29.4.5 Hypertrophic Scarring

This condition may be treated with intralesional corticosteroid injections or silicone topical therapy (e.g., Cica-Care, Kelo-cote gel). Perform scar revision only after complete wound maturation.

consultation will again prevent further confusion and frustration. Having meticulous surgical technique and fully understanding the facial anatomy is crucial in avoiding serious complications. Keeping the patient comfortable in the postoperative period with appropriate medicine and communication skills will keep the surgeon above and beyond the complication arena.

Transient traumatic alopecia is likely to normalize in 3 months. Permanent alopecia may be corrected with local flaps or micrografts and minigrafts. Observe earlobe distortion for spontaneous improvement. Surgical correction with local advancement flaps may be used for persistent deformity.

29.4.7 Parotid Gland Pseudocyst

Treat this condition with frequent needle aspirations and suction drain insertion.

Even though we have entered an age in medicine where noninvasive technology is competing, and potentially outdoing our traditional surgical modalities, there has always been and always will be a place for surgical intervention in the right population of patients. If proper channels are utilized, the results can be spectacular with high patient satisfaction. Our success as surgeons depend on patient satisfaction, so the surgical intervention of face-lifting should address the primary concerns of our patients, not the physicians, taking into account safety, morbidity, and efficacy. We should always stay true to our mission as cosmetic surgeons: unparallel personalized service (UPS).

29.5 Discussion

The different approaches to face-lifting presented here can achieve the desired results for any cosmetic surgeon if the “rules” are followed carefully. First and foremost patient selection is critical, knowing who to do the surgery on is very important. However, knowing which patients not to do the surgery on is an art. The selection criteria will prevent unnecessary patient drama postoperatively. Making sure the patient is fully and completely comfortable with all the risks, complications, and benefits explained in

References

1.Passot R. La chirugie esthetique des rides du visage. Presse Méd. 1919;27:258–62.

2.Baker DC. Minimal Incision rytidectomy (short scar facelift) with lateral SMA Sectomy. Aesthetic Surg J. 2001;21: 68–79.

3.Gladstone GJ, Myint S, Black EH, Brazzo BG, Nesi FA. Oculoplastic surgery atlas: cosmetic facial surgery. New York: Springer; 2005.

4.Becker FF, Castellano RD. Safety of face-lifts in the older patient. Arch Facial Plast Surg. 2004;6(5):311–4.

Facelift is a procedure to pull sagging tissue of face by means of excising skin in front of the ear so as to conceal postoperative scar. Excision of skin is a means; it is not a purpose. The goal of facelift is to correct bulges and grooves which develop due to sagging deformity in an aging face and to restore smooth facial contour.

Sagging of soft tissue is more evident in the central zone of the face where the tissue is more mobile for facial expression than in the lateral cheek near the ear. It is, therefore, anticipated that facelift procedure should correct the aging deformity of the central facial zone. Skin excision in the preauricular region can stretch the soft tissue in the lateral cheek, but it cannot provide sufficient lift to the medial face. To achieve expected stretch in the central face, it is essential to manage the subcutaneous musculoaponeurotic system (SMAS) and retaining ligaments. Facelift procedure with treatment of SMAS and retaining ligaments only provide one-dimensional pull. However, the aging deformity occurs in two or three dimensions. The facelift may not be adequate enough to restore bulges and grooves in selective cases. For those situations, liposuction and lipofilling are to be applied.

Different areas of the face show different signs of aging (Figs. 30.1 and 30.2). Up to now, surgeons have developed many procedures to treat each area; for example, forehead lift for the forehead, upper blepharoplasty for upper eyelid, lower blepharoplasty for lower eyelid, and facelift for lateral cheek and neck. Each procedure treats aging deformity of limited area. The facelift does not rejuvenate the

K. Fukuta

Verite Clinic Ginza, New Ginza Building 3rd floor, 5-5-7 Ginza Chuo-ku, Tokyo, 104-0061, Japan e-mail: fukuta@veriteclinic.com

Fig. 30.1 Different surgical procedures are available to treat the forehead, upper eyelid, lower eyelid, midface, cheek, and neck separately

Fig. 30.2 (Left) Facelift procedure to correct sagging deformity in the preoperative lateral cheek marked in a red circle. The effect of the facelift must be evaluated regarding a change in

shape within the red circle. (Middle) Patient’s expectation for the facelift. (Right) Actual outcome 8 months after facelift, lower blepharoplasty, and upper blepharoplasty

whole face. Therefore, when we evaluate the surgical outcome of facelift procedure, we must examine correction of the contour in the lateral lower part of the face, particularly on the jowl, marionette line and nasolabial fold.

