Scientific Abstract Presentations: Aesthetic 4 Sunday, October 29 Sun, Oct 29 8:00-9:30 a.m. CDT

Background: There is no published guidance on how the pre-operative position of the upper lip should influence decision making, specifically if tip augmentation is indicated. This is a retrospective cohort analysis of the incidence of upper lip malposition in primary rhinoplasty patients followed by the senior author's 40+ years of experience regarding the choice of tip augmentation technique based on upper lip position.

Methods: A total of 150 consecutive patients who presented seeking primary rhinoplasty were identified and reviewed. The upper lip position was measured during smile in reference to incisor and/or gum show. The nasal length, tip projection and columella position were documented. Multivariate logistic nalysis was performed to assess for correlation between nasal parameters and upper lip positions. The most commonly encountered primary rhinoplasty scenarios are then described followed by the senior author's recommended tip augmentation technique.

Results: Standardized photos of 139 primary rhinoplasty patients who met the inclusion criteria were analyzed. 117 (84%) patients were female. 49 (35%) patients had an "ideal" upper lip position, 83 (60%) patients had insufficient incisor show, and 7 (5%) patients had excessive gum show. None of the nasal parameters were found to be predictive of upper lip position. Tip over-projection (OR 3.03, p=0.02) and hanging columella (OR 2.97, p=0.001) were predictive of a long nasal length. Tip under-projection was predictive of short length (OR 35, p<0.0001). Based on the senior author's experience, the most commonly encountered tip deficient scenarios in primary rhinoplasty are: 1) isolated insufficient lobule volume, 2) hanging columella, 3) short columella, excessive gingival show, 4) short columella, inadequate incisor show, adequate nasal length, 5) short columella, inadequate incisor show, short nose. To achieve tip augmentation and favorably influence the upper lip position, the author recommends: 1) tip graft, 2) Fred technique, 3) columellar strut, 4) tip suspension suture, 5) extended spreader grafts with columellar strut, for each of the scenarios, respectively.

Conclusion: The majority of primary rhinoplasty patients present with an upper lip malposition, which highlights the importance of its inclusion when deciding between rhinoplasty techniques, specifically for tip augmentation. Tip augmentation maneuvers in rhinoplasty can have a significant effect on upper lip position, which oftentimes can be detrimental. The pre-operative position of the upper lip during smile should play an integral role in the selection of tip augmentation technique. If the surgeon fails to notice it pre-operatively, excessive gingival show or insufficient incisor show can inadvertently worsen. Even though, tip augmentation maneuvers may not fully optimize upper lip positioning, careful technique selection is vital to improve and not exacerbate the position of the upper lip.

Objectives: Historically facelift procedures are performed in hospital settings owing to the nature of invasiveness and complexity of the surgery. However, with the normalization of outpatient surgery and surgery center procedures, many patients are looking for a surgery experience away from the hospital. This growth trend is most popular among the liposuction procedures, but more recently has grown to include the facelift population. Our experience in AAAASF surgical facilities performing deep plane facelifts with tumescent anesthesia over the past 2 years and over 100 patients demonstrates that such complex procedures can be performed safely with excellent outcomes and may be the model for the future

Methods: Procedures were performed in AAAASF Class A facility under local anesthesia with oral valium and oxycodone for anxiolytic and narcotic control with supplementation by tumescent local solution which includes epinephrine and lidocaine. All patients were screened by the medical team for acceptable level of care within the AAAASF facility by blood pressure assessment and ASA class. Patients were instructed to stop aspirin at least 2 weeks prior to surgery and were administered intravenous antibiotics on the day of the procedure. All patients were allowed to eat and drink their normal meals, including right up to the time of the procedure. All patients were discharged 30 minutes after the end of the procedure.

Results: 100 patients, 91 women and 9 men with the average age of 62 years old underwent deep plane facelift surgery between January 1 2021 and December 31 2022. Complications included 1 hematoma and 5 soft tissue wound infections all of which were managed with wound care and antibiotics. 3 patients had soft tissue ischemia at wound edges which were treated with local wound care and resolved spontaneously. 3 patients had transitory nerve palsy of the depressor angularis oris which resolved with conservative care.

