Publications by authors named "Bryan Mendelson"

46 Publications

Commentary on: Sub-SMAS Reconstruction of Retaining Ligaments.

Aesthet Surg J 2022 Jun 22. Epub 2022 Jun 22.

Plastic surgeon in practice practice in Toorak, Victoria, Australia.

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http://dx.doi.org/10.1093/asj/sjac169DOI Listing
June 2022

Correction: Aesthetic Enhancement of the Brow using Hydroxyapatite.

Aesthetic Plast Surg 2022 Apr 28. Epub 2022 Apr 28.

The Centre for Facial Plastic Surgery, 109 Mathoura Road Toorak, Melbourne, VIC, 3142, Australia.

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http://dx.doi.org/10.1007/s00266-022-02890-yDOI Listing
April 2022

Aesthetic Enhancement of the Brow using Hydroxyapatite.

Aesthetic Plast Surg 2022 Mar 14. Epub 2022 Mar 14.

The Centre for Facial Plastic Surgery, 109 Mathoura Road Toorak, Melbourne, VIC, 3142, Australia.

Background: An aesthetically pleasing appearance of the 'eyes' usually includes good projection of the outer brow. Weak bony projection of the superolateral periorbital region tends to be not only less attractive, but also predisposes to hooding over the temporal part of the upper lid. Congenital lack of skeletal volume is exacerbated by ageing due to lipoatrophy and soft tissue laxity. The rationale and technique for performing skeletal augmentation of the superolateral orbital rim is described, along with long-term results from a series of cases.

Material And Methods: A series of patients having augmentation of the superolateral orbital rim, using the technique described, were evaluated. A forehead crease incision was used, then a precise subperiosteal pocket developed in the lateral brow region between the supraorbital foramen and the superior temporal septum. The hydroxyapatite granule mixture was incrementally placed using modified syringes. The patients were followed to assess the long-term results.

Results: Two hundred and fifty patients, 80% women, mean age = 53 years [range 23-78] underwent supraorbital rim augmentation using subperiosteal hydroxyapatite granules, during a 12-year period, commencing in 2007. The mean follow-up was 41 months (range 1-12 years). The mean volume used for augmentation was 1.0 mL per side (range 0.4-2.3 mL). Projection of the upper lateral periorbital prominence was effectively increased, resulting in enhancement of the brow position and shape. Twenty-seven patients (11%) had an undercorrection, requiring additional volume augmentation, all during the first three years of the experience. Twelve patients (5%) required correction of contour irregularities. There were no infections and no long-term complications. Resorption of the hydroxyapatite volume over time was not noted.

Conclusion: The aesthetic significance of superolateral orbital rim projection is introduced. Patients who have a degree of skeletal deficiency of the zygomatic process of the frontal bone should be considered for hydroxyapatite augmentation of the bone as a complement to upper lid blepharoplasty and brow elevation. This procedure should be considered in the spectrum of upper periorbital aesthetic procedures.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-022-02793-yDOI Listing
March 2022

Asian Face Lift with the Composite Face Lift Technique.

Plast Reconstr Surg 2022 Jan;149(1):59-69

From W Aesthetic Plastic Surgery; the Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital; and the Centre for Facial Plastic Surgery.

Background: The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

Methods: Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

Results: Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

Conclusion: The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000008686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700314PMC
January 2022

Invited Discussion on: What is Beauty?

Aesthetic Plast Surg 2021 10 17;45(5):2177-2179. Epub 2021 Jun 17.

Centre for Facial Plastic Surgery, 109 Mathoura Rd Toorak, Melbourne, 3142, Australia.

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http://dx.doi.org/10.1007/s00266-021-02401-5DOI Listing
October 2021

Invited Discussion on: A Meta-Analysis and Systematic Review of the Incidences of Complications Following Facial Threadlifting.

Aesthetic Plast Surg 2021 10 1;45(5):2159-2162. Epub 2021 Jun 1.

Centre for Facial Plastic Surgery, 109 Mathoura Rd Toorak, Melbourne, 3142, Australia.

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http://dx.doi.org/10.1007/s00266-021-02360-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8481211PMC
October 2021

Upper Blepharoplasty - Nuances for Success.

