the temporal line. This author does not routinely make this superior extension, unless a composite procedure is necessary to sling the orbicularis muscle laterally. This can cause skin redundancy in the temporal region which necessitates this superior extension. It is not felt by the author that the amount of posterior pull in the temporal region justifies the visible temporal scar that most of these patients complain about several years down the road once they start to lose hair in this region.

The incision is carried inferiorly, behind the tragus in women and men. Most men do not mind shaving up to the tragus if it lessens the visibility of the preauricular component of the incision. This is especially true in patients who do not have a deep natural preauricular fold to hide the incision. The marking then extends inferiorly, around the lobule of the ear, and continues posterosuperiorly on the conchal bowl and then into the hairline where the helix meets the hair. The origin of the zygomatic major and minor muscles is marked at the anterior inferior malar eminence. A line is drawn from this point to the oral commissure. This marks the path of the zygomaticus major. Another line is drawn from this point to the nasal ala, marking the path of the zygomaticus minor muscle. The nasolabial fold occurs between the skin insertions of these two muscles. A line is also drawn from the zygomatic origin to the angle of the mandible. Another line is drawn from the angle of the mandible, along the body of the mandible, toward the chin. The anterior limits of the platysmal bands are also marked.

A submental incision is planned a few millimeters anterior to the natural crease. This allows for the advancement of submental tissues during the imbrications of the platysmal muscle. This allows for the reduction or softening of any “witches’ chin” crease that may exist. If a concurrent blepharoplasty or endoscopic brow-lift is performed, these markings are also made with the patient in the sitting position prior to entering the operating room.

38.4 Anesthesia

Improvements in anesthesia techniques have mirrored improvements in operative procedures. Shorter halflives of medications, a broader scope of induction and maintenance techniques have improved the efficacy and safety of these procedures. The choice of monitored intravenous sedation versus general anesthesia is based upon the comfort of the surgeon and patient with these different techniques. Care should be exercised when offering monitored intravenous sedation. The patient

with a short attention span, the easily agitated patient, or the continuous talker, should be advised toward a general anesthetic. MAC versus general is also an anesthe- siologist-dependent choice based upon their expertise.

The last thing the operating surgeon needs is to have his attention diverted away from the rejuvenation task at hand to worry about a substandard anesthetic. The choice of anesthesiologist is as important as the patient selection. Experience with cosmetic procedures, and a confidence of the same is required. This is especially true relating to intraoperative induced hypotension, intraoperative steady state, smooth reversal with no coughing or bucking, no nausea, and meticulous postop pain and comfort control. A bad anesthetic will overshadow a great face-lift in the eyes of a patient, and their friends are sure to hear about it.

Once intravenous (IV) sedation or general anesthesia is initiated, subcutaneous infiltration is commenced. The author prefers 0.5% Lidocaine with epinephrine 1:100,000. Initially the neck and left side of the face are infiltrated. At the point of skin suturing on the left face, the right face is infiltrated. This timing provides for optimal vasoconstriction and divides the total amount of infiltrative anesthesia over a greater amount of time. A 25 gauge 1.5 in. needle in a 10 ml syringe is used to infiltrate for a gentle delivery. The first incision is made 10 min after the infiltration process was initiated.

38.5 Deep Plane Technique

The procedure is started in the submental region. A #15 blade is used to make the skin incision anterior to the natural submental crease. Usually, a 2 cm incision is made. This allows for liposuction and adequate visualization and instrumentation for platysmal imbrications. A modified Freeman Rhytidectomy Scissor is used to elevate the submental and submandibular subcutaneous tissue from the platysmal muscle. A single hook is used for retraction during scissor elevation. A flat 4 mm cannula is used to remove excess fat from the region and off the surface of the platysmal. Care is taken to leave 2–3 mm of fat on the dermis so as to avoid any surface irregularities. The extent of dissection inferiorly is to the level of the thyroid cartilage, laterally to the anterior border of the sternocleidomastoid muscles. A determination is then made as whether to imbricate or simply plicate the platysmal bands. This is a crucial decision point as the anterior neck is what the patient looks at in the mirror all the time.

Failure to provide the sharpest defined neck versus not skeletonizing the platysmal muscle is the tightrope the surgeon walks. Preoperative lateral views with the patient respecting the Frankfurt Plane will reveal the answer to the surgeon.

