the pave (peeling-assisted volume-enhancing) lift: a ... · the pave (peeling-assisted...

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) xx, 1e6

The PAVE (peeling-assistedvolume-enhancing) lift: A retrospective6-year clinical analysis of a combinedapproach for facial rejuvenation*

Kai Oliver Kaye a, Hans-Eberhard Schaller b, Patrick Jaminet c,Phillipp Gonser a,b,*

a Centre for Plastic and Aesthetic Surgery, Ocean Clinic, Marbella, Malaga, Spainb Department for Plastic, Reconstructive, Hand and Burns Surgery, BG-Trauma Centre,Schnarrenbergstrasse, Tuebingen, Baden-Wuerttemberg, Germanyc Centre for Plastic and Aesthetic Surgery, St. Marien-Hospital, Am Boltenhof, Borken, Nordrhein-Westfalen, Germany

Received 13 August 2015; accepted 24 April 2016

KEYWORDSFacelift;Peeling;Autologous fatgrafting;Combined single-stage approach;Phenol/croton oilpeel;TCA peel

* Presented at 1) BAPRAS & RBSPS,ESPRAS, Edinburgh, July 2015 4) ISAPAesthetic Surgeons, Frankfurt am Mai* Corresponding author. Centre forTel.: þ49 151 6577 0890; fax: þ34 95

E-mail address: [email protected] (P.

Please cite this article in press as: Kanalysis of a combined approach for f10.1016/j.bjps.2016.04.012

http://dx.doi.org/10.1016/j.bjps.2016.01748-6815/ª 2016 British Association of P

Summary The peeling-assisted volume-enhancing (PAVE) lift is a single-stage approach thatcombines superficial musculoaponeurotic system (SMAS) plication techniques with fat graftingand different peeling agents. To evaluate the safety of this approach, we analyzed the recordsof 159 patients who underwent surgery between 2008 and 2014.

The percentage of complications observed was not higher than values reported in the liter-ature for each treatment entity surgical facelift: nZ3 haematomas (1.89 %), nZ2; temporaryapraxia of the mandibular branch (1.26%); fat transfer: minor asymmetry in n Z 5 cases(3.14%); peeling: temporary hyperpigmentation in trichloroacetic acid (n Z 5; 3.8%) andphenol peels (nZ 4; 3.1%), permanent hypopigmentation (nZ 6; 5.6%), formation of skin mili-ae persisting longer than 2 to 3 months (nZ 5; 4.6%) and prolonged erythema (nZ 3; 0.28%) inphenol peels.

The single-stage use of chemical peels, autologous fat transfer, and surgical rhytidectomywas safe.ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Else-vier Ltd. All rights reserved.

Scientific Summer Meeting, Belgium, June 2015 2) ASPS Aesthetica meeting, Las Vegas, May 2015 3)S, Rio de Janeiro, September 2014 5) VDAPC Spring Academy of the German Association of Germann, May 2014.Plastic and Aesthetic Surgery, Ocean Clinic, Av. Ramon y Cajal 7, 29600 Marbella, Malaga, Spain.2 868 827.Gonser).

aye KO, et al., The PAVE (peeling-assisted volume-enhancing) lift: A retrospective 6-year clinicalacial rejuvenation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/

4.012lastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

mailto:[email protected]

http://dx.doi.org/10.1016/j.bjps.2016.04.012



2 K.O. Kaye et al.

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Background

Together with the evolution of newly available techniques,expectations and demands in facial rejuvenation havegrown.1 Many attempts have been made not only to un-derstand the complexity of the multimodal process of facialaging but also to halt and reverse the process of extrinsicand intrinsic aging.

Facial aging is a complex, three-dimensional processdefined by skeletal changes, volume loss, and gravitationaldescent.2,3 In addition, the aging of the skin itself, thegradual loss of elasticity, the reduction of skin appendages,and the decrease of dermal thickness enhance the aggra-vation of folds and wrinkles.4 Facial aging must be seen as acombination of all these factors, and thus cannot besatisfactorily addressed by purely surgical techniqueslimited to suspension, lift, and volume replacement.