Conclusions: Deep plane facelift surgery remains the pinnacle of facial rejuvenation based on complexity and technical challenge of surgical intervention.1 Currently only 5% of plastic surgeons who perform facelift do so with the deep plane technique. The major concern appropriately is avoiding facial nerve injury.2 However, our experience demonstrates that the awake patient can provide important and valuable feedback during surgery as facial motor nerves have sensory afferent fibers which enable the patient to share real time information about pain sensation despite adequate local anesthetic. This allows for increased tactile response during surgical release of retaining ligaments.3 Deep plane facelift surgery under tumescent anesthesia may not only be more desirable for the patients but may also allow for augmented feedback for nerve injury avoidance.

1. Jacono AA, Bryant LM, Alemi AS. Optimal Facelift Vector and its Relation to Zygomaticus Major Orientation. Aesthet Surg J. Mar 23 2020;40(4):351-356. doi:10.1093/asj/sjz114
2. Hamra ST. The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg. Jun 2004;113(7):2124-41; discussion 2142-4. doi:10.1097/01.prs.0000122410.19952.e7
3. Cakmak O, Emre I. Modified Composite Plane Facelift with Extended Neck Dissection. Facial Plast Surg. Dec 2022;38(6):584-592. doi:10.1055/a-1862-9024

Background: Aesthetic goals in abdominoplasty are changing as patients desire not only a thin waist but also an hourglass figure with round hips. Standard body contouring techniques do not necessarily address the hip as an aesthetic unit, and rarely work to expand the hip. The authors present their experienced using fat transfer for hip expansion, which can be useful in various aesthetic procedures, including abdominoplasty. This technique allows for the hip to be contoured into an aesthetically pleasing hourglass figure. The authors also describe the hip aesthetic unit and its boundaries and specific contours, which should be addressed to achieve a youthful body profile when fat grafting for hip expansion.

Methods: A retrospective review was performed by the senior author (W. C.). Medical records of patients who underwent hip expansion with abdominoplasty between March 1st, 2014 and May 31st, 2022 were analyzed. Every patient had a minimum follow-up time of one year. A total of 1125 consecutive cases were found. Photographic records were taken before and during follow-ups at 1 month, 3 months and 12 months.

Results: Hip expansion with fat grafting with abdominoplasty was successfully achieved in 1125 cases. Average age was 38 years old (standard deviation: 8 years, maximum: 68 years, minimum: 20 years). Average body mass index (BMI) was 29 kg/m2 (standard deviation: 4 kg/m2, maximum: 42 kg/m2, minimum: 18 kg/m2). Average amount of aspirated fat was 1896 ccs (standard deviation: 760 ccs, maximum: 3000 ccs, minimum 400 ccs). Average amount of fat injected into the bilateral hips was 493 ccs (standard deviation: 220 ccs, maximum: 1700 ccs, minimum: 50 ccs). Complications were as follows: Bleeding requiring transfusion (N = 6, 0.5%), infection (N = 19, 1.7%), seroma (N = 6, 0.5%), fat necrosis (N = 10, 0.9%), incisional dehiscence (N = 25, 2.2%), spitting sutures (N = 4, 0.4%), hematoma (N = 3, 0.3%), pulmonary embolism (N = 3, 0.3%), deep vein thrombosis (N = 4, 0.4%) with one case resulting in mortality, and medical complications including hypertension, urinary retention, and urinary tract infection (N = 26, 2.3%).

Conclusion. Adding a hip expansion to popular cosmetic procedures such as abdominoplasty offers a safe and reliable technique that improves patient surgical results. This technique should be part of a plastic surgeon armamentarium, particularly for patients who request an improved waist-to-hip ratio. The authors recommend adding the hip anatomical area as a new aesthetic unit that needs to be taken into consideration.

