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Endoscopic Foreheadplasty: A Twenty-Seven-Year Experience

Over the past 27 years, the endoscopic foreheadplasty has evolved into the procedure of choice for aesthetic surgeons with a goal of rejuvenating the brow-forehead complex. Harmony between brow position, symmetry, and improvement of forehead and glabella wrinkles can be achieved if the surgeon possesses a thorough understanding of the endoscopic techniques, regional neurovascular, muscular, and soft tissue anatomy. Since first introduced in 1985, endoscopic foreheadplasty…

The Open Browlift

History The brow has historically been overlooked in the rejuvenation of the aging face. The focal procedure of facial rejuvenation has always been the rhytidectomy. Surgical forehead rejuvenation began at the turn of the 20th century . Passot has been generally recognized as a pioneer in the field. Several other surgeons described their work over the subsequent years . The interest in these procedures waned, as…

Skin Resurfacing

Introduction Facial aging is complex and occurs at all tissue levels, from the underlying skeletal scaffolding, through the musculature, adipose tissue, and skin. Advances in aesthetic medicine now allow us to not only recognize specific changes in these tissue layers, but also address and in some cases correct the clinical signs of aging at its respective anatomic site. The skin ages through two main processes: intrinsic…

Topical Skin Care and the Cosmetic Patient

One of the most important components of any anti­aging treatment plan is topical skin care. A basic skin care regimen includes a cleanser, moisturizer, and sunscreen. Moisturizers that contain beneficial ingredients are called cosmeceuticals and can be used to improve skin tone, texture, radiance, hyperpigmentation, pore size, fine lines, and wrinkles . Treatment outcomes from lasers, chemical peels and even surgical procedures are significantly impacted by…

Injectables and Resurfacing Techniques: Botulinum toxin (BoNT-A)

This chapter was created using the content from Neligan & Rubin, Plastic Surgery 4 th edition, Volume 2, Aesthetic, Chapter 5.3, Injectables and resurfacing techniques: Botulinum toxin (BoNT-A), Michael A. C. Kane. Introduction There are many components to the process of facial aging. Thinning of the dermis, elastosis, loss of facial volume, genetic factors, gravity, skeletal changes, sun damage, and smoking all play a part in…

Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age

History and Introduction As noted by Pessa, “there are many arbitrary definitions of what constitutes a youthful face but the appearance of youth is not arbitrary; it is simply difficult to define” . In an effort to solve any problem, one must first define the problem, come up with a solution, and then successfully execute the solution. The progression of facial shape with aging is the…

Applied Facial Anatomy

Introduction The anatomy of the face is fairly constant. Variant anatomy is seen in the thickness of the soft tissue layers, and in the size and orientation of cartilaginous structures such as the nasal cartilages (nose), tarsal plates (eyelids), and facial bones (maxilla, mandible, zygoma, etc.). The relationships of nerves, vessels, and muscles of the face are fairly uniform. The facial anatomy combines to give the…

Facial Embryology

Embryogenesis Embryogenesis is a dynamic multiple-step process that begins when an oocyte from a female is fertilized by the sperm from a male (the pre-embryonic period). The first 2 weeks after fertilization focus on rapid proliferation and differentiation of the embryo with subsequent implantation of the egg into the wall of the uterus. Also, the development of the amniotic cavity and the embryonic disc gives rise…

Instructions for Sonography of the Mimic Musculature

Based on the German version from Maik Sauer, Jena 2013 (Sauer M. 2013. Statische und dynamische Sonographie der mimischen Muskulatur bei Probanden und Patienten mit peripherer Fazialisparese – Erhebung geschlechtsspezifischer Referenzbereiche [Dissertation] Jena: Friedrich-Schiller-Universität). 1 Introduction These instructions for sonography of the mimic musculature are intended to help sonographers to better understand the very complex sonographic cross-sections of the mimic and mastication musculature and to be…

Surgical Management of Post-FacialParalysis Synkinesis

Introduction Features of a natural smile include spontaneity, symmetric simultaneous superolateral excursion of the oral commissure, appropriate orientation of the nasolabial fold, and symmetrical upper and lower teeth show. , These components are compromised in patients with facial palsy and almost all facial reanimation options do not obtain a significant number of these key features of a normal smile. The only way to attain these components…

