Edward D. Buckingham

Volume rejuvenation of the facial upper third.

The next three articles in this issue take a unique approach to discussing volumetric restoration. Robert Glasgold has provided an assessment for each facial region and five different renowned authors (TK, SPS, RF, SML, and EFW) have been asked to speak on a particular volumetric product, of which they are considered an expert, as it applies to the different regions of the face. The articles are broken into the following: (1) upper third which corresponds to the upper eyelid, brow, temple, and forehead; (2) middle third which will cover lower eyelid, cheek, and perioral area; and (3) lower third which discusses the marionette, prejowl, and jawline. Our hope is that by placing differing opinions of experienced authors, organized by facial region together, the reader will have the opportunity to more readily compare the options. The contributing authors and their product area are as follows: Theda Kontis, MD-hyaluronic acid; Steve Smith, MD-calcium hydroxyl appetite; Rebecca Fitzgerald, MD-poly-L lactic acid; Sam Lam, MD-polymethyl methacrylate; and Edwin Williams, MD-Autologous Fat Transfer. If the author included general comments on the product, they are included in the article on the upper face only and are not repeated. Please note that other individuals may also have significantly assisted in the production of these articles, but those listed above are the senior authors.

Autologous Fat and Fillers in Periocular Rejuvenation

Facial volume loss is an important component of facial aging, especially in the periocular region. The authors evaluate the normal and aging anatomy of the periocular region and then discuss volume restoration of this region using hyaluronic acid, calcium hydroxylapatite, and autologous fat transfer. Preoperative assessment, operative technique, postoperative care, and complications are addressed.

Poly-L–Lactic Acid Facial Rejuvenation: An Alternative to Autologous Fat?

Facial volume loss is an important component of facial aging and tends to present at an earlier age than other aspects of aging. Several surgical and nonsurgical products and techniques are available to replace volume loss associated with aging. One surgical technique uses a patients fat cells to replace or augment volume deficiency. Poly-L-lactic acid (PLLA) injection is a nonsurgical option. This article compares these 2 volume augmentation procedures and discusses characteristics of facial aging, the consultation process involved in assessing individual volume loss, procedure details of autologous fat grafting and PLLA injection, the decision of PLLA versus autologous fat, and patient outcomes.

Volume Rejuvenation of the Lower Third, Perioral, and Jawline

This is the third and final article discussing volumetric rejuvenation of the face. The previous two articles, Rejuvenation of the Upper Third and Management of the Middle Third, focused on the upper two-thirds of the face while this article focuses on the lower face, including the marionette area, jawline, and neck. Again, the authors of the previous two articles have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Fat Transfer Techniques: General Concepts

Facial volume loss has become widely accepted as one of the contributing factors in global facial aging. Some have even suggested that bony, muscular, fatty, and dermal/epidermal changes are more integral in the aging process than gravitational influence. Although detractors of autologous fat transfer persist, facial autologous fat transfer has become widely utilized as one option for volume restoration. Various techniques in harvesting, processing, and injecting autologous fat have been debated at length without clear guidelines emerging to maximize outcomes. This article aims to present one surgeons experience in successful fat grafting philosophy and technique. Areas covered will include preparation, harvesting, processing, and injection techniques. The injection techniques are organized by facial region and into the general philosophy and thinking regarding the facial region as well as the specific technique that has been utilized over 7 years and hundreds of successful procedures.

The Difficult Neck in Facelifting

As the popularity and acceptance of facial and cervical rejuvenation procedures grows, surgeons are increasingly encountering patients with less favorable anatomical characteristics for rhytidectomy. These patients will typically display an obtuse cervicomental angle, underprojected chin, excess cervical adiposity, and platysmal banding, in addition to ptotic submandibular glands, tenacious jowls, and prejowl volume deficits. Recognition of these problems and the correct application of available techniques to address the difficult neck in facelifting are critical in maximizing success.

Volume Management of the Middle Third-Lower Orbit/Midface

This is the second of the three articles discussing volumetric rejuvenation of the face. The previous article, Volume Rejuvenation of the Facial Upper Third, focused on the upper one-third of the face while this article focuses on the middle one-third, primarily the lower eyelid, cheek, and perioral area. Again, the authors (RG, TK, SPS, RF, SL, and EFW) from the upper face article have provided a summary of rejuvenation utilizing a product of which they are considered an expert. Robert Glasgold has provided volumetric analysis of the region as an introduction.

Novel Use of a Volumizing Hyaluronic Acid Filler for Treatment of Infraorbital Hollows

Importance Hyaluronic acid filler can be safely used as a soft-tissue filler for correction of infraorbital hollowing. It has a high overall patient satisfaction profile among patients. Objective To report safety and patient satisfaction outcomes of Juvéderm Voluma XC for correction of infraorbital hollows. Design, Setting, and Patients This was a retrospective observational study performed at a private ambulatory facial plastic and reconstructive surgery practice. Participants were all patients 21 to 85 years old who presented to our practice and underwent Juvéderm Voluma XC treatment for correction of infraorbital hollows as a singular intervention from February 2016 to March 2017. Interventions Injection of Juvéderm Voluma XC to the tear trough, nasojugal fold, and/or palpebromalar groove. Main Outcomes and Measures Primary outcome measures include the number of recorded short- and long-term adverse events, need for additional treatment, and patient questionnaire FACE-Q scores. Results A total of 202 eyes were treated in 101 patients with a mean follow-up of 12 months. Patients were principally female (90 [89%]) with an average age of 54 years (range, 21-85 years). Most patients (99) had Fitzpatrick grade 1 to 4 skin type (98%) and had an infraorbital hollows score of 2 to 4 (89 [88%]). The average initial treatment volume was 1 mL with 18 patients (18%) requiring additional treatment within 3 months. The average time until additional treatment was 35.7 days. Adverse effects include bruising (in 10 [10%], contour irregularities (2 [2%]), swelling (3 [3%]), and Tyndall effect (1 [1%]). Hyaluronidase was required in 3 patients (3%). Forty-one patients completed the FACE-Q Satisfaction With Eyes survey, and 42 patients completed the FACE-Q Satisfaction With Decision survey (41% and 42%). Overall mean (SD) patient satisfaction (based on FACE-Q scores) was 71.1% (27.3) and 65.6% (31.3), respectively. Conclusions and Relevance Juvéderm Voluma XC has a high patient satisfaction profile and an acceptable safety profile for the correction of infraorbital hollowing. Level of Evidence 4.