Purpose: There are many functional and aesthetic benefits to lipoabdominoplasty, including increase in core strength, reduction in urinary incontinence, and improvement in lower back pain. However, patients are still hesitant to undergo surgery due to the perceived fears of post-surgical drains, and post-operative pain. This study proposes a standardized multimodal pain protocol for patients undergoing lipoabdominoplasty procedures that aims to improve post-operative pain control.

Methods/Materials: A total of 80 patients operated on between July 2020 to December 2021 were evaluated in this study. Patients all underwent lipoabdominoplasty and were administered a standardized pre-, intra-, and post-operative pain regimen. Pain scores were measured across all patients in the immediate post-operative period, and post-operative days 1, 7, 28, 90.

Results: Mean pain scores in the PACU were 0.46/10 (+/- 0.18). Subsequent reassessment in the post-op recovery suite yielded mean pain scores of 0.34 (+/- 0.15). Mean pain scores on POD1 were 1.23 (+/- 0.15), and consistent through to POD7 at 1.24 (+/- 0.11) with patients taking an average of 6.65 total percocet 5mg during the week. After POD7, 95% (76/80) of patients were only taking NSAID medications. A total of 75/80 patients (93.75%) reported zero pain at 4-6 weeks after surgery (mean pain score 0.10 +/- 0.08).

Conclusions: The multimodal analgesia protocol consisting of preoperative or immediate induction IV tylenol, precut local analgesia with marcaine and lidocaine, and intraoperative use of liposomal bupivacaine, can improve perioperative pain control in patients undergoing lipoabdominoplasty.

Introduction Lateral osteotomies (LO) are the mainstay modality to address prominent dorsal humps or widened nasal bones in patients undergoing rhinoplasty. Despite their accepted role in rhinoplasty, there is variation in how surgeons osteotomize the nasal bones, with classic reports describing an intranasal or percutaneous approach. Description of intraoral LOs are scant, likely due to the difficulty in surgeon experience and comfort. The Piezoelctric Device has garnered attention in craniofacial surgery, as it enables surgeons to perform accurate osteotomies, while reducing thermal injury and soft tissue damage. Here, we present the first report of using the piezoelectric device to perform LOs through an intraoral approach in a series of cadavers.

Materials and Methods All dissections were performed on cadavers without history of previous rhinoplasty, septoplasty or other nasal surgery. Traditional open rhinoplasty was performed followed by a 2cm intraoral dissection of the bilateral medial maxillary buttresses intraorally exposing the nasofacial junction. Piezoelectric surgery (MT8-20 L long osteotomy saw (Piezosurgery, Columbus, OH) was utilized to perform low to low lateral osteotomies in all cadavers. The duration of exposure, dissection and osteotomy was recorded along with dimensions of dissection. Dissected planes were individually stained with two different color dyes. Video nasal endoscopy was subsequently performed to evaluate for intranasal mucosal injury. Control group included intranasal lateral osteotomy with guarded osteotomes with video nasal endoscopy confirmation.

Results All experimental cadavers were Caucasian (5 females and 2 males), with a median age of 77.8 years old (IQR 5.5). The median time to open the nose was 13.77 (IQR 5.05 minutes). The median intraoral incision, dissection, and exposure was 1.59 minutes (IQR 0.26 minutes) and 1.22 minutes (IQR 0.30 minutes) for the right and left side, respectively. The median piezo osteotomy time took 1.70 (IQR 0.53 minutes) and 1.73 (IQR 1.06 minutes) for the right and left side, respectively. Visibility was maintained with good control and direct visualization in all cadavers from the piriform aperture to medial canthus. Out of the 7 cadavers, with 14 total dissections and osteotomies, all sides demonstrated no mucosal lacerations, confirmed via intranasal video endoscopy. The external branch of anterior ethmoidal nerve and infraorbital nerve were always preserved. Mucosal perforations were encountered in each control group (n=6) traditional lateral lacerations as well as irregular greenstick fractures of the nasal bones.