Therefore, we introduced the peeling-assisted volume-enhancing (PAVE) lift as a multilayer approach toward facialrejuvenation that overcomes surgical limitations.5 It com-bines the well-known “lift-and-fill” facelift with differentpeels.6 The concept behind the PAVE lift is a combination ofsuperficial musculoaponeurotic system (SMAS) plication andstacking techniques,3 with autologous fat transfer and amedium-depth peel, deep peel, or combination (mosaic)peel as a single-stage approach. For medium-depth peelson subcutaneous undermined areas, a 20e40% trichloro-acetic acid (TCA) peel is applied,7 whereas a phenol/crotonoil peel solution is applied for deep peels in nonunderminedareas with intact vascular patency, such as the perioral,nasal/perinasal, or glabella regions.8,9

Even though all techniques and their beneficial rejuve-native effects are well known to plastic surgeons and thesingle-stage combination of lifting and filling is common,the literature lacks evidence on the safety of applyingdifferent peeling agents in previously subcutaneousundermined facial skin flaps. For this reason, we revisedthe charts of all our patients who underwent the PAVEprocedure during the past 6 years to include the appliedpeel, the time until the return to socialization, and post-operative complications for comparison with those re-ported in the literature for each single entity.

Methods

The procedures were performed under intravenous (i.v.)sedation with remifentanil and propofol. After infiltrationof both sides of the operative field with liposuction solu-tion containing lidocaine 2% and adrenaline 1:80,000, lip-osculpting of the face and, if necessary, jowls and neckwas performed. Subsequently, the facelift incision wasperformed, starting 2e4 cm cranial from the cranial helixpole, descending as a curved incision toward the lowerhelix pole. In cases of an Omega lift, the incision wasprolonged, ascending retroauricularly in the retroauricularfold and then descending again along the occipital hair-line, allowing lift of the neck. Facelift dissection wasperformed from this incision line by sharp dissection of thesubcutaneous liposuction plane medially to the zygoma-ticemalar area, caudally below the mandible, and if

Please cite this article in press as: Kaye KO, et al., The PAVE (peelinanalysis of a combined approach for facial rejuvenation, Journal of Plas10.1016/j.bjps.2016.04.012

necessary laterally to the infraauricular area until theoccipital hairline. All patients underwent extended sub-cutaneous surgical undermining of the facial skin. TheSMAS lift was performed with three to four 2/0 Vicrylplication sutures anchored in the preauricular fascia (Lore)and in the lateral platysma in the neck if necessary. Thedissected facial skin was pulled upward following a verticalvector through the ear base, and the excess skin wasremoved sequentially from the caudal helix pole to thecranial pole. After skin closure of the facelift incisions,autologous fat transfer was performed in areas with softtissue volume deficits using a modified Coleman’s tech-nique (centrifugation at 2000 rpm for 2 min) with fat eitherfrom the liposculpture of the face/neck or, in cases oflarger volumes, from the abdomen.

After the autologous fat transfer, the skin was cleanedwith chlorhexidine solution and an ether/acetone (1:1) so-lution for defatting. If a phenol/croton oil peel was applied,the facial skin was treated for 6 weeks before the surgerywith a topical skin agent containing hydroquinone 4% andascorbic acid 1% six nights a week. TCA 25% full-face peelswere applied in patients with Glogau type 2 skin and minorcoloration disorders or early actinic keratosis. TCA 40% full-face peels were applied in patients with Glogau type 3 skin.Mosaic peels with TCA 40% in surgically undermined areasand phenol/croton oil in surgically nonundermined areaswere applied in patients with Glogau type 4 skin. The TCApeels were applied for 3e4 min until even frosting and werethen neutralized (Figure 1). The phenol/croton oil peelswere applied in two to three layers (Figure 2) depending onthe anatomical area, and an occlusive silicone tape dressingwas applied for 24 h. After the TCA peels were applied, notopical agents were applied until the skin was shed; after-ward, a panthenol cream was applied three times a day for1 month. The regions peeled with phenol/croton oil weretreated with a drying and disinfecting powder (bismuthtrioxide, Bi2O3) for 6 days, and then with panthenol creamapplied three times a day for 1 month. Sun protection wasapplied for 3e6 months.

The medical records of all patients who received thePAVE procedure between 2008 and 2014 were reviewedby the first, third, and the senior author in a double-dataextraction technique. The first and the third authorsextracted each half of the data for gender, age at proce-dure (minemax and median), lifting technique, additionalsurgical procedures (blepharoplasty, brow lift, or pla-tysmaplasty), type of applied peel, time until return tosocialization, and postoperative complications, while thesenior author verified the extracted data to minimize dataextraction errors.

The aesthetic outcome was documented by the first andthe senior authors using standard photographical docu-mentation obtained 6, 12, and 24 months postoperatively.