Eyelid Rehabilitation in Post-Facial Paralysis With Synkinesis

Periorbital Synkinesis Background Eyelid paralysis, related to facial nerve injury, is a debilitating condition that causes significant functional impairment and cosmetic disfigurement. The most common eyelid and ocular sequelae resulting from facial paralysis include upper and lower lid retraction, lagophthalmos, exposure keratopathy, ectropion, ocular discomfort, visual deficit, and epiphora. Some of these changes can also contribute to corneal decompensation and psychosocial detriment. An additional potential long-term…

Facial Neuromuscular Retraining for Synkinesis

Introduction We rarely think of facial movement. It is spontaneous and emotional as it morphs effortlessly from one mood and expression to the next. Facial palsy devastates normal function, often resulting in significant functional and psychosocial consequences that negatively impact quality of life for those afflicted. Facial muscles are unique in the human body. They move the facial skin in multiple directions to produce a wide…

Objective Measurement of Outcomes inFacial Palsy

Acknowledgement We thank Fabian Bachl and Jakob Hochreiter for recording and editing the EMG-Videos. Parts of the presented work were supported by the German Federal Ministry of Education and Research (BMBF; IRESTRA grant 16SV7209), the Deutsche Forschungsgemeinschaft (DFG) grant DE 735/15-1 and GU-463 and the DEGUM (German Society for Medical Ultrasound). Current Standards for the Classification of Motor Function Disorder and Synkinesis in Facial Nerve Palsy…

Assessment and Grading of Synkinesisand Facial Palsy

Introduction Facial palsy affects many areas of life for the individual: social, aesthetic, functional, and psychological. Management of such patients has been overwhelmingly directed to physical interventions and in order to determine the effects of any interventions, there has been a need to document the status of the patient before and after intervention in order to monitor progress. Currently, rigorously validated quantitative measures of outcome are…

The Role of Botulinum Toxin in Facial Palsy Management

Introduction Facial palsy may cause functional, aesthetic, psychological, and social consequences. The commonest cause, Bell’s palsy, will affect approximately 1 in 60 of the population over a lifetime, with almost 70% of these patients not fully recovering. Regardless of the cause, for those who do not completely recover from facial palsy, the motor sequelae has three main categories: flaccid paralysis, facial paresis, and facial synkinesis. Both…

Smile Analysis for Facial Nerve Disorders

Introduction Facial palsy is a devastating event in a patient’s life and can result in disfiguring permanent flaccid paralysis or synkinesis, a long-lasting muscle discoordination caused by aberrant facial nerve regeneration. Synkinesis generates both hypertonicity of recovered muscles and also involuntary, discoordinated facial movements that may significantly interfere with facial functions such as blinking, chewing, speaking, nasal breathing, and, often most disturbing to patients, smiling. Patients…

Facial Nerve Consultation

Introduction Facial paralysis and its sequela is a complex medical issue that can be both physically and emotionally distressing. Patients may present to us at any time along the continuum of their recovery or lack of recovery. In addition to the medical aspects of treatment, psychosocial impacts are common and must also be addressed. Here we discuss our approach to the evaluation and early management of…

Psychosocial Impact of Facial Palsy

Introduction “Societal interest in appearance has a long history,” and today this seems more important than ever. Social media, the importance of “the perfect picture,” and the desire and possibilities to change and enhance the body create more unrest and discomfort. Older studies show that physical attraction is an important predictor in entering relations and dating. Physical attraction is also associated with success, happiness, and better…

Etiology, Epidemiology, and Pathophysiology of Post-Facial Paralysis Synkinesis

The neural activity responsible for voluntary facial expression relies on an intricate set of interconnections distributed across multiple cortical facial motor areas, the amygdala, and other subcortical areas. The target end-organs for this intricate neural system are the facial muscles directly innervated by last order postsynaptic axons in the facial nerve. The muscles of the upper and lower face are controlled by anatomically distinct motor areas…

Facial Nerve and Muscle Anatomy

Introduction The facial nerve, also known as the seventh cranial nerve, combines motor, general sensory, special sensory, and autonomic (visceral) components. The intricate course of the facial nerve as it runs intracranially, intratemporally, and extratemporally is essential for any surgeon operating in the head and neck to understand. The facial nerve innervates the muscles derived from the second branchial arch and carries sensory and parasympathetic fibers…