Conclusion Direct visualization of the dissection and osteotomy allows for a more consistent and precise approach at narrowing the nasal bones. Traditional osteotome technique is blinded, inconsistent and has demonstrated to have a higher likelihood of multiple nasal mucosal lacerations. This study demonstrates that piezoelectric intraoral lateral osteotomies through an intraoral approach are a safe, expeditious and reproducible means to narrow the bony vault without the need for extensive nasal dissection.

Introduction: Panniculectomy is a commonly performed procedure that restores abdominal cosmesis, improves hygiene, and enhances health-related quality of life for patients who experience massive surgical or medical weight loss. However, obesity-related dysmorphic changes in the pannus, comorbidities, and subclinical nutritional deficiencies may contribute to an elevated complication profile in these patients. Risk mitigation strategies include preservation of lymphatics, mattress and progressive tension sutures, hemostatic agents, tissue adhesives, and negative pressure wound therapy. Tranexamic acid, which blocks the conversion of plasminogen to plasmin, is gaining recognition as a pharmacologic adjunct to reduce hematoma, bruising, blood product transfusion, and post operative edema. By harnessing its antifibrinolytic and anti-inflammatory properties, we hope to discern the effectiveness of parenteral tranexamic acid to reduce bleeding complications following panniculectomy.

Methods: A retrospective chart review was performed on consecutive patients who underwent panniculectomy by a single surgeon from 2017-2023. Patient charts were queried for demographics, operative factors, primary outcomes including hematoma or transfusion, and secondary outcomes including post operative change in hemoglobin concentration or hematocrit. Tranexamic acid was given as a loading dose followed by an infusion delivered prior to incision. The treatment group for tranexamic acid was compared to a historic cohort of panniculectomy patients that did not receive it.

Results: 139 patients were identified with an average of 7 months of clinical follow up. The average age was 44±17 years. Average BMI was 32.2. 91% were female gender. 87% were nonsmokers, 10% were former smokers, and 3% were current smokers. 79% had it least one surgical weight loss procedure. 47% underwent an infraumbilical skin excision while the other 53% underwent a fleur-de-lis pattern skin excision. A total of 19 patients received tranexamic acid treatment. Overall, the hematoma rate was low in both groups, 1 (5%) and 2 (2%) in the treatment group and control, respectively, and not significantly different.

Conclusions: The use of tranexamic acid in plastic surgery continues to expand. Though its safety in surgery is widely demonstrated, it may not be effective in preventing complications and reducing surgical morbidity after panniculectomy. Randomized clinical trial data may be needed to determine the utility of this adjunct to reducing clinically meaningful bleeding.

Purpose: Revision rhinoplasty and trauma-related rhinoplasty is often made more challenging by the lack of available autologous septal tissue. While other autologous and homologous graft options exist, they are fraught with their own challenges.1 Fresh frozen costal cartilage (FFCC) is an increasingly popular alternative that yields the benefits of homologous tissue while having a lower theoretical risk profile.2 Given the novel nature of this method, this study aims to analyze the long-term complication rates of MTF (Musculoskeletal Transplant Foundation) FFCC.

Methods: A retrospective chart review of the use of FFCC in rhinoplasty in the senior author's practice was conducted. 282 cases were reviewed and analyzed for rates of infection, warping, and resorption. The inclusion criteria were cases with a minimum of 12 months of follow-up.

Results: The mean age was 35.8 years old, with 27 males and 255 females. 40 cases were primary rhinoplasties while the remaining 242 were revisions. Mean follow-up period was 20.3 months. Six patients (2.1%) required antibiotics for post-operative redness, zero patients had clinical signs of warping, resorption, or displacement, and six patients (2.1%) required operative revision.

Conclusions: To date, this is the largest known study with the longest follow-up analyzing the complication profile of MTF FFCC in rhinoplasty. Acute infection, warping, and resorption rates were found to be no greater than rhinoplasty complication rates when autologous or homologous tissue are used. FFCC is a safe, convenient, and patient-centered option for graft tissue in rhinoplasty.

