Wednesday, 11 January 2023

What is 'Bundling'; the new global trend in Plastic Surgery?

WHAT IS TRENDING IN PLASTIC SURGERY WORLDWIDE?  

With a consistent surge in popularity since the pandemic, plastic surgery procedures continued to rise in 2022. One major change that seemed apparent globally, was the higher demand for facial surgeries and this was close to taking the top spot from breast augmentation (which has been a firm favourite for many years). With younger people opting for face surgeries as well as more male and female patients taking the leap, plus the fact there are multiple procedures concerning the face, this seemed to have shifted into first place for 2022. 


SO, WHAT IS THE BIG NEW TREND IN PLASTIC SURGERY FOR 2023?



Now that the Zoom boom in facial plastic surgery is easing off, the focus is centring back on the body. Ever heard of ‘bundling’? That’s the name for when patients request, and go through with, multiple surgical procedures in one go. This is not a new concept as, at Ocean Clinic, we often recommend a combination of procedures, depending on the individual, in order to achieve the optimal outcome. The shift globally however, seems to be coming forward in a new pattern; people used to ‘fix’ one thing at a time, nowadays patients are tending to lean towards the idea of getting multiple areas of the body done at once. This is to save time, recovery time, money (this can prove to be a more economical option), and the number of times they need anaesthesia in a one-stop rejuvenation process. 


Usually a client would focus on one area of the body or face and, once satisfied, may well move on to other parts at other times in life. The ‘bundling’ trend sees people checking over every part of themselves and having all the procedures (where possible, there are of course limits to how much can be done in one sitting) at the same appointment. 


There are historically some ‘bundles’ that have gained popularity over the years and been given their own namesakes such as the ‘mommy make-over’ and the ‘daddy do-over’ - these entail a combination of surgical procedures. The first can include a selection of the following; breast augmentation (with fat grafting or implants), breast lift, breast reduction, liposuction, tummy tuck or mini tummy tuck, BBL (Brazilian butt lift), labiaplasty, as well as some non-surgical procedures to tighten and rejuvenate the skin. The ‘dad bods’ are rejuvenated with a selection of treatments such as liposuction, eye bag surgery (blepharoplasty), injectables, micro fat transfer, facial fat grafting, and body contouring, for example. 



IS IT SAFE TO BUNDLE TREATMENTS? 


This latest surge does not come without complication and warning, however. For the team at Ocean Clinic it is essential that every client and case is taken as unique.The patient is fully assessed and their desires addressed in order to create the correct diagnosis and treatment plan for their particular situation. A person’s health is the most vital consideration when deciding upon procedures suitable for their body. It may not be appropriate or acceptable for some to undergo more than one procedure at a time, and therefore could create post-op problems if a ‘bundle’ were to be carried out on someone whose body simply isn’t up to that level of interference.


NOT ALL SURGERIES CAN BE BUNDLED:


Certain procedures cannot be carried out during the same sitting due to the positioning of the surgery. For example, if the patient is undergoing a gluteal augmentation (Brazilian Butt Lift) it would take place face down, the patient would have to switch position to have a surgery on the flip side and the site of the operation would have to experience pressure, so a simultaneous rhinoplasty, for instance, would not be a good idea. It is possible, but would not be recommended. 


The success of each operation is paramount and bundling together certain procedures may compromise this, therefore a professional, experienced surgeon should know what will and will not work in this respect and so diagnose and treat according to the individual’s final outcome. Some procedures are just not feasibly combined such as a brow lift at the same time as a hair transplant for example - one may compromise the success of the other and so should not be carried out in one sitting. 



SO, WHICH SURGERIES CAN BE ‘BUNDLED’? 


Most cosmetic procedures can be bundled if there are no major positioning, technical, or aftercare issues. Ocean Clinic has carried out many combination facial procedures such as rhinoplasty, blepharoplasty, brow lift and facelift, for example.