The majority of patients will benefit from subplatysmal dissection of excess fat. A right angle retractor is held by the surgical assistant. The surgeon grasps the most anterior portion of the platysmal bands with a forceps and progressively pinches inferiorly to determine the safe amount of muscle edge to excise. Less is better. At the conclusion, there can be no tension on the sutured muscle bands so as to avoid dehiscence of the suture repair and subsequent unsightly skeletonization of the anterior neck. Once the redundant muscle has been excised, the subplatysmal fat is grasped sequentially, superior to inferior, again to determine the safe amount for excision. This is a vascular area, and a bipolar forceps is used to sequentially cauterize the fat prior to each scissor cut. The excess fat is removed to the level of the thyroid cartilage. The bipolar is then used to sculpt any residual fatty contour anomalies. Clean platysmal edges are desired prior to suturing. Beginning just superior to the thyroid notch, sequential 3–0 Proline buried sutures are used to approximate the freshly cut platysmal edges. During this process, the patients’ neck is hyperextended. This allows for smooth approximation and an element of anterior advancement of the muscle which allows for filling in of ant submental depression which may have accentuated a “witches chin” appearance preoperatively. Additional subcutaneous undermining at the lateral edges of the incision is frequently required as a medial indrawing occurs with the platysmal suturing which impedes skin draping and the final contour. Once happy with the neck contour and the proper skin redraping setup, the lateral face can be addressed. The submental incision is left open, covered with moist gauze until the end of the procedure so as to ensure meticulous hemostasis.

Attention is then directed to the lateral face. A #15 blade is again used to make the skin incision. The tissue is grasped with a hook superior to the tragus, and the tissue first dissected off the tragus with the assistant providing medial counter-traction. There must be no damage to the tragus during this stage so as to not create any unnatural contour deficits postoperatively. The skin is elevated from the zygoma in a deep subcutaneous plane, moving in an anterior direction to the

Fig. 38.2 The extent of sharp dissection in the midcheek. The anterior line of sharp dissection between the malar eminence and the angle of the mandible is the posterior margin of the deep plane dissection

skin marked by the line between the malar eminence and the angle of the mandible (Fig. 38.2). This elevation is completed by the outward observance of the progressing scissor tip without internal direct view.

If the temporal extension is utilized, the rhytidectomy scissor is used to dissect down to the deep temporalis fascia. Blunt finger dissection is used to separate the superficial temporalis fascia above from the deep temporalis fascia below. These tissues are separated to the temporal line. At this point there is a deep plane of dissection over the deep temporalis fascia and a superficial plane of dissection over the lateral face. The superficial dissection should not go below the line marked along the body of the mandible. The tissue between the superficial and deep dissection contains the superficial temporal artery and vein. The frontal branch of the seventh nerve lies just anterior to the superficial temporal artery. The artery and vein are transected and carefully cauterized so as to lend to adequate posterior mobility of the flap.

After the superior deep dissection is completed, attention is directed to the postauricular dissection. The scalpel is used to complete the skin incision. The rhytidectomy scissor is then used to elevate the flap anteriorly to the angle of the mandible. The cervical dissection

separates the platysmal muscle from the neck skin in the subcutaneous plane from the angle of the mandible to the level of the thyroid notch, thus communicating the central submental dissection with the lateral neck dissection. This will ensure smooth redraping of the skin envelope upon completion of the deep muscle lifting. This will ensure longevity of results.

The final portion of the procedure is the anterior face, where the deep plane-lift is performed. A longblade lighted retractor is recommended for this maneuver. The deep plane dissection divides the face into thirds. The dissection over the masseter muscle is the lower third. Care must be taken here, not to extend the lower dissection deep to the zygomatic muscles. These muscles are innervated on their deep surface, and dissection deep to them carries risk of nerve damage. With the scissor over the masseter muscle, a firm downward motion with the blade on the belly of the muscle is made while opening and closing the scissor. The muscle is easily identified with its deep red color and thin white vertical striations. At this point the surgeon is deep to platysmal inferiorly. Continued dissection is easy by opening the scissor at right angle to masseter. This plane is carried inferior and anterior below the area of jowl fat. Next, dissection is taken over the superior surface of the zygomatic muscles. The tissue is more adherent here than over the masseter. The deep subcutaneous plane is separated until the insertion of the zygomatic major is observed anterior and inferior to the malar eminence. Continuing anteriorly, the zygomatic minor will be encountered lying more toward the nasal ala. Once at this point, notice that the scissor is in a triangle formed by the oral commissure, nasal ala, and the malar eminence. With the upper and lower thirds of the anterior face completed, the middle third is completed by opening the scissor again at right angles to the skin. The buccal nerve will be encountered here. As spreading with the scissor parallel to the nerve is the method used, there is little chance for nerve damage here. If there is excessive cheek fullness, the buccal fat pad can be sculpted at this point. This is a vascular fatty pedicle, so care and caution must be exercised when teasing out the fat.