30.3Anatomic Location

of the Retaining Ligaments

The skin and subcutaneous fat of the face adhere to the underlying deep structure such as the parotid gland, deep temporalis fascia, masseter muscle, and facial skeleton (Fig. 30.3). The strength of adherence is not uniform all over the face. The retaining ligaments, which are present in limited areas, anchor the skin to the deep tissue [1–3]. Those ligaments originate from the deep structure, penetrate the SMAS,

and insert into the dermis with many ramifications. Therefore, the ligaments provide with strong adhesion between the skin and SMAS and also between SMAS and deep structure. The parotid cutaneous ligaments connect the preauricular skin to the parotid fascia along the anterior margin of the parotid gland. The zygomatic ligaments adhere to the zygomatic body from just lateral to the zygomatic major muscle, extending medially across the zygoma and maxilla in relation to the origin of the zygomatic minor muscle and levator labii superioris muscle. The masseteric ligaments are the vertical septum-like structure which conjoins with the masseteric fascia at the anterior border of the masseter muscle and attaches to the mandibular ramus and body along the anterior margin of the masseter muscle. The mandibular ligament anchors to the anterior third of the mandibular body. The orbital retaining ligament adheres to the inferior orbital rim.

2

3

Fig. 30.3 Anatomical location of the retaining ligaments. (1) Parotid cutaneous ligaments. (2) Masseteric ligaments. (3) Mandibular ligament. (4) Zygomatic ligaments. (5) Orbital retaining ligaments

30.4Role of the Retaining Ligaments in Aging Face

During the process of aging, the skin and subcutaneous fat lose the firmness and become difficult to maintain their shape while resisting against the gravity (Figs. 30.3–30.5). The adherence of the skin to the underlying structure is not uniform in strength, as the retaining ligaments attach the skin to the facial skeleton or fascia in limited areas. The skin over those ligaments shows minimal displacement under the influence of gravitation. The skin adjacent to the retaining ligaments loosely adheres to the deep tissues and shows greater ptosis.

In the upright position, the skin between the retaining ligaments, due to the lack of strength of the retaining ligaments slides down due to the gravity. The retaining ligaments hold the soft tissue falling down from the above. This creates depressions or grooves at the skin over the retaining ligaments and bulges in the neighboring area.

The jowl deformity is a bulge along the mandibular border, which develops due to sagging of the soft tissue between the masseteric ligaments and mandibular ligament. The lower border of jowl overlies the mandibular ligament. The malar pouch is a bulge due to

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3

Fig. 30.4 Bulges and grooves develop with aging on the skin surface in accordance with presence of the retaining ligaments. (1) Parotid cutaneous ligaments. (2) Masseteric ligaments. (3) Mandibular ligament. (4) Zygomatic ligaments. (5) Orbital retaining ligaments. Bulges develop at the area bounded by the different retaining ligaments

ptosis of the soft tissue between the orbital retaining ligaments and zygomatic ligaments. The mid-cheek groove overlies the zygomatic ligaments [3]. Thus, the face develops multiple grooves (concavities) and bulges (convexities) on the surface with aging.

30.5Role of the Retaining Ligaments on Facelift

The purpose of the facelift procedure is to pull up the sagging skin and subcutaneous fat and to change a facial contour with bulges and grooves into a smooth one (Figs. 30.5–30.7). The aging sign of the face is more prominent in the central portion of the face than in the lateral part. The facelift is a procedure which excises the skin in front of the ear; thereby the operation can stretch the facial skin in the lateral cheek with greater tension. Because the skin is an elastic tissue, the traction power of facelift, which is applied to the lateral edge of skin flap, is less efficient in the central part of the face. It is considered that lifting of the central tissue

Fig. 30.5 Jowl deformity is a bulge of skin and fat between the masseteric ligaments and mandibular

ligaments

vector of facelift

jowl

lifting of skin edge

dissection

masseteric ligaments restrain lifting power

parotid cutaneous ligaments

masseteric ligaments

vector of facelift

mandibular ligament

jowl

release of masseteric great effect ligaments

of lifting

Fig. 30.6 The lift procedure with limited subSMAS dissection. The masseteric ligaments that are left intact block a lifting power applied to the skin along the preauricular incision

Fig. 30.7 Extensive subSMAS dissection releases the masseteric ligaments. The traction applied at the preauricular tissue stretches the medial cheek including the jowl