Also the very popular Mommy Makeover or Daddy Do-Over are very popular and successful. Despite there being multiple sites for the surgeries, the complications and risks are minimal as they are a far enough distance that there is not too much going on in one area of the body and also they are all taking place on the same side of the body. 


One major actor to be considered when discussing which procedures to go ahead with is that generally a maximum of 8 hours in the operating theatre is an acceptable amount of time. The longer the surgery time, the greater the risk of complication.


BOTTOM LINE


Bundling together surgeries is generally safe so long as you approach an experienced, board-certified surgeon to discuss your personal requirements. The doctor should be very clear on what can and cannot be achieved or carried out and explicit in explaining your recovery time and aftercare requirements. Contact Ocean Clinic today to discuss your needs and arrange a consultation with our outstanding, professional team. 


Saturday, 7 January 2023

What is a facelift-lite? Why 40-something is the new age for facelifts...


 Lighter facelifts for forty-somethings… 


Cosmetic surgery procedures rise and fall in popularity through social and cultural shifts as well as innovative technique developments, lifestyle and economy, and little things like global pandemics! The predictions for the biggest trends in 2023 are definitely leaning towards the more natural appearance and longer-term maintenance plans rather than a one-stop fix. People have a deep fear of looking unnatural and so this is absolutely having an effect on the choices being made for surgery this year - those which create impactful, but not excessively altering, facial effects will most likely be among the top choices as well as procedures with minimal recovery time.



Enter the facelift-lite! 


Over the last few years the age of people requesting or debating a facelift at a younger age has increased dramatically. Mid to late forties is becoming a regular age range for people to consider a surgical lift for a longer-lasting outcome. Due to technological advances and developments in technique, the facelift is now something which can offer a less dramatic alteration to the overall look and so facelifts can be more of a maintenance plan (having lighter lifts once a decade, for example, to keep your looks as natural as possible) as opposed to a one off rejuvenation procedure in later years. 





What does a light facelift entail?


During a lighter facelift there would still be a removal of some excess skin (an incision is made close to the ear and the inner layer of the face and neck muscles are lifted) but due to the youth of the patient, the skin’s laxity would be a lot less and so there is less work to be done than in a much older patient. The procedure would be quicker and require slightly less down time to recover. A facelift may also include a fat transfer whereby the patient’s own fat is removed from a donor site from their body, processed, and reintroduced in any areas of the face that have lost volume or to reduce the impression of the tightness of their newly lifted skin. 


Facelift recovery…


A facelift is far more advanced these days and the results are far more natural in order to allow patients to continue to look their best. Recovery from any facelift, light or otherwise, requires some post-op down time. A full facelift may take around two weeks, but a lighter one could possibly be more on the one week scale, depending of course on the individual. A younger patient may well recover quicker than an older one and the swelling and bruising is reduced by age as well as severity of the surgery. 


How long will a light facelift last?


The facelift is a long lasting procedure, however a lighter version will typically last for 5-10 years as some laxity will begin to show during this time. The more full facelift offers around a ten year mark as there was more work done to achieve the goal. 


The long term face plan


As mentioned, the lighter facelift is not a one-stop procedure for eternal youth. The 40 something is more likely to have a long game in mind, a plan in which this is just one of the steps. The future of their face is under construction in this plan, for example they may be opting for a light facelift at a young age and will combine some non-invasive treatments such as injectables to support the results of this until perhaps the day comes when their second light facelift is due. Doing this can help the patient to maintain their looks, have a good idea of the financial commitment and allow them to plan accordingly. This more long-term planning is absolutely becoming a popular way for younger patients to be able to keep their facial features theirs; not to have a shocking transformation at a later stage in life, but to slowly and gradually maintain their looks in the most natural looking way possible. 


