References

38.1 Introduction

The ongoing improvement in Health Care has yielded an increasingly aged population. As people live longer, healthier lives, they begin to realize that they do not feel as old as they sometimes look. The concurrent improvement in cosmetic surgical techniques has mirrored increased longevity. Worldwide, there has been increased awareness regarding the benefits of cosmetic procedures. Increased awareness has brought about greater acceptance of the concepts of maintenance overruling the stereotypical judgments of vanity. We have therefore seen a younger population of patients in their 30s and 40s seeking aesthetic improvement. This has led to a myriad of modifications to time-tested techniques seeking to decrease invasiveness and healing time. Many trendy techniques have not stood the test of time, especially when longevity of results are objectively studied. Conversely, the ongoing improvement in traditional face-lifting has dramatically improved results.

The acceptance of rhytidectomy in modern times has been slow in the making. A historical perspective on the evolution of this tremendous procedure is found in another chapter of this book. As the procedure has evolved over the years, there has become a greater understanding of facial anatomy, particularly the facial nerve. This enhanced knowledge has led to several modifications, and the subsequent adoption of what are known to be, “deep plane” techniques. There are now many studies from different aesthetic academies highlighting the safety, efficacy, reliability,

W.G. Chernoff

Chernoff Cosmetic Surgery, Indianapolis, IN, USA e-mail: greg@drchernoff.com

reproducibility, and the longevity of the results of the procedure.

From a patient’s perspective, there are many misconceptions as to what the term “face-lift” means. Many are still intimidated by the term, thinking that everyone who undergoes the operation will end up with a “done” or “over-pulled” look. It is prudent to identify what the patients’ preconceived ideas entail. Helping the patient to be realistic as to what to expect, goes a long way to ensuring their satisfaction. Time should be spent in front of a mirror, showing the patient the natural results that can be achieved. They are shown that the entire face is improved with this technique, including the temporal region, the lateral face, the midface, the jaw line, the submental region, platysmal banding, the lateral neck, and the postauricular region. The difference between an overdone look and a natural result can be easily demonstrated to alleviate fears, and educate as to what is realistic to expect. With a successful lift, the scars should be barely noticeable. The hairlines should remain unchanged. Healing time should be no more than a week, with subtle edema resolving over 6 months. Postoperative discomfort should be minimal. Expectations of results should be realistic. Longevity varies from patient to patient. Consistent, long lasting results are the norm to be attained. The patient can expect to always look better having done the procedure than if they had not.

The decision to perform a deep plane lift versus a previously traditional SMAS elevation is based upon the patients’ anatomy. This procedure is geared toward the middle-aged patient who is concerned about the relative flattening of the midface, due to decent of the malar fat pad and facial musculature, deepening of the nasolabial folds, decent of the jowl below the oral commissure, and presence of submalar fat in conjunction with loose submalar skin and obvious platysmal banding.

38.3 Preoperative Markings

As each patient is different, the marking varies proportionate to the intricacies of each case (Fig. 38.1). The basics are the same and these will be highlighted. Remember what the patient sees and talks about… visible, unsightly, scars, and their hair, especially if there is loss or change in the hair line.

The most controversial portion of the deep plane face-lift is the temporal extension of the incision above the root of the helix. Most authors extend the incision

Fig. 38.1 (a) External landmarks defined in preoperative patient. The malar eminence is marked. Lines are drawn along the course of the zygomatic muscles. The angle of the mandible to the eminence is drawn. The course of the body of the mandible is identified. (b) Extent of submental and submandibular dissection. (c) Posttragal marking

superiorly from the helical attachment for 5–6 cm. They make this to facilitate the placement of a suture between the elevated scalp and the underlying deep temporal fascia, and to mobilize the temporal scalp to