Standard Facelifting

29.1 Introduction

Traditional face-lifting techniques consisted of only elevation and redraping of the facial skin [1]. Since then, there has evolved many different surgical variations including the more recent minimally invasive procedures involving less dissection and more simplified anatomical approach [2]. This paradigm shift in the surgical approach to face-lifting has been predicated on the demand of the patient population wanting less morbidity and faster recovery. As we understand more of the facial dynamics and facial anatomy, cosmetic facial plastic surgeons are staying in the cutting edge of constantly searching for more innovative and improved methods to perform this very successful cosmetic procedure. In trying to understand the demands of the patient, surgeons must realize that sometimes less is better. This chapter will lay down the basic fundamentals of face-lifting technique via skin flap, addressing the SMAS with redraping.

29.2 Technique

Some relative contraindications for rhytidectomy include (1) smoking and/or alcohol abuse; (2) collagen vascular disorders; (3) poor nutritional status; (4) anticoagulation bleeding disorder; (5) use of Accutane,

S.A. Myint

Ophthalmic Plastic and Reconstructive Surgery and Orbital Diseases and Eye and Facial Plastic Surgery of Las Vegas,

7955 West Sahara Ave. Suite 101, Las Vegas, NV 89117, USA

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high-dose steroids, or immunosuppressants; and (6) poor medical condition (e.g., uncontrolled hypertension, poorly controlled diabetes, significant chronic airway disease (CAD), significant chronic obstructive pulmonary disease (COPD).

The surgeon should first and foremost understand the patient’s needs. Place a mirror in front and ask them what about their face bothers them, and what specific areas in the face they want addressed. This initial patient evaluation is of paramount importance. Unrealistic desires can lead to a surgery, which fails to please them. Make note of the quality of the skin, the amount of redundant tissue, presence or absence of platysmal bands, and the amount of submental fat. Evaluation of the chin and neck directly affects the surgery performed in this area. If submental fat and skin laxity is present, submental liposuction or lipectomy is performed. The skin dissection in this case should not extend to the central neck and submental area. If there is significant laxity and submental fat then the dissection extends further into the neck (Fig. 29.1) with possible lipectomy and platysmal plication.

In addition to the surgical evaluation preoperatively, it is important to discuss the importance of smoking and medication usage with the patient. Smoking can lead to flap necrosis secondary to vasoconstriction. It is imperative the patient stops smoking. If they continue, it is imperative to tell them to stop 2 weeks before and 2 weeks after the surgery. Any medications that inhibit platelets or coagulation must be stopped 1–2 weeks prior to surgery. These include, but not limited to, NSAIDS, aspirin, Warfarin (coumadin), and clopidogrel (Plavix). All these medications can increase the risk of hematoma under the skin flap, which can potentially lead to flap necrosis.

With the patient sitting up, the incision is marked both in front of the ear continuing behind the ear (Fig. 29.2). If the patient presents with significant cervical skin laxity, a retroauricular skin flap may be

Fig. 29.1 Extent of subcutaneous skin dissection for minimal and severe laxity of the neck skin

necessary for optimal results [3]. Marking should be performed prior to administering the anesthetic. If there are platysmal bands, they should be marked to facilitate finding the medial borders during the plication procedure. If significant submental fat is present, the lateral extent of this compartment should be marked to guide submental liposuction or direct lipectomy.

Once the markings are completed, intravenous (IV) sedation is utilized depending on the preference of the surgeon. For surgeons starting to do face-lifts for the first time, it is recommended to use IV sedation instead of straight local injection. An equal mixture of 1% lidocaine with epinephrine and 75% bupivicaine is injected along all incision lines. When significant submental fat is present, either liposuction from a submental incision or direct lipectomy is performed at this time. A 2.5 cm submental incision allows direct visualization of the fat and eventually the edges of the platysmal muscle. A subcutaneous dissection is performed in the previously marked submental area. Approximately, 5 mm of subcutaneous fat is left attached to the skin flap which prevents adherence to the underlying tissues. Preplatysmal fat is removed. The edges of the platysma muscle can be visualized and plicated if significant platysmal bands are present (Fig. 29.3). The medial edges are plicated with multiple 4–0 permanent sutures. Skin

closure is usually performed with running 6–0 nylon or plain gut. Skin excision here is usually not performed unless there is significant amount of excess submental skin.