Finding the right surgeon is ultimately the most important thing when considering any surgical procedure and so Ocean Clinic always recommends doing your research, speak to a variety of doctors and practitioners, as well as existing patients and find the surgeon you connect with as this may well be a long term relationship. Trust is paramount, at Ocean Clinic we always offer an in-depth analysis of every individual and ensure that our understanding of their wants and desired outcome is on point. Expectations can sometimes be difficult to translate and so it is absolutely vital that this is agreed upon and understood prior to any procedure planning. 




Before & after photos : PAVE facelift and neck lift



If you are considering a facelift, contact our highly professional and experienced team of surgeons at Ocean Clinic, Marbella for a consultation. 

Thursday, 5 January 2023

Do you have unwanted unsightly scars? Here is what you can do about them...

Scars can have a big impact on your life, not only from the way in which you got them - perhaps through a trauma or surgery, but the changes they make to your appearance.



Many people still believe that scars are for life and there's not much you can do about them once they are a part of you; especially when they are the result of a previous surgery. Well, this is not the case - scar correction surgery can often work wonders in reducing the size, smoothing the texture and minimising the visibility of a scar. 


Scar correction can also help in cases where the skin has healed in such a way that it is restricting movement or causing pain as well as reducing burns and deep acne scars. 


Director of Ocean Clinic Group Dr Kai Kaye is a specialist in scar revision, having trained in this field at the Plastic and Reconstructive Surgery Department at the University of Aachen in Germany.


So, what causes bad scarring and what can be done to correct it?


Why do I have a bad scar?


Scarring can turn out badly for a number of reasons. Factors that influence how well you heal include:


  • Your skin type - some people simply scar worse than others. Darker skin is more prone to make the worst scars and people with very pale skin can also be poor scar makers.

  • The location of the scar - if it’s along a joint, on skin which has a lot of movement (on a knee, for example) the scarring will be worse than if it’s on skin that doesn’t move (like behind the ear).

  • The suture technique - if your wound is not stitched up well - or you fail to get medical attention for a wound - it can result in uneven healing.

  • Your aftercare - if you fail to look after your scar during the healing process, for example by exposing it to UV light, it can become discoloured. 


Scar Types:


Beyond normal, fine-line scars, there are four different types of scars that can result in a less than optimal healing outcome:


Keloid scars - A keloid scar is one that’s raised, often red, and goes beyond the boundaries of the original wound. They’re caused by an overgrowth of tissue that happens when too much collagen is produced at the site of a wound. Some people are prone to keloid scarring, especially people with more pigment in their skin. In these individuals, even a simple insect bite can end up in a significant scar. Keloid scars are often itchy or painful and can restrict movement if they're near a joint.


Hypertrophic scars - Like keloid scars, hypertrophic scars are ones that rise above the surface of the skin, however, they do not extend beyond the boundary of the original wound. They’re also the result of an imbalance in collagen at the site of the wound. Hypertrophic scars occur when there is a lot of tension around a healing wound. They may continue to thicken for up to 6 months before gradually improving over a few years.


Atrophic scars -  These are pitted or sunken scars caused by a bad case of acne or chickenpox. They can also develop as a result of an injury that causes a loss of underlying fat.  Atrophic scars stay within the boundary of the original wound and typically occur in the face or on the back.


Scar contractures - Scar contractures are tight scars that occur on a joint. They’re often caused by burns and happen when the skin "shrinks" and pulls on the surrounding tissue. This restricts movement of the joint, which can also make them painful. 



What’s a ‘good’ scar?


A 'good' scar is one that fades to be a barely noticeable fine line that blends in with the surrounding skin tone. It should be placed in the right direction to ensure there is not too much tension exerted on the scar. Wherever possible, the scar should be hidden in the natural folds of the skin, for example beneath the breast or in the groin. 


Experienced surgeons can influence the result through meticulous technique and by using dissolving sutures or glue and removing other stitches early enough to avoid stitch marks. What’s more, proper aftercare - such as using silicone sheets - will ensure best results. 


How can a bad scar be repaired?