References: 1. Chen K, Schultz B, Mattos D, Reish R. Optimizing the Use of Autografts, Allografts, and Alloplastic Materials in Rhinoplasty. Plastic and Reconstructive Surgery. 2022;150(3):675e-683e. 2. Rohrich RJ, Abraham J, Alleyne B, Bellamy J, Mohan R. Fresh frozen rib cartilage grafts in revision rhinoplasty: A 9-Year experience. Plastic and Reconstructive Surgery. 2022;150(1):58–62.

Purpose: The use of various image and video based social media applications has become exceedingly common. Obtaining self-taken images on such applications has had an effect on perception of body features, resulting in increased demand for aesthetic procedures. This study aims to explore social media application incurred software distortions in facial features using common applications compared to baseline images obtained on built-in smartphone cameras.


Methods:  A model's face was imaged at average human armlength (75 cm) with the camera at level (0°) with nose or, to simulate selfie angles, 30° above or below. The front and back cameras of an iPhone 14 Pro Max were utilized to obtain standard images. The front/back cameras were then used with three common social media applications including Snapchat, Instagram and TikTok. Cephalometric measurements using predefined anatomical landmarks were obtained from photographs. Average ratio values of cephalometric measurements were calculated and compared using t-tests holding built-in iPhone camera standard.


Results:  Based on comparison of various cephalometric ratios obtained within the social media applications to the standard photographs obtained using the built-in smartphone camera, extensive distortion patterns were noted when using all tested social media applications. Distortions were present with both front and rear phone cameras. In general, vertically oriented anatomical features were more distorted than horizontal features across most platforms. General trends also demonstrated decreases in size of central facial features and these distortions were accentuated when selfies were taken at angles above and below level with the face. Extensive quantitative details of specific anatomical distortions are explored in depth in the complete results.

Conclusions: Social media applications imposed distortions when taking selfies at level and above or below face. This suggests that the aforementioned social media applications have inherent software-based alterations. We propose that these alterations may be secondary to the applications over correcting smartphone induced hardware or software distortions. Awareness of these distortions are important to consider when patient requests are based around smartphone photographs obtained using common social media applications.

INTRODUCTION Obesity has currently taken on epidemic proportions, being considered a huge public health problem. Bariatric surgery is the most effective method in the treatment of morbid obesity (BMI> 40kg/m2), guaranteeing the patient a quick recovery and surgical success, representing a loss of up to 50% or more of weight after the procedure. Skin excess and flaccid, with inferior quality compared to other patients. Therefore, it is understood that surgeons should be aware of the skin alterations and seek to understand their etiology in order to create strategies that guarantee an increasingly superior functional aesthetic result. The review aims to determine existing skin changes after bariatric surgery. MATERIAL AND METHODS A search was carried out in electronic databases (MEDLINE, Pubmed, LiLacs, Scholar google) using the keywords: "skin laxity", "post bariatric" (after bariatric surgery), "massive weight loss".). The articles identified by the initial search strategy were evaluated according to the following inclusion criteria: (1) population (patients undergoing bariatric surgery), (2) intervention (skin analysis), (3) outcome (related skin changes). Studies that met the inclusion criteria were assessed for methodological quality using the PEDro scale, based on the Delphi list, described by Verhagen et al. Studies with low methodological quality (PEDro score less than 3) were excluded. Articles that presented repeated information or information available in other articles were also excluded. RESULTS Were found 312 articles, but just 5 met the inclusion criteria and had methodological quality accessed by PEDro Score. DISCUSSION Macroscopically, there was a disarrangement of the subcutaneous layers with loss of continuity of the superficial fascia, with a structural disarrangement, and the lack of support provided by the subcutaneous tissue could be the cause of the skin flaccidity. Already microscopically, it was observed a decrease in the amount, density and diameter of collagen fibers in patients after bariatric surgery, as well as depletion of elastic fibers, which would cause reduced tensile strength in the skin, causing sagging despite the resection of excess skin. The current literature, however, needs to establish a consensus on the etiology of these changes, with an assumption that they occur due to skin stretching caused by obesity associated with nutritional factors that bariatric surgery as a complicating factor causes. CONCLUSION The literature demonstrates skin alterations caused by the great weight loss after bariatric surgery, more specifically changes in collagen fibers; however, there is a need for more specific studies to determine the etiology of these alterations, allowing intervention planning to minimize or circumvent them. REFERENCES Choo S; Marti G; Nastai M; Mallalieu J; Shermak MA. Biomechanical properties of skin in massive weight loss patients. Obes Surg. 2010; 20(10):1422-8 Orpheu SC1, Coulter PS, Scopel GP, Gomez DS, Rodrigues CJ, Modolin ML, Faintuch J, Gemperli R, Ferreira MC. Collagen and elastic content of abdominal skin after surgical weight loss.Obes Surg. 2010 Apr;20(4):480-6. Silva SL. Anatomical variations of the subcutaneous tissue after weight loss. Rev. Bras. Cir. Plastic (Impr.), São Paulo , v. 25, no. 4, p. 675-678, Dec. 2010 .