Facial Plast Surg Clin North Am 2021 May 24;29(2):179-193. Epub 2021 Apr 24.

W Aesthetic Plastic Surgery, 06 - 28/29, Mount Elizabeth Novena Specialist Center, 38 Irrawaddy Road, Singapore 329563, Singapore.

Given the central importance of the "eyes," meaning the periorbital region, to facial appearance, the motivated blepharoplasty patient has the opportunity to improve appearance significantly beyond the minimum of age reversal, to reveal inner beauty or add attractiveness. Bright and beautiful eyes have good three-dimensional contouring. The benefits of a quality eyelid crease enable the surgical focus to be on lid contouring with a reduced requirement for lid skin and fat excision. A durable crease maintains fixation of both the tarsal and infrabrow segments. The softness of youthful eyes can be regained by precise, but cautious, use of lipofilling.
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http://dx.doi.org/10.1016/j.fsc.2021.01.001DOI Listing
May 2021

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula.

Aesthet Surg J 2021 09;41(10):1120-1129

Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore.

Background: The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes.

Objectives: The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented.

Methods: Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance.

Results: A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.

Conclusions: This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjab039DOI Listing
September 2021

Upper Eyelid Ptosis Correction with Levator Advancement in Asian Patients using the Musculoaponeurotic Junction of the Levator as the Key Reference Point.

Plast Reconstr Surg 2020 12;146(6):1268-1273

From W Aesthetic Plastic Surgery; the Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital; and The Centre for Facial Plastic Surgery.

Upper eyelid ptosis correction is a complex procedure. The ethnic differences in the Asian upper eyelid anatomy are compounded by the technical challenges of primary and revision ptosis correction. The authors present a technique of upper eyelid ptosis correction that estimates the exact location of suture fixation that uses the musculoaponeurotic junction of the levator as the reference point. The preoperative considerations in determining the fixation point relative to the musculoaponeurotic junction include the following: A, the extent of ptosis correction needed; B, the degree of compensatory brow elevation with eye opening; and C, eye dominance. The benefits of this approach are the shortened operative time because of more precise preoperative planning and greater predictability and reproducibility of the results. The authors have found that this technique produced consistent and superior results for ptosis correction in Asian patients.
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http://dx.doi.org/10.1097/PRS.0000000000007386DOI Listing
December 2020

Dog faces exhibit anatomical differences in comparison to other domestic animals.

Anat Rec (Hoboken) 2021 01 24;304(1):231-241. Epub 2020 Sep 24.

The Centre for Facial Plastic Surgery, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1002/ar.24507DOI Listing
January 2021

Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation.

Aesthetic Plast Surg 2020 08 12;44(4):1151-1158. Epub 2012 May 12.

W Aesthetic Plastic Surgery, Mount Elizabeth Novena Hospital, 38 Irrawaddy Road, #08 - 42, Singapore, 329563, Singapore.

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-01823-xDOI Listing
August 2020

Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation.

Aesthetic Plast Surg 2020 08;44(4):1159-1161

W Aesthetic Plastic Surgery, 28/29, Mount Elizabeth Novena Specialist Center, 38 Irrawaddy Road, Singapore, 329563, Singapore.

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http://dx.doi.org/10.1007/s00266-020-01785-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447647PMC
August 2020

Invited Discussion on: Mesh Suspension Thread for Facial Rejuvenation.

Aesthetic Plast Surg 2020 06 24;44(3):775-779. Epub 2020 Mar 24.

Centre for Facial Plastic Surgery, 109 Mathoura Rd Toorak.3142, Melbourne, Australia.

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http://dx.doi.org/10.1007/s00266-020-01670-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280356PMC
June 2020

The Long-Term Static and Dynamic Effects of Surgical Release of the Tear Trough Ligament and Origins of the Orbicularis Oculi in Lower Eyelid Blepharoplasty.

Plast Reconstr Surg 2019 09;144(3):583-591

From W Aesthetic Plastic Surgery and The Centre for Facial Plastic Surgery.

Background: Release of the tear trough ligament and the origins of the orbicularis oculi is a key maneuver with many lower blepharoplasty techniques. The long-term static and dynamic effects of this release have not been studied previously.