Once the neck is addressed, the face-lift incision can be performed. The incision is kept parallel with the hair follicles to avoid hair loss. In the temporal region, blunt dissection avoids damaging the hair follicles and stays superficial to the frontal branch of the facial nerve which runs along the superficial temporal fascia (Fig. 29.4). The limit of the subcutaneous dissection is half way between the ear and the lateral canthus.

Anterior to the ear, a subcutaneous skin flap is created approximately 3–8 cm in length. Behind the ear the skin overlying the mastoid process is quite adherent to the skin and careful dissection is done to overcome this. As the dissection proceeds inferiorly in the neck, it is important to maintain a superficial dissection plane between the subcutaneous tissue and the superficial musculature. The greater auricular nerve becomes extremely superficial as it crosses the body of the sternocleidomastoid muscle 6.5 cm below the external auditory canal. Deep dissection in this area can severe the nerve.

Once the flaps have been raised, various techniques can be used to treat the superficial musculoaponeurotic system (SMAS). The goal of the SMAS modification is to provide deeper support and tightening for

the areas of the jowls, nasojugal fold, nasolabial fold, and neck. SMAS modification can impart longevity to the procedure and allows less tension to be applied directly to the skin, giving a more natural appearance. One has an option to do SMAS plication, SMAS imbrication, or deep SMAS dissection. The SMAS plication is the simplest of the three techniques. The SMAS is sutured to itself in several locations without excising any tissue. When the SMAS is grasped near the anterior mandibular ramus and the platysma is grasped in the neck, the entire complex can be repositioned in a posterolateral direction. A nonabsorbable suture such as 4–0 is used for the plication. Three primary areas of the SMAS are tightened (Fig. 29.5). The first and most superior suture addresses the nasolabial fold. The next suture repositions the jowls and nasojugal fold. The final suture helps elevate the neck. Several interrupted or mattress sutures are used in each location (Figs. 29.6 and 29.7).

SMAS imbrication involves excising an ellipse of the SMAS and suturing the edges together. A safe area of the excision lies between the zygomatic arch and the angle of the mandible. The facial nerve is deep to the

Fig. 29.4 Anatomy of the temporoparietal fascia, facial nerve, and deep fascia

Fig. 29.5 Typical superficial musculoaponeurotic system (SMAS) incision and direction of the SMAS elevation

SMAS in this area. The marginal mandibular nerve is at risk if the excision extends over the angle of the mandible. The excision starts just below the zygomatic arch and extends 1.5 cm anterior to the tragus. Excision is performed toward the angle of the mandible. The greater the tissue laxity the wider the dissection. Sutures are placed in the same area as the plication. One additional suture is placed grasping the platysma below the ear and elevates it superiorly and slightly posteriorly, attaching it to the fascia overlying the mastoid process.

During a deep SMAS dissection, a shorter skin flap is created. Again, the safe area of the SMAS dissection is between the inferior border of the zygoma and the angle of the mandible. Dissection continues medially to the area of the malar eminence. Redundant SMAS is excised, elevated, and sutured as described previously. Because a smaller skin flap is created, this technique is more dependent on SMAS repositioning for optimum result. This type of approach is more appropriate for those patients with prominent jowls and nasojugal folds.

Once the SMAS is repositioned, the skin can be redraped in a natural appearing posterior and slightly

superior direction. Very little tension is applied to prevent significant scarring. Prior to skin excision, cardinal staples are placed to provide support for the skin flap with minimal tension. The first is placed at the anterosuperior border of the ear where the ear meets the scalp. When the ideal angle is determined, the point of overlap is marked. A linear incision is made to the point of overlap, and the flap is secured to the fixation point with a single staple. The second cardinal staple is positioned at the most anterior portion of the occipital incision in the retroauricular sulcus. The skin of the neck is elevated posteriorly and superiorly to reduce the rhytids in the neck.

Subcutaneous sutures are then placed to close the remainder of the occipital region. The skin must be trimmed and closed meticulously. In the preauricular area, it is critical the skin is closed without tension to minimize scarring. Additionally, the tragus can be pulled forward opening the ear and producing an unnatural postsurgical appearance. A running nonabsorbable suture such as 6–0 nylon can be used here. Only a small amount of skin is typically excised in the