physiologic changes take place. The dermis and epidermis
thin and broblasts decrease resulting in decreased collagen and hyaluronic acid
production. As a result, the skin loses elasticity and volume. Facial rejuvenation
techniques aim to remedy these changes, restoring skin elasticity and restoring lost
volume using a combination of noninvasive and invasive methods.
Laser andLight-Based Rejuvenation
Laser technology has been utilized for facial rejuvenation since the 1980s, evolving
from ablative full-eld CO2 lasers to a wide range of fractional/non-ablative lasers.
Laser and other light-based technology rejuvenate the skin by utilizing a specic
wavelength of energy, which targets specic chromophores (typically water),
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causing local tissue injury and coagulation of tissue. Full-eld lasers produce dramatic visible results but are often associated with long recovery times and high rates
of post-inammatory hyperpigmentation and often have limited use in darker skin
tones (Fitzpatrick 4 and up). Fractional laser technology was introduced in the
mid- 2000s for facial resurfacing with the purpose of improved tissue precision and
less thermal damage, which allowed for faster healing and reduced complications
[18, 19]. Fractional laser delivers smaller pulses of energy in a grid pattern with
islands of healthy tissue in between treated skin. Fractionated CO2 (10,000nm) and
Erbium:YAG (2940 nm) are mainstays of current facial resurfacing treatment.
Erbium is thought to result in pure ablation of tissue with minimal collateral heat
transfer and damage to melanocytes and thus can be used in darker skin tones.
Though Erbium:YAG does not result in as much coagulation as CO2 lasers, both
technologies produce similar results for facial rejuvenation with a similar rate of
complication [19]. Traditionally, laser facial resurfacing has been either ablative or
non-ablative, in which ablative laser targets the damaged external layers for epidermal renewal, while the non-ablative lasers penetrate deeper to direct the energy at a
precise depth below the intact skin surface for deep dermal rejuvenation. The use of
laser in facial rejuvenation has been revolutionized with integration of newer technology of hybrid fractional lasers that delivers both ablative and non-ablative wavelengths at the same treatment zone for optimal results. The hybrid Erbium:YAG
fractional laser delivers an ablative (2940 nm) wavelength to address outer skin
texture and pore size issues with a sequential non-ablative (1470nm) wavelength
that addresses the deeper photoaging and other dermal pigment issues and also
stimulates collagen formation. This technology allows each wavelength to be tuned
independently for precise coverage and depth to vaporize tissue in a controlled manner to achieve effective outcomes. The use of hybrid fractional laser has gained wide
popularity and signicant improvement in facial rejuvenation has been observed,
especially in cases of photoaging and dyschromia, with decreased recovery time
and pain [18, 20]. Though there are limited studies examining long-term outcome of
the hybrid laser technology, it does appear to offer a viable option with promising
early results and enhanced wound healing.
P. Sinha et al.
Radiofrequency Micro-Needling
Laser rejuvenation relies on externally applied photothermal energy, resulting in
temperatures highest at the skin surface. This is of particular importance to patients
with darker skin tones, as they are at increased risk of the post-inammatory hyperpigmentation complications, even with the use of fractional technology.
Additionally, lasers rely on the pilosebaceous unit to replenish damaged skin cells.
These functional units are limited in certain regions of the face and, particularly,
the neck. Radiofrequency micro-needling is an alternative technique for facial rejuvenation and skin tightening that utilizes electrothermal energy directed through
the epidermis and dermis with small needles. The rst radiofrequency
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micro-needling device was introduced in the early 2000s for aesthetic use, and
since then multiple devices have been developed to further rene the technology
for application in facial rejuvenation. The radiofrequency micro-needling technique allows for deposition of energy deeper in tissues with minimal epidermal
heating and thus is not limited by skin tone and presence of pilosebaceous units.
The radiofrequency micro-needling method creates high local dermal temperatures
ranging from 65 to 100°C, which causes denaturing of type I collagen resulting in
thickened and contracted collagen bers and increased skin tension [21]. Microneedling can be done with both insulated and non-insulated tips, manual versus
mechanical insertion, and variable versus xed needles, all of which affect the
precision with which a provider can deliver electrothermal energy to the dermis
and overlying epidermis. Radiofrequency micro-needling overall appears to have
minimal patient downtime with few complications. While studies have shown
radiofrequency micro-needling to achieve good clinical results in facial rejuvenation and acne scar treatment, there is no evidence yet of its therapeutic superiority
compared with other available techniques. However, its use could be considered in
patients with darker skin phototypes and areas of the face and neck with low pilosebaceous units [21].
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Platelet-Rich Fibrin/Autologous Nanofat Graft
While laser and micro-needling technologies aim to contract existing collagen,
autologous products like platelet-rich brin (PRF) and fat grafting rejuvenate the
face by augmenting existing soft tissue and regenerating lost ones. Platelet-rich
brin acts in a similar fashion to the more established platelet-rich plasma (PRP).
Platelet-rich plasma induces the migration of stem cells and the secretion of local
growth factors through the release of platelet alpha granules. The growth factors are
localized at the intended site through interaction with newly formed clot. Together
these processes result in increased broblast production and collagen formation,
augmenting volume loss and improved skin laxity. Platelet-rich brin attempts to
improve upon PRP by utilizing a naturally formed brin scaffold to guide clot formation and conne localized growth factors to local tissues. While PRP utilizes
bovine-derived additives to facilitate clot formation, PRF creates the brin scaffold
spontaneously and without additives. This results in a more durable scaffold that
protects degradation of growth factors and helps sustain growth factor release
attracting more mesenchymal stem cells [22]. By prolonging the growth factor
release, the duration of their effects is increased (up to 7days for some factors), and
the lack of additives reduces the risk of adverse reactions [22]. Due to these benets,
PRF can be used in a variety of settings. The gel-like consistency of the brin matrix
not only attracts mesenchymal stem cells but also stimulates the growth of broblasts and increases collagen production. This allows providers to use it as a ller
material where repeated treatments have shown improvement in rhytids and hollowing tear troughs [22]. Some providers have also used it in combination with
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