Methods: From December of 2012 to June of 2017, 105 patients were treated with the extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution as described previously. The long-term effect of the release was assessed by evaluating the effectiveness in correcting the tear trough deformity, the effect on the lower eyelid position, and the dynamic changes of the patient's smile.

Results: The mean patient age was 41 years (range, 23 to 62 years). The mean follow-up was 31 months (range, 12 to 53 months). The tear trough was effectively corrected with this maneuver. This release did not compromise the tarsoligamentous support of the lower eyelid, with no increase in scleral show in 99 percent of patients and with no patients developing ectropion. Functionally, the change in the action of the orbicularis oculi as a result of detachment of its origins resulted in a change in appearance of the smile. Elimination of the tethering at the tear trough ligament and the downward pull toward the medial suborbital maxilla resulted in elevation of the lid-cheek junction with smiling. Reduced efficiency of orbicularis contraction resulted in a diminished pretarsal bulge and in reduction of crow's feet with smiling.

Conclusions: The maneuver is effective in correcting the tear trough deformity while not weakening the lower eyelid tarsoligamentous support. Functionally, the patient's smile became more youthful and rejuvenated, with less wrinkling and elevation of the lid-cheek junction with smiling.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000005908DOI Listing
September 2019

Response to "Clarification Regarding the Modified Finger-Assisted Malar Elevation (FAME) Technique".

Aesthet Surg J 2019 04;39(5):NP163-NP164

Mendelson is a plastic surgeon in private practice in Victoria, Australia.

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http://dx.doi.org/10.1093/asj/sjz038DOI Listing
April 2019

Commentary on: Modified Composite-Flap Facelift Combined with Finger-Assisted Malar Elevation (FAME): A Cadaver Study.

Aesthet Surg J 2018 11;38(12):1284-1288

Plastic surgeon in private practice in Singapore.

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http://dx.doi.org/10.1093/asj/sjy184DOI Listing
November 2018

Reply: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Plast Reconstr Surg 2018 08;142(2):236e-237e

The Centre for Facial Plastic Surgery, Toorak, Victoria, Australia.

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http://dx.doi.org/10.1097/PRS.0000000000004556DOI Listing
August 2018

Reply: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Plast Reconstr Surg 2018 03;141(3):446e-447e

The Centre for Facial Plastic Surgery, Toorak, Victoria, Australia.

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http://dx.doi.org/10.1097/PRS.0000000000004140DOI Listing
March 2018

Reply: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Plast Reconstr Surg 2018 03;141(3):443e-445e

The Centre for Facial Plastic Surgery, Toorak, Victoria, Australia.

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http://dx.doi.org/10.1097/PRS.0000000000004138DOI Listing
March 2018

Reply: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Plast Reconstr Surg 2018 03;141(3):442e

The Centre for Facial Plastic Surgery, Toorak, Victoria, Australia.

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http://dx.doi.org/10.1097/PRS.0000000000004136DOI Listing
March 2018

Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

Plast Reconstr Surg 2017 Aug;140(2):273-282

Singapore; and Toorak, Victoria, Australia.

Background: The transconjunctival lower eyelid blepharoplasty is advantageous for its quick recovery and low complication rates. Conventional techniques rely on fat removal to contour the lower eyelid. This article describes the authors' extended transconjunctival lower eyelid blepharoplasty technique that takes dissection beyond the orbital rim to address aging changes on the midcheek.

Methods: From December of 2012 to December of 2015, 54 patients underwent this procedure. Through a transconjunctival incision, the preseptal space was entered and excess orbital fat pads were excised. Medially, the origins of the palpebral part of the orbicularis oculi, the tear trough ligament, and orbital part of the orbicularis oculi were sequentially released, connecting the dissection with the premaxillary space. More laterally, the orbicularis retaining ligament was released, connecting the dissection with the prezygomatic space. Excised orbital fat was then grafted under the released tear trough ligament to correct the tear trough deformity. When the patients had significant maxillary retrusion, structural fat grafting was performed at the same time.

Results: The mean follow-up was 10 months. High satisfaction was noted among the patients treated with this technique. The revision rate was 2 percent. Complication rates were low. No chemosis, prolonged swelling, lower eyelid retraction, or ectropion was seen in any patients.