If you wish to improve the appearance of a particularly bad scar that is causing you problems whether aesthetic or physically restricting, in addition to surgical excision, there are non-surgical treatments that can help. Usually, the best results can be achieved through a combination of surgical and non-invasive procedures. 


Surgical correction


Scar excision - In simple terms, scar excision is cutting out the existing scar and resealing the wound. But there are a number of different excision techniques a surgeon can use depending on the type of scar you have. For example, extramarginal scar excision involves excision of a small margin of the normal skin along with the scar in order to get normal tissue at the wound margins. On the other hand, intramarginal scar excision is done by cutting away portions of the scar at intervals of 6-12 weeks in order to preserve the normal skin as much as possible.


Tissue expansion - This is a procedure performed to promote the growth of healthy supplementary skin used for the replacement of damaged skin. It’s carried out by placing a balloon-like expander underneath the skin near the damaged region. Over time, the expander is filled with saline (or saltwater) solution causing the skin around it to stretch and grow. Once the new skin has reached its ideal size the tissue expander is removed and the new skin is redistributed, replacing the damaged area of skin. Often, tissue expansion is done before reconstructive burn surgery, using the new skin to replace scar tissue at the burn injury site.


Skin flaps - A skin flap is healthy skin and tissue that is partly detached and moved to cover a nearby wound. Flaps are transferred with their own, original blood supply (pedicle flap) and can be ‘local’ or ‘regional’. Local flaps are flaps that are located adjacent to the scar site. Regional flaps are located at a distance from the donor site and are used for extensively burned contractures on movable areas such as the anterior neck. Sometimes a flap is moved to a new site and the blood vessels are surgically reconnected. This is called a ‘free’ flap.


Skin graft - A skin graft involves removing skin from one area of the body and moving it (without its blood supply) to another. Skin grafts survive as oxygen and nutrients diffuse into them from the underlying wound bed. A ‘split-thickness’ graft involves removing the top layer of the skin (the epidermis) as well as a portion of the deeper layer of the skin, called the dermis, usually harvested from the front or outer thigh, abdomen, buttocks, or back. Split-thickness grafts are used to cover large areas. ‘Full-thickness’ grafts involve removing all of the epidermis and dermis from the donor site. These are usually taken from the abdomen, groin or forearm and are used for small wounds on highly visible parts of the body, such as the face. 


Fat graft - Fat grafting involves the extraction of fat from a donor site on the body (such as the tummy). It’s then processed and used to restore volume under depressed or adherent scars. Because fat tissue is rich in growth factors and stem cells it also results in skin regeneration, with excellent results for scar correction. 




Non-surgical correction


Steroid injections - Especially effective in keloid scars and hypertrophic scars, steroids are injected directly into the scar tissue to help decrease the itching, redness, and burning sensations that these scars may produce. The injections also help to decrease the size of the scar and soften the scar tissue. Injections are repeated over a 3-6 months period, resulting in progressive improvement. 


Laser resurfacing - Laser resurfacing uses high-energy light to burn away damaged skin. Lasers may be used to smooth a scar, remove the abnormal colour of a scar, or flatten a scar. 


Dermabrasion -  Dermabrasion involves removing the top layers of skin with an electrical machine that abrades the skin. As the skin heals from the procedure, the surface appears smoother and fresher. It’s a useful treatment for small surgical scars and acne scars.


Chemical peels - Chemical peels offer another method for resurfacing the skin. A chemical solution is applied to dissolve the top layer of skin. This triggers the skin to regenerate, often improving the appearance of superficial scars and correcting irregular colour.


Microneedling - Tiny needles are used to create micro-injuries to the inner and outer layers of the scar tissue, triggering the body’s healing process. By encouraging the production of new collagen and elastin, microneedling improves the texture of the scar. The channels created by the needles can also be used for the deep delivery of topical creams. 


Ultrasound treatment - Ultherapy is an ultrasound treatment used to stimulate collagen and elastin. It does this by heating the layers beneath the skin and creating thermal microtrauma - this leads to a reformation of elastic fibres and improves the appearance of scars. 