Results

From 2008 to 2014, 159 patients received the PAVE treat-ment and all patients were Caucasians. The demographicsand results are presented in Table 1 and the complicationsin Table 2.

g-assisted volume-enhancing) lift: A retrospective 6-year clinicaltic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/

Figure 1 A 65-year-old female patient with a TCA 25% full-face peel after a secondary facelift with upper blepharo-plasty, alar base reduction, and fat graft (nasolabial: 2 cc oneach side; marionette folds: 2 cc on each side; and infraorbi-tal: 1 cc on each side), showing the point of even frosting(blanching) before neutralization after application for 3 min.

Figure 2 A 64-year-old female patient with a mosaic peel(three layers of phenol/croton oil perioral and TCA 40%peeling) after a secondary facelift with upper and lowerblepharoplasty and fat graft (malar: 3 cc on each side; teartrough: 1 cc on each side; nasolabial: 2 cc on each side; andmarionette folds: 1.5 cc on each side), showing the applicationof the TCA peel with a previously performed perioral phenol/croton oil peel.

Table 1 Demographics and results of the chart review ofn Z 159 Caucasian patients for age (median: m; inter-quartile ranges: IQRs), gender, surgical technique (Omegaincision to define and correct the jawline and neck, modi-fied MACS lift with a short preauricular scar), additionalfacial surgery, applied peeling (trichloroacetic acid: TCA,phenol/croton oil in surgically nonundermined areas;mosaic), and postoperative recovery in days until patientswere able to take part in normal socialization.

Demographics and results:n Z 159 patients

age median 59 years IQR 53 years,64 years

gender female n Z 152 (96%)male n Z 7 (4%)

surgical technique Omega incision n Z 136 (85.5%)modified MACS n Z 23 (14.5%)

additional facial surgery blepharoplasty n Z 147platysmaplasty n Z 32brow lift n Z 24

applied peeling mosaic peel n Z 80 (50.3%)TCA full face n Z 51 (32.1%)phenol croton oil n Z 28 (17.6%)

postoperative recovery 14e16 days

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All patients, even those with postoperative complica-tions, reported high subjective satisfaction with the effectof facial rejuvenation (Figures 3e5).

Discussion

Surgical facelift techniques, volume fat grafting, andchemical peels all play an important role as single entitiesin the armamentarium for modern facial rejuvenation.

A new, well-informed generation of patients has begunto visit our offices. They have first-hand experience withskin rejuvenation procedures and increasingly ask for amore complete, intrinsic rejuvenation that goes beyond thewell-known surgical “lift-and-tuck” approach.


The simultaneous combination of facelift techniqueswith a TCA peel was described in the mid-1990s as empir-ically safe; all 35 patients treated with a deep-planefacelift and a 35% TCA peel experienced a clinicalimprovement without increased morbidity.7

A preliminary study of Kaye’s introduction of the PAVElift showed the positive effect of combining SMAS plicationand stacking techniques, fat grafting, and peels in amultilayer single-stage approach.5

The present study retrospectively evaluated the safetyof this combined approach over a 6-year period and is thefirst study to combine peeling procedures on subcutaneousundermined skin flaps with an SMAS lift and not a deepplane-lifting procedure in a single-stage, thereforedemonstrating the safety of this approach.

Swanson analyzed the outcome of 93 patients treatedwith a deep-plane facelift and found that the average timeoff work was 24 days, with a mean time of 2.5 months untilthey were “back to normal”.10

Considering that the reepithelialization period is wellknown to last 7e10 days after chemical peels,11 it is evidentthat a combined single-stage approach combining surgicaland peeling-based rejuvenation techniques can reducedowntime.

The complications of facelift surgery are well known andhave been described previously. Our percentage of com-plications (1.89%; nZ 3 hematomas) is compatible with thevalue of 1.8% for hematomas described by Mustoe in ameta-analysis of 41 studies published between 2001 and2013.12 Fisher’s exact test comparing the results of Mus-toe’s meta-analysis with ours did not show any statisticallysignificant difference (p < 0.001).

In our study, no adverse events related to fat graftingoccurred except for minor volume asymmetry in n Z 5


Table 2 Complications of the n Z 159 treated patients between 2008 and 2014 classified according to the treatment entity(surgical facelift, autologous fat transfer, TCA peel, and phenol/croton oil peel). We did not observe peeling-associated necrosisof the skin or hypertrophic scars in any of our patients.

