title: Rejuvenation of the nasolabial complex with inverted triangular-shaped SMAS grafts.
abstract: BACKGROUND
  One of the most challenging aspects of facial aesthetic surgery is rejuvenating the nasolabial complex. Unfortunately, the numerous existing techniques for this purpose have shown limited results due to factors such as long-term unpredictability, modest levels of improvement, and failure to address all of the anatomic/biomechanical alterations simultaneously. In this paper we present our experience with the use of inverted triangular SMAS grafts to rejuvenate the nasolabial complex, analyzing important aspects of surgical technique, indications, and outcomes.
  
  
  METHODS
  Fifteen patients underwent rejuvenation of the nasolabial complex using inverted triangular SMAS grafts, with a mean follow-up period of 18 months. Treatment of the nasolabial complex was performed concurrently to an extended SMAS facelift. The triangular-shaped grafts were harvested from the redundant tissue resulting after traction and inset of the SMAS flaps in the preauricular area. Dissection of the graft's pocket is carried out in the subcutaneous plane through a perialar incision. The resulting shape of the pocket resembles an inverted triangle or funnel, with more extensive dissection in the superior area. A Reverdin needle is inserted through a small 2-3-mm incision at the end of the nasolabial crease, adjacent to the oral commissure. The graft is then tied to the needle and inserted by simply extracting the latter from the inferior incision; the tied triangular graft falls naturally into position inside the pocket.
  
  
  RESULTS
  Rejuvenation of the nasolabial complex was performed satisfactorily in all patients. The graft's design provided enough tissue to appropriately fill and attenuate the depressed triangular area in the upper region of the crease. Contour of the inferior two-thirds of the crease was improved by the narrower portion of the graft. Postoperative recovery occurred uneventfully, the grafts were not palpable/perceptible, and there was no need for complementary treatment modalities.
  
  
  CONCLUSIONS
  The presented procedure offers an additional means of rejuvenating the nasolabial complex with excellent results in selected patients. When compared to more conservative techniques such as the injection of alloplastic materials, the use of more consistent autogenous tissue offers permanent integration and less reabsorption, without the need for complementary treatments. The presented technique addresses all the fundamental treatment principles and provides an anatomically based, natural, and long-lasting solution for this challenging problem.
authors.forename: Henrique Ladvocat Pessoa
authors.initials: HL
authors.lastname: Cintra
authors.forename: Alan
authors.initials: A
authors.lastname: Landecker
mesh_terms: D000328:Adult; D005145:Face / Q000601:surgery*; D005152:Facial Muscles / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D017060:Patient Satisfaction; D012060:Rejuvenation; D015361:Rhytidoplasty / Q000379:methods*; D013524:Surgical Flaps; D013997:Time Factors; D019737:Transplants; D016896:Treatment Outcome