Hyaluronic acid filler - To fill atrophic scars (sunken or pitted), Radiesse, an injectable filler and biostimulator can be used. The filler is diluted (mixed with saline and lidocaine to 'thin it') and injected superficially. As well as adding volume and making the surface of the scar smoother, it can help to improve discolouration. 


Downtime and aftercare


In most cases, scar correction treatment can be done on an outpatient basis and requires little to no downtime. Only when extensive skin grafting is required do patients need to stay overnight in the clinic. 


To achieve the best possible results, all our scar correction treatments include advanced scar care dressings. Silicone sheets and patches are important tools as they help to soften and decrease the redness of scars. 


We also provide compression garments to wear over the treated area and apply pressure to the scar. Especially useful in the treatment of burn scars, pressure therapy may be applied continuously for many months in order to avoid the scar elevating above the surrounding skin level and to reduce itching, redness and swelling.


If you would you like to know more on how the appearance of your scar could be improved please Contact Ocean Clinic to book a consultation.


Tuesday, 27 December 2022

A Systematic Approach to Non-Surgical Neck Rejuvenation


Gabriela Casabona shares her seven-step approach to treat skin laxity and restore volume to the neck

December 27th 2022 | Minimally InvasiveInjectablesAesthetic Features

A Systematic Approach to Non-Surgical Neck Rejuvenation, by Dr. Gabriela Casabona et al. 


Aesthetic procedures can have a positive impact on self esteem and therefore improve lifestyle; rejuvenation of the neck is a highly popular request from patients seeking improvement of their appearance. When approaching aging of the neck we have to inform patients that the problem is not just an issue within the skin but is due to a combination of aging in other areas such as the mid-face, mandible (lower jaw and mouth) and temples. To therefore understand the aging within each layer; SMAS (Superficial Muscular Aponeurotic System; a thin fibrous layer covering the anterior face and neck), skin and fat is vital to be able to evaluate and determine a plan for each patient when considering energy based devices, threads, biostimulators, or fillers. 


In 2019 a study was carried out using 200 patients whereby the ageing of the SMAS, superficial and deep fat layers in different age groups, gender and BMI (body mass index). Im 2022 a similar study was carried out but this time included skin thickness as a variable. Both studies concluded that, with age, the SMAS became more superficial in specific areas such as; pre-auricular (in front of the ear), submandibular (lower jaw and mouth), and neck due to the loss over time of superficial fat layer, as well as an evident age-related thinning of the skin especially in the neck. 


Therefore, when addressing neck rejuvenation in a patient over 45, it is more likely that the skin will require thickening as well as to add support to the skin below the dermis by adding or restoring the lost fat layer. For this the combination of : PRP, micro needling or radio-frequency can be used for the skin, plus HA (Hyaluronic Acid) or Bio-stimulators to restore the sub-dermal layer (or any other layer) in order to cover the ageing process holistically. 


The anatomy of a patient also assumes an important role in making a responsible decision for the treatments used. In 2019 Casabona et al highlighted the importance of the order in which the areas of the face are treated makes a significant impact on the effectiveness of the treatment as well as the amount of product required.  The same applies for the neck; treatments in posterior temples and lateral face affect the lower face, or more precisely in mandible area, as much as treatments in the chin area also improve the submandibular area. 


We observed the results from a pool of Ocean Clinic’s neck rejuvenation patients over the last five years and recognised that each was satisfied when there was a certain pattern in their treatment plan. It was very important to understand and consider what the patient really wants and how much they are willing to invest to get there, as well as how much post-procedure downtime they can afford. Using a scale helps to visualise a language and reference point for patients to gauge their own severity and pinpoint whether they have a lack of volume or laxity. Over the last 5 years at Ocean Clinic we have developed a systematic approach to evaluate a patient to ensure that the treatment plan we construct for them is more precise and accurately meets the patient’s expectation. Considering the fact that most patients have high expectations in the improvement of their neck laxity and/or volume we developed the following seven steps to follow for assessment and development of combination techniques.  