Conclusion: The extended transconjunctival lower blepharoplasty using the midcheek soft-tissue spaces is a safe and effective approach for treating patients presenting with eye bags and tear trough deformity.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000003561DOI Listing
August 2017

The Lymphatic Anatomy of the Lower Eyelid and Conjunctiva and Correlation with Postoperative Chemosis and Edema.

Plast Reconstr Surg 2017 Mar;139(3):628e-637e

Melbourne, Toorak, and Fitzroy, Victoria, Australia.

Background: There are minimal data in the literature regarding the lymphatic drainage of the conjunctiva and lower eyelid and the relationship with postoperative chemosis and edema.

Methods: Injection, microdissection, and histologic and radiologic studies were conducted on 12 hemifacial fresh cadaver specimens. Indocyanine green lymphography was conducted in five volunteers.

Results: Histology identified lymphatic vessels superficial and deep to the orbicularis oculi. Cadaveric dissection, injection, and radiographic studies identified interconnecting superficial and deep facial lymphatic systems and a conjunctival lymphatic network draining through the tarsal plate to the deep lymphatic system. The superficial lymphatic collectors traveled in subcutaneous fat within the lateral orbital and nasolabial fat compartments. The lateral deep lymphatic collectors traveled beneath orbicularis oculi, then through the superficial orbicularis retaining ligament, and into the sub-orbicularis oculi fat in the roof of the prezygomatic space. These vessels descended to preperiosteal fat at the level of zygomaticocutaneous ligaments to travel adjacent to the facial nerve into preauricular nodes. Indocyanine green lymphography identified correlating draining pathways laterally to the parotid nodes and medially to submandibular nodes.

Conclusions: The authors have found that the lower eyelid and conjunctiva are drained by interconnecting superficial and deep lymphatic systems of the face. The superficial system is vulnerable to damage in incisions and dissection in the infraorbital area. The deep system is vulnerable to damage in dissection around the orbicularis retaining ligament and the zygomaticocutaneous ligaments. The authors suggest that concurrent damage to both the superficial and deep lymphatic systems, especially laterally, may be responsible for postoperative chemosis and edema.
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http://dx.doi.org/10.1097/PRS.0000000000003094DOI Listing
March 2017

Biologic Behavior of Hydroxyapatite Used in Facial Augmentation.

Aesthetic Plast Surg 2017 Feb 23;41(1):179-184. Epub 2016 Dec 23.

The Centre for Facial Plastic Surgery, 109 Mathoura Road, Toorak, Melbourne, VIC, Australia.

Introduction: The recent finding that shrinkage of key areas of the facial skeleton contributes to the aging appearance of the face has prompted a search for the most appropriate bone-like implant material. Evidence that hydroxyapatite, in granular form, maintains volume in the long term supports its use in the correction of aging, in addition to its use in the correction of inherently deficient areas of the facial skeleton. The biologic response of hydroxyapatite needs to be fully understood for its use to be confidently recommended.

Materials And Methods: Samples of 'living' hydroxyapatite from the anterior maxilla, zygoma, and mandible of 17 patients were analyzed. These were obtained during revision procedures performed between 6 months and 15 years following original placement on the facial skeleton.

Results: Histology showed that in every case, the individual granules were embedded within a mass of collagen that made up about half of the total implant volume. The collagen mass also contained fine elastin, fibroblasts, lymphocytes, occasional granulomas, and vessels. By 2 years, a new compact bone containing osteoblasts and osteocytes was present in all specimens in the deep (osseous) aspect. Bone progressively replaced the original collagen between the granules with a sharply defined transition at the interface.

Conclusions: This study confirmed a two-stage biologic change following onlay placement of hydroxyapatite granules on the facial skeleton, i.e., initial collagen formation with subsequent conversion to bone. This integrates the implant with the host bone which stabilizes the implant position and shape initially and in long term.

No Level Assigned: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-016-0707-9DOI Listing
February 2017

The Mobility of the Human Face: More than Just the Musculature.

Anat Rec (Hoboken) 2016 12;299(12):1779-1788

Centre for Facial Plastic Surgery, Toorak, Victoria, Australia.

