Theda C. Kontis

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.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics

Importance Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented. Objective To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD. Design, Setting, and Participants This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016. Methods All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE). Results Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; Pu2009=u2009.01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE. Conclusions and Relevance Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care. Level of Evidence NA.

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success

Importance Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking. Objective To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health. Design, Setting, and Participants In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients’ preoperative estimated mean age was compared with the patients’ actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain. Main Outcomes and Measures Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health. Results A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients’ preoperative estimated mean (SD) age (59.6 [9.0] years) and patients’ actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662u2009=u2009−0.47; 95% CI, −6.07 to 3.72; Pu2009=u2009.64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, −3.69; 95% CI −4.15 to −3.23; Pu2009<u2009.001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; Pu2009<u2009.001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; Pu2009<u2009.001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; Pu2009<u2009.001). The ordinal rank changes for an average individual were −21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health. Conclusions and Relevance In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions. Level of Evidence NA.

Midface Volumization with Injectable Fillers

The aging midface has long been overlooked in cosmetic surgery. Our understanding of facial aging in terms of 3 dimensions has placed increased importance on volume restoration. Although an off-label indication for most fillers in this facial region, volumization of the midface with injectable fillers is usually a safe and straightforward procedure technically. Injectors, nevertheless, need to have an excellent understanding of facial anatomy and the characteristics of the injected products should problems arise.

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.

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.

Cosmetic Botulinum Toxin: Has It Replaced More Invasive Facial Procedures?

Botulinum toxin (BoNTA) has become the modern generations treatment of choice for facial aging. Advanced uses of neurotoxin have treated specific areas of the face, in addition to the glabella, which is the only site for injection approved by the Food and Drug Administration. This article suggests that BoNTA has replaced surgical procedures that treat oral commissures, mild brow ptosis and brow asymmetries, and hypertrophic orbicularis oculi muscles. It is becoming increasingly used for lip asymmetry, platysmal banding, and necklift, although it has not replaced traditional procedures for the correction of these areas.

Association of rhinoplasty with perceived attractiveness, success, and overall health

Importance To date, the impact of rhinoplasty surgery on social perceptions has not been quantified. Objective To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health. Design, Setting, and Participants In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain. Main Outcomes and Measures The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health. Results A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual’s perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively. Conclusions and Relevance As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes. Level of Evidence NA.

Injectable Fillers: Panel Discussion, Controversies, and Techniques

Injectable products are now being designed to treat specific areas of the face, including the lower lid/cheek region, the midface, and circumoral rhytids. Expert injectors from 3 core disciplines (facial plastic surgery, oculoplastic surgery, and dermatology) were asked to discuss their approaches to the midface, lower lid, and cheek region and their opinions about using cannulas versus needles. The authors describe their techniques for avoiding and managing filler complications. They give insight into how their techniques have changed over the past few years and their use of new products that have been developed.

The Art of Camouflage: When Can a Revision Rhinoplasty Be Nonsurgical?

Abstract Rhinoplasty surgery is known to have revision rates up to 20%. Surgical revisions include the risk of anesthesia and scarring. The skilled injector may offer nonsurgical alternatives to patients when considering revision surgery. Injections can be done to improve symmetry or improve/camouflage deformities that are possibly too minor for surgery but bothersome to the patient. Injections can be performed using different filler materials, but these treatments also carry inherent risks.