The author will rely on his 22 year experience with modern croton oil peels to propose them as the premiere method for facial resurfacing and as an alternative to lasers. The argument that skin resurfacing is an indispensable part of facial rejuvenation will be made with multiple examples. Tactics for incorporating these peels into your practice safely will be discussed including how to perform them as an office procedure with mild oral sedation.

Facial resurfacing is a fundamental part of rejuvenation but it is often ignored because of the perceived difficulty. Lasers are an option, but they have proved inadequate for difficult rhytids (i.e., perioral) both in quality and longevity. Croton oil peels can give excellent results with remarkable permanence. The misconception of danger and difficulty will be dispelled and the reality that these peels are within the grasp of any practitioner will be made evident and that they can be safely and comfortably performed in an office setting.

Purpose:

While 95% of cosmetic surgery patients use online resources for medical information, the quality and completeness of these resources regarding rhinoplasty remain uncertain.1 Previous studies of OPEMs have found inadequate coverage of unsatisfactory results, need for revision, and risks of bleeding and infection.2,3 However, there has been no recent in-depth analysis of complication reporting. The objectives of this study were to evaluate whether rhinoplasty OPEMs comprehensively inform patients of complications and their prevalence in non-technical language, list strategies to prevent/manage complications, and are of high technical quality.

Methods:

The first 100 Google search results for "rhinoplasty patient information" were collected and narrowed down to 65 OPEMs that met inclusion criteria (i.e directed to patients, not post-operative instructions). Websites were categorized based on type (academic/hospital, private practice, health reference site), and WebsiteGrader was used for technical analysis. Assessment for the extent of complications mentioned was performed, and websites were evaluated based on several factors, including the percentage of complications listed in medical terms, discussion of complication prevention and management strategies, mention of complication prevalence, and inclusion of medical disclaimers.

Results:

23 OPEMs were categorized as academic/hospital, 38 as board-certified private practice, and 4 as online health resources. Hospital/academic sites had a 14% higher technical quality score compared to private practice sites (p=.003). Online health resources reported the highest number of complications on average. 94% of sources listed less than 25% of complications in medical terminology. There was no significant difference in listing of strategies for prevention/management of complications, complication prevalence, or technical quality between hospital/academic and private practice sites. 27% of OPEMs listed complication management strategies, 81% listed complication prevention strategies, and less than 50% mentioned complication prevalence. Only 12 websites specifically referenced the author's credentials. 27% of sources included a medical disclaimer.

Conclusion:

Rhinoplasty OPEMs are notably lacking in providing comprehensive procedural information and disclaimers acknowledging this. Though the majority list complications in plain language, there is a significant lack of mention of strategies to manage potential complications and author information. Given the prevalence of cosmetic surgery OPEM use, we hope this study highlights the importance of providing high-quality, accessible patient information.

Limitations include the limit to the first 100 search results and lack of video OPEM inclusion. Future analyses will include validated quality assessments.

References:

[1] Montemurro P, Porcnik A, Hedén P, et al. The influence of social media and easily accessible online information on the aesthetic plastic surgery practice: literature review and our own experience. Aesthetic Plast Surg. 2015;39:270.

