31.3.7 Infiltration

The infiltration fluid is simple to constitute:

1.Saline, 250 ml at normal temperature

2.Lignocaine, 20 ml, 1%

3.Pure adrenaline, 1:1,000

Chloromycetin eye ointment or chloramphenicol drops is used in the eyes.

A spinal needle with a 10 ml syringe is used to infiltrate preferably LuerLock.

The neck is infiltrated first according to markings. Being left-handed, the author starts on the right face. The preauricular subcutaneous tissue is injected to the level of the markings, and beyond, in the temporal region, the injections are placed deeper above the galia as the dissection changes planes. Retroauricular injections are placed carefully to cover the whole extent of the operative field using about 125 ml per side. One side is infiltrated at a time.

31.3.8 Instrumentation

Very few instruments are used to perform this operation but some of the specialist tools make the operation a lot easier. The main instruments are:

1.A nice pair of forceps and scissors that fit the hand and are sharp and flat at the tip. This helps to get into the plane of dissection.

2.Two skin hooks and two cats paws.

3.One fiberoptic retractor with suction at the end to check the flaps for bleeding.

a

4.Nerve stimulator (Fig. 31.1).

5.Prolene, monocryl sutures, and staples for the skin.

6.Vaselene gauze.

7.Cotton bandage and dressings.

8.Bandage, 4 in.

9.Elastoplast roll, 1 in.

10.The author’s special cannulas for liposuction of the neck.

31.4Procedure

The author always starts with liposuction to the neck. This is performed with the patient in neutral position. A small 2 mm cannula (Fig. 31.2) is introduced in the midline. The author uses the Mercedes variety to start with to take the maximum volume out.

Remember your other hand must help you assist with position of the cannulas at all times. Other longer flat cannulas are then introduced to remove the rest. A layer of fat must be left behind to drape over the tissue. A second incision is performed under the ear lobe to get the jowl area and the rest of the fat in the neck. Using the pinch technique will assist in determining the correct amount to be removed and also ensure the smoothness of the surface.

The facelift incision begins in the temporal scalp, approximately 4–5 cm above the ear and 5 cm behind the hair line, curves parallel to the hairline toward the superior root of the helix just in front to avoid a bridle scar, continues caudally into a natural skin crease or intratragal until passes under the lobe of the ear. The posterior incision is outlined on the posterior surface

b

of the concha, slightly higher as it tends to migrate downward; the rest of the incision is inside the hairline, occipitally. A retractor is used.

Subcutaneously, the dissection is started in the retroauricular area (Fig. 31.3). The correct plane of dissection is identified. There are three layers of fat;

supraplatysmal, subcutaneous, and a fine layer in between. The author chooses the supraplatysmal plane as this is the most bloodless. The assistant retracts with cats paws; dissection should be meticulous and bloodless. It is easier to start posteriorly toward the occipital end as this is the softest part. Dissection in the neck proceeds toward “Erbs” point avoiding the superficial nerves, mainly the posterior auricular. Dissection then continues toward the neck (Figs. 31.4 and 31.5) for about 7 cm then stops. A gauze swab is placed in the wound, and dissection started on the front.

An incision is made with a scalpel in the front either preor postauricular. Treat the skin delicately and establish a plane of dissection superficial to avoid any

nerves (Figs. 31.6 and 31.7). In the temporal region, a deeper plane is established and the transitional zone is the zone of Morano where the vessels and nerves are situated.

In the front, dissect until the mid-cheek is reached where a fiberoptic retractor is used. Undermining must extend beyond the area of redundancy. In general, the dissection extends within 1 cm of the lateral orbital rim, across the malar region to nasolabial folds and inferiorly to the thyroid cartilage. It is important to release the zygomatic ligament and the mandibular ligament so you can get a better traction and a better jaw line.

Fig. 31.6 Dissection below the zygomatic arch can reach anterior eminence

31.5 The SMAS

The superficial musculoaponeurotic system (SMAS) is a fibromuscular fascial extension of the platysmal muscle that arises superiorly from the fascia over the zygomatic arch and is continuous in the inferior cheek with the platysmal muscle. The facial nerve lies deep to the SMAS and innervates the mimetic muscles of the forehead and mid-face from the ventral aspect of the muscles.

The SMAS fascia is a fanlike fascia that envelops the face and provides a suspensory sheet which distributes forces of facial expression. The SMAS is continuous with the platysma muscle inferiorly and the superficial temporal fascia superiorly, and it is superficial to the parotomasseteric fascia. The SMAS connects to the fascial musculature in the nasolabial, perioral, and periorbital regions.

The anatomy of the SMAS/platysma must be studied in detail before embarking on this. The SMAS dissection begins transversely one finger breadth below the zygomatic arch (Figs. 31.8 and 31.9), then a vertical incision is made 0.5 cm anterior to the tragus extending downward beyond the mandibular angle to connect with the lateral margins of the platysma muscle. They are both dissected in continuity (Fig. 31.10). The dissection is extended to the anterior border of the parotid gland after elevating it from the parotid fascia.