The human face has the greatest mobility and facial display repertoire among all primates. However, the variables that account for this are not clear. Humans and other anthropoids have remarkably similar mimetic musculature. This suggests that differences among the mimetic muscles alone may not account for the increased mobility and facial display repertoire seen in humans. Furthermore, anthropoids themselves outpace prosimians in these categories: humans > other anthropoids > prosimians. This study was undertaken to clarify the morphological underpinnings of the increased mobility and display repertoire of the human face by investigating the SMAS (the superficial musculo-aponeurotic system), a connective tissue layer enclosing the mimetic musculature located between the skin and deep fascia/periosteum. Full-thickness samples from the face near the zygoma region from the anthropoids Homo sapiens (humans, N = 3), Pan troglodytes (chimpanzees, N = 3), Hylobates muelleri (gibbons, N = 1), and Macaca mulatta (rhesus macaque, N = 3) and the prosimians Tarsius bancanus (tarsiers, N = 1), and Otolemur crassicaudatus (galagos, N = 2) were used. All samples were processed for paraffin-based histology and stained sections were viewed under light microscopy to determine if a SMAS layer could be identified. Results indicate that a SMAS layer was present in all anthropoid species but neither of the prosimian species. This connective tissue layer may be a factor in the increased facial mobility and facial display repertoire present in these species. Anat Rec, 299:1779-1788, 2016. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ar.23451DOI Listing
December 2016

Commentary on: SMAS Fusion Zones Determine the Subfacial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging.

Aesthet Surg J 2016 May 1;36(5):529-32. Epub 2016 Mar 1.

Dr Mendelson is a plastic surgeon in private practice in Victoria, Australia. Dr Wong is a plastic surgeon in private practice in Singapore.

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http://dx.doi.org/10.1093/asj/sjw038DOI Listing
May 2016

Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Aging Changes in the Craniofacial Skeleton and Facial Ligaments.

Plast Reconstr Surg 2015 Nov;136(5 Suppl):44S-48S

Novena, Singapore; and Toorak, Victoria, Australia From W Aesthetic Plastic Surgery, Mount Elizabeth Novena Specialist Center; and the Centre for Facial Plastic Surgery.

Logical correction of aging contour changes of the face is based on understanding its structure and the processes involved in the aging appearance. Aging changes are seen at all tissue levels between the skin and bone although the relative contribution of each component to the overall change of facial appearance has yet to be satisfactorily determined. Significantly, the facial skeleton changes profoundly with aging as a consequence of significant resorption of the bones of dental origin in particular. The resultant loss of skeletal projection gives the visual impression of descent while the reduced ligamentous support leads to laxity of the overlying soft tissues. Understanding the specific changes of the face with aging is fundamental to achieving optimum correction and safe use of injectables for facial rejuvenation.
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http://dx.doi.org/10.1097/PRS.0000000000001752DOI Listing
November 2015

Midcheek Lift Using Facial Soft-Tissue Spaces of the Midcheek.

Plast Reconstr Surg 2015 Dec;136(6):1155-1165

Singapore; and Toorak, Victoria, Australia From W Aesthetic Plastic Surgery and The Centre for Facial Plastic Surgery.

Background: This article describes a preperiosteal midcheek lift technique performed by means of the midcheek soft-tissue spaces by precise release of the retaining ligaments that separate the spaces.

Methods: From November of 2009 to June of 2014, 184 patients underwent this procedure. A transcutaneous lower eyelid blepharoplasty incision was used to access the preseptal space. Medially, the orbicularis oculi origins and tear trough ligament are released sharply, connecting the dissection with the premaxillary space. More laterally, the orbicularis retaining ligament is released, connecting the dissection with the prezygomatic space. With this release, the entire midcheek can be effectively lifted. The fat pads were managed by transposition, excision, or with septal resets as indicated. Canthopexy is performed routinely to provide lower eyelid support. Superolateral traction on the orbicularis oculi elevates the entire midcheek, and this was secured to the lateral orbital rim periosteum. In patients with significant volume loss in the midcheek, structural fat grafting is performed.

Results: All patients demonstrated a significant rejuvenation of the midcheek with elimination of the eye bags and elevation of the lid-cheek junction and the cheek prominence and improvement of the nasolabial folds. The majority of the patients (96 percent) were satisfied with the procedure. Complication rates were low. Ectropion occurred in 1 percent of patients, and lower lid retraction occurred in 1 percent of patients.