STEP 1- Choose regions to treat (the more severe the case, the more regions involved). Consider the anatomy in order to understand the impact each region will have on the rest -  e.g., treatment of the zygoma area has a great impact on the mandible area, and, after treatment of the posterior temples we see a great impact in the lateral face; zygoma and  mandible regions will therefore impact in the upper neck. 



STEP 2- Choose vectors; during the ageing process we experience the loss of bone, fat, and skin thickness, each of which have a different impact in the vectors against gravity, and so each region of the face has more important vectors to treat. For lower face and neck rejuvenation, the vertical and horizontal vectors are more important than the projection. (FIG 2) Specifically for the neck, the vertical vector means either to enhance the vertical height of the mandible or to shorten structures such as the SMAS (Platysma + fascia) from mandible to clavicle, and horizontal vectors - to create some shortening in the direction of the back the neck by strengthening the SMAS - skin connection or creating skin retraction. The only projection vector that can affect the neck is the width enhancement of the chin or masseter, but those can be only performed in few individuals with that kind of need.





STEP 3 - Identify the problematic layer: bone, fat, muscle, fascia or skin. 

STEP 4 - Choose treatment according to the vectors: every procedure we do strengthens or weakens a different vector against gravity. E.g., if we inject a bolus of HA (Hyaluronic Acid) in the zygoma area we strengthen the projection effect, whereas if you inject CaHA dilute in lateral face, you strengthen the horizontal vector of the face. Or, if you inject the same HA in lower border of mandible, we strengthen the vertical vector. (Figure 3,4)








Figure 4 (A) was taken during injection of a patient for projection of zygoma with CaHA in bolus on the bone. 

(B) was taken during injection of CaHA dilute in subdermal plane for biostimulation.


STEP 5 - Choose the layer to treat according to best use of the products. Sometimes one product has a better projection capacity if used in the supraperiosteal area instead of in the subdermal area. The use of a bolus rather than retrograde injections have a better projection capacity. (Figure 4)




 

STEP 6 - Choose the amount of product to use depending on the severity (Figure 5)





STEP 7 - Choose a maintenance plan depending on the severity (Figure 5). 




After the step-by-step approach for treatment, the next step is to follow-up with our patients through their journey and to monitor results, but also to follow up in the short term to prevent any possible complications. Depending on the procedure there is a specific time that should be respected for immediate and long term follow up, for example: filler injected should be followed up the next day to check for any lumps, pain, bruising or discoloration, to guarantee there is no complications. For toxin injection follow up occurs around day 15 as this is when any major complications can present, such as ptosis, asymmetries and lack of result. 

figure 6


Figure 6 (A) Before and (B) after 1 year of combination treatment: Ulthera®(Merz Aesthetics, Germany), Radiesse® (Merz Aesthetics, Germany) dilute 1:1 and Belotero Soft® (Merz Aesthetics, Germany) taking place on the same day.


When severity differs, different goals and different layers are involved and so patients will be given contrasting treatment plans and combinations of treatments. This illustrates very well how complicated the decisions for neck rejuvenation can be.


The conclusion from these studies show that is that is vital to be systematic not only in the evaluation of neck aging, but also when electing procedures and the specifics for each patient; each decision makes a difference to the amount of product required and time needed to achieve optimal, desired results. 