[2] Heilbronn C, Cragun D, Wong BJF. Complications in Rhinoplasty: A Literature Review and Comparison with a Survey of Consent Forms. Facial Plastic Surgery and Aesthetic Medicine. 2020;22(1):50-56.

[3] Shamil E, Scenza GD, Ghani SA, Fan KS, Ragulan S, Salem J, Šurda P, D'Souza AR. A Quality Assessment of Online Patient Information Regarding Rhinoplasty. Facial Plast Surg. 2022 Oct;38(5):530-538. doi: 10.1055/s-0041-1735622. Epub 2021 Sep 28. PMID: 34583412.

Abstract Text:

NO MORE ECTROPION! LOWER EYELID REJUVENATION WITH HELIUM RF PLASMA AND FAT GRAFTING Goals/Purpose:

Traditional lower eyelid Blepharoplasty techniques with skin excision involves a significant risk of ectropion and lagophthalmos, despite incorporating intra-operative techniques such as lateral canthopexies or canthoplasties. In order to avoid these complications that are difficult to correct, the author presents lower eyelid rejuvenation without any skin excision, thereby avoiding trauma to the lower eyelid middle lamella, the most common area for scarring that can lead to post-operative cicatricial ectropion. Instead of skin excision, the author describes her technique of lower eyelid rejuvenation utilizing helium RF plasma skin resurfacing combined with structural macrofat grafting in the tear trough and lid-cheek junction areas. This technique is ideal for patients with lighter skin tones Fitzpatrick 1-3. Methods/Technique:

The author presents her single surgeon retrospective experience of 60 patients treated in a five year period (2017-2022). Patients age range from 55-74, with 55 females and 5 males. Fifty patients underwent the procedure in conjunction with full face resurfacing and fat grafting, while ten patients had peri-orbital resurfacing only, along with fat grafting. Fifty five patients had their procedures performed under IV Sedation, and five patients were under general anesthesia. Patient follow up was one day after surgery, followed by weekly, then monthly for three months, then annually. The longest follow up is five years. All patients were Fitzpatrick 1-3. Technique:

Following successful induction of IV Anesthesia or General Anesthesia, the face is prepped and draped in the usual sterile fashion. The peri-orbital areas were then prepped with acetone, then corneal protectors placed. Tumescent solution was then infiltrated into the lower eyelids, approximately 7-10 cc per side. Next, helium RF plasma resurfacing was performed at 40% with 4 liter helium flow at a single pass. Next, macro fat grafting was performed utilizing blunt cannulas via radial Coleman technique, beginning from the tear trough or nasojugal fold, going laterally along the lid-cheek junction. Approximately 1 cc is placed along the nasojugal fold, and a range of 4-7 cc along the lid-cheek junction, just superficial to the infra-orbital periosteum. The patient is then instructed to wash their face twice a day and apply laser balm for the next two weeks. Results/Complications:

There were no patients who experienced ectropion or lagophthalmos post-operatively. There were two patients in the full face resurfacing group who experienced complications. One patient experienced post-inflammatory hyperpigmentation of her forehead at three weeks post-op, but resolved after six weeks of treatment with hydroquinone based skin care. One patient experienced cellulitis of her forehead at eight weeks post-operative, but resolved after two weeks of oral antibiotics. All patients treated had significant improvement of the skin laxity in the lower eyelid area and correction of the volume loss in the nasojugal fold and the demarcation between the lid-cheek junction. Conclusion:

Lower eyelid rejuvenation can be effectively and safely achieved utilizing a combination of helium RF plasma for lower eyelid skin resurfacing, along with macro fat grafting to correct the volume loss of the nasojugal area and the lid-cheek demarcation. By avoiding any skin excision, possible trauma to the middle lamella compartment of the lower eyelid is avoided, therefore preventing the occurrence of cicatricial ectropion and lagophthalmos. This technique also avoids the presence of a visible lower eyelid incision line. The author's goal is to continue to treat more patients and have longer post-operative follow up.