Conclusion: The midcheek lift by means of the facial soft-tissue spaces is safe, effective, and long lasting. As the dissection is atraumatic, recovery is quick and complications are minimized.
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http://dx.doi.org/10.1097/PRS.0000000000001826DOI Listing
December 2015

Submandibular Gland Reduction in Aesthetic Surgery of the Neck: Review of 112 Consecutive Cases.

Plast Reconstr Surg 2015 Sep;136(3):463-471

Toorak, Victoria, Australia; and Toronto, Ontario, Canada From The Centre for Facial Plastic Surgery and Trillium Health Partners, Joseph Brant Hospital.

Background: The indications for reduction of excessive submandibular gland volume in aesthetic rejuvenation of the neck have been well described, as has the surgical anatomy and the surgical technique. Despite this, submandibular gland reduction does not appear to be widely adopted, nor have significant case series been reported in the literature. This review of a consecutive series of aesthetic submandibular gland reductions was undertaken to provide a perspective about its place in neck contouring.

Methods: A retrospective chart review was conducted of all patients on whom the senior author (B.C.M.) had performed submandibular gland reduction for aesthetic reasons. Complications and reoperations were specifically analyzed.

Results: Submandibular gland reduction was performed in 112 of 736 consecutive face lifts between 2002 and 2013, an incidence of 13 percent in primary face lifts and 25 percent in secondary face lifts. The median patient age was 57 years, and 87 percent were women. Major complications were those requiring early reoperation (1.8 percent) to manage significant hematomas; one was potentially fatal. Minor complications (10.8 percent) were managed nonoperatively. Submandibular sialocele (4.5 percent) and marginal mandibular branch neurapraxia (4.5 percent) were the most frequent, and all resolved fully by 3 months. Significantly, no patient reported a permanent dry mouth.

Conclusions: The complication rate with submandibular gland reduction is comparable to that of a neck lift with platysma plication alone, with some additional specific risks: (1) catastrophic airway compression from bleeding deep in the neck, (2) significant increase of neurapraxias in secondary neck lifts, and (3) a moderate incidence of benign submandibular sialocele.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000001526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548544PMC
September 2015

Secondary upper lid blepharoplasty: a clinical series using the tarsal fixation technique.

Plast Reconstr Surg 2015 Mar;135(3):508e-516e

Toorak, Victoria, Australia From the Centre for Facial Plastic Surgery.

Background: One hundred consecutive secondary upper lid blepharoplasties were reviewed retrospectively to determine the lid characteristics of patients undergoing secondary blepharoplasty and the outcomes of all the procedures, which were performed using a tarsal fixation technique performed by one surgeon.

Methods: The median age of the patients was 54 years, and 99 percent of the patients were women. The median time since primary blepharoplasty was 8.7 years (range, 2 to 22 years). At surgery, no additional skin was removed in 37 percent, and the median amount excised in the remainder was only 2 mm. Revision surgery was performed in 13 percent, mainly for incomplete correction of asymmetry (5 percent) or ptosis (4 percent). Nonsurgical complications were mainly ocular (8 percent). There were no cases of persistent postoperative lagophthalmos or dry eyes.

Results: The term "postblepharoplasty look" was introduced to describe the different aging changes that follow primary blepharoplasty, mainly dermatochalasis (70 percent), with a high or absent and often poorly defined lid fold, with fat distribution irregularities. The tarsal fixation technique is advantageous in secondary blepharoplasty, as its benefit does not depend on further skin removal, minimizing the risk of lagophthalmos and dry eye syndrome. Lipoinfiltration for volume contouring is another major advance. The higher revision rate in secondary blepharoplasty reflects the incidence of asymmetry, lid ptosis, and scar from the original blepharoplasty, and from ongoing aging.

Conclusions: The postblepharoplasty look of patients undergoing secondary upper lid blepharoplasty differs from the lid appearance of patients presenting for primary blepharoplasty. Tarsal fixation and lipoinfiltration are major advances in secondary upper lid blepharoplasty.
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http://dx.doi.org/10.1097/PRS.0000000000001042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342320PMC
March 2015
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