REFERENCES :

  1. Cohen JL, Rivkin A, Dayan S, Shamban A, Werschler WP, Teller CF, Kaminer MS, Sykes JM, Weinkle SH, Garcia JK. Multimodal Facial Aesthetic Treatment on the Appearance of Aging, Social Confidence, and Psychological Well-being: HARMONY Study. Aesthet Surg J. 2022 Jan 12;42(2):NP115-NP124. doi: 10.1093/asj/sjab114. PMID: 33751048; PMCID: PMC8756087. 
  2. Friedman O, Shamban A, Fabi S, Duncan DI, Artzi O. The Aging neck-A Case base treatment algorithm. J Cosmet Dermatol. 2021 Feb;20(2):569-576. doi: 10.1111/jocd.13877. Epub 2020 Dec 19. PMID: 33340202
  3. Casabona G, Kaye K. Facial Skin Tightening With Microfocused Ultrasound and Dermal Fillers: Considerations for Patient Selection and Outcomes. J Drugs Dermatol. 2019 Nov 1;18(11):1075-1082. PMID: 31738490.
  4. PĂ©rez P, Hohman MH. Neck Rejuvenation. 2022 Feb 27. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32965900. 
  5. Casabona G, Frank K, Koban KC, Schenck TL, Lopez VP, Webb KL, Hamade H, Freytag DL, Green JB, Cotofana S. Influence of Age, Sex, and Body Mass Index on the Depth of the Superficial Fascia in the Face and Neck. Dermatol Surg. 2019 Nov;45(11):1365-1373. doi: 10.1097/DSS.0000000000001909. PMID: 30882511.
  6. Kwon SH, Ahn GY, Lew BL, Shin JW, Na JI, Huh CH. Clinical Implication of the Regional Thickness of the Lower Facial Skin, Superficial Fat, and Superficial Musculoaponeurotic System on High-Intensity Focused Ultrasound Treatment. Dermatol Surg. 2022 May 1;48(5):527-531. doi: 10.1097/DSS.0000000000003393. Epub 2022 Jan 26. PMID: 35093961.
  7. Casabona G, Frank K, Koban KC, Freytag DL, Schenck TL, Lachman N, Green JB, Toni S, Rudolph C, Cotofana S. Lifting vs volumizing-The difference in facial minimally invasive procedures when respecting the line of ligaments. J Cosmet Dermatol. 2019 Aug 12. doi: 10.1111/jocd.13089. Epub ahead of print. PMID: 31402563.
  8. Casabona G, Frank K, Moellhoff N, Gavril DL, Swift A, Freytag DL, Kaiser A, Green JB, Nikolis A, Cotofana S. Full-face effects of temporal volumizing and temporal lifting techniques. J Cosmet Dermatol. 2020 Nov;19(11):2830-2837. doi: 10.1111/jocd.13728. Epub 2020 Oct 5. PMID: 32946624.
  9. Gawdat H, Allam RSHM, Hegazy R, Sameh B, Ragab N. Comparison of the efficacy of Fractional Radiofrequency Microneedling alone and in combination with platelet-rich plasma in neck rejuvenation: a clinical and optical coherence tomography study. J Cosmet Dermatol. 2022 May;21(5):2038-2045. doi: 10.1111/jocd.14331. Epub 2021 Jul 10. PMID: 34214220.
  10. Vanaman Wilson MJ, Jones IT, Butterwick K, Fabi SG. Role of Nonsurgical Chin Augmentation in Full Face Rejuvenation: A Review and Our Experience. Dermatol Surg. 2018 Jul;44(7):985-993. doi: 10.1097/DSS.0000000000001461. PMID: 29309340.
  11. Truswell WH. Complications in Lower Face Rejuvenation: Avoiding, Minimizing, Recognizing, Dealing with Them, and Helping the Patient through the Process of Fixing the Problems. Facial Plast Surg. 2020 Aug;36(4):462-477. doi: 10.1055/s-0040-1713823. Epub 2020 Aug 31. PMID: 32866983.
  12. Gentile RD. Renuvion RF-Helium Plasma for Subdermal Skin Tightening, Facial Contouring and Skin Rejuvenation of the Face and Neck. Facial Plast Surg Aesthet Med. 2020 Jul/Aug;22(4):304-306. doi: 10.1089/fpsam.2020.0070. Epub 2020 May 5. PMID: 32379988; PMCID: PMC7374633