Complications:n Z 159 patients

surgical facelift hematoma requiring surgical revisionhematoma treated by bedside drainagetemporary neurapraxia of the mandibular brancha

n Z 2n Z 1n Z 2

autologous fat transfer minor volume asymmetry n Z 5prolonged swellingpostoperative cellulitisfat necrosis

n Z 0n Z 0n Z 0

TCA peel temporary hyperpigmentationb n Z 5phenol/croton oil peel hypopigmentation (Figure 6) n Z 6

formation of skin milia over2e3 months

n Z 5

temporary hyperpigmentationb

prolonged erythema (>8 weeks)cardiac arrhythmiac

n Z 4n Z 3n Z 1

a Complete regression within 4 resp. 6 weeks.b Complete regression within 3e4 months under complete sun protection and treatment with topical hydroquinone 4%.c Completely reversible with adequate drug treatment.

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patients (3.1%) who required a second instance of fattransfer. Autologous fat grafting is generally regarded to bea safe procedure, but there are several reports of associ-ated morbidity, such as cellulitis, fat necrosis or cysts or fatemboli, leading to loss of vision, hemiplegia, global apha-sia, or even stroke.13

An important concern is the possible permanent hypo-pigmentation of phenol/croton oil-peeled areas, which

Figure 3 A 62-year-old female patient preoperatively and 12 moscar with upper and lower blepharoplasty; fat transfer: 0.5 cc uppe0.5 cc infraorbital; and TCA 25% full-face peel.


occurred in six cases (Figure 6). Extensive informed consentis mandatory preoperatively, including informationabout temporary hyperpigmentation/hypopigmentation,prolonged erythema, and milia formation, as well as pre-operative topical skin preparation.

One patient experienced cardiac arrhythmia afterapplying the phenol/croton oil peel, which is known tocause arrhythmias in the context of systemic absorption.14

nths postoperatively: SMAS full face and neck lift with Omegar lips; 0.5 cc lower lips, 1 cc nasolabial, 0.5 cc marionette folds,


Figure 4 A 64-year-old female patient preoperatively and 12 months postoperatively: SMAS full face and neck lift with Omegascar with upper blepharoplasty; fat transfer: 2 cc infraorbital, 2 cc malar, 1 cc nasolabial, and 1 cc perioral; mosaic peel: TCA 25%full face and phenol/croton oil perioral.

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Even though Landau states that the incidence of cardiaccomplications in appropriately performed deep chemicalpeeling is lower than previously appreciated, a full healthcheckup, including electrocardiogram (ECG) and standardblood counts, is indispensable. Any known heart disease

Figure 5 A 63-year-old female patient preoperatively and 12 mOmega scar, upper and lower blepharoplasty, and temporal lift; fmalar, 4 cc cheeks, 2 cc nasolabial, and 4 cc perioral; mosaic peel


requires special precautions in collaboration with theanesthesia department, and in our opinion preexistingarrhythmia or conduction disorders, such as Wolff-Parkin-son-White (WPW) syndrome, are an exclusion criterion, forthe application of phenol/croton oil peels.

onths postoperatively: high SMAS full face and neck lift withat transfer: 2 cc infraorbital, 1 cc tear trough deformity, 3 cc: TCA 40% full face and phenol/croton oil perioral.


Figure 6 A 68-year-old female patient, 5 years after thePAVE procedure (Figure 5). Note the persistent perioralhypopigmentation.

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Conclusion

In our study, the use of the adjuvant phenol/croton oil orTCA peeling techniques and autologous fat transfertogether with surgical rhytidectomy has proven to be a safeand effective approach to overcome the limitations ofconventional surgical lifts.

Patients’ downtime was decreased when the treatmentswere combined.

This approach is effective and safe when the limitationsand contraindications are followed properly and the sur-geon is experienced with each of the combined techniques.

Conflict of interest statement

The authors have no financial interests to declare in rela-tion to the content of this article.


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10. Swanson E. Outcome analysis in 93 facial rejuvenation patientstreated with a deep-plane face lift. Plast Reconstr Surg Feb2011;127:823e34.

11. Bassichis BA. Superficial and medium-depth chemical peels.In: Shiffman MA, Mirrafati SJ, Lam SM, Cueteaux CG, editors.Simplified facial rejuvenation. Springer; 2008. p. 99e108.

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14. Landau M. Cardiac complications in deep chemical peels.Dermatol Surg Feb 2007;33:190e3. discussion 3.


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