Upon completion of the dissection, the entire composite flap of midface skin and malar fat pad becomes mobilized. The vector of pull is parallel to the body of the mandible. This repositions the malar fat pad superiorly and brings back the youthful bulk of the midface. Fixation and closure are very important. Care must

Fig. 38.3 Excess skin is redraped

be taken to adequately reposition the tissue so as to achieve the desired pull. There is a fine line between enough pull and too much, yielding an overdone or “too tight” look. There can be no tension on the skin closure or unsightly scars will follow.

The posterior margin of the platysmal is first addressed. If traction reveals posterior mobility, several 3–0 Proline sutures are used to anchor the platysmal to the capsule of the sternocleidomastoid muscle beneath the earlobe where it is secured. This further tightens the jaw line in addition to the imbrications that was performed in the submental region. In some patients, a bridge of soft tissue is left attached to the body of the mandible to allow a tight closure at this point. Additional 3–0 imbrication sutures are placed, securing the lateral superficial musculoaponeurotic system (SMAS) to the tissue anterior to the tragus and inferior to the zygoma. The composite flap is anchored to the deep temporalis fascia, just above the ear. This suture stabilizes the malar fat pad on the malar eminence. Number 10 Jackson-Pratt drains are inserted and secured with 2–0 silk.

The skin is then redraped (Fig. 38.3). No tension should be placed on the skin. The posterior skin flap is set so as not to change the hairline. A 3–0 Vicryl suture is used here. Excess skin is trimmed and a layered closure obtained with 3–0 chromic and 5–0 Proline interrupted sutures to facilitate meticulous tailoring of tissue. Surgical clips (staples) are not used. The lobule of the ear is set ensuring no tethering, one of the worst signs of a poorly executed face-lift closure. Similarly, the anterior skin is excised. A tragal fixation suture of

3–0 chromic is placed to avoid blunting, one of the surgical telltale signs of a sloppy face-lift. Layered closure anteriorly is performed using 4-0 chromic followed by a 6–0 Proline followed by a 5–0 fast absorbing cat gut. The opposite side is performed in an exact manner to the first side. The submental incision is closed lastly, in a layered fashion using 4–0 chromic followed by 6–0 Proline (Fig. 38.4).

Most patients also undergo CO2 laser skin exfoliation at the same time. This allows for simultaneous qualitative improvement of the skin at the same time that the gravitational issues are addressed with the face-lift. A light feathering is performed over the elevated skin, while a therapeutic level of exfoliation is performed over the skin of the central zone of the face which was subjected to the deep plane dissection. This does not prolong healing time, and dramatically improves the final aesthetic result. At the conclusion of the procedure, a rhytidectomy dressing is applied, and left on overnight.

38.6 Postoperative Care

The author keeps all rhytidectomy patients overnight. This provides a stress-free course for the patient and family members alike. Reversal of anesthesia is gradual. Postoperative nausea is guarded against religiously. The patient is kept calm, relaxed, and encouraged throughout. The nursing staff suctions the drains every hour for the first 8 h, then every 2 h until discharge. The dressing is removed the following morning. The drains are

38.7 Complications

The patient who undergoes a deep plane face-lift is at risk for the usual problems and complications following any face-lift. Generally, the incidence should be 1% or less. These would include infection, bleeding, hematoma, and fifth nerve and seventh nerve weakness. Meticulous surgical technique, coupled with unwavering anatomical knowledge keeps the latter two complications minimal at best. Pencil-thin scars are achieved with tension-free, layered, nonstapled closures, using only finesse hand-sewing. Hair lines are preserved and tragus and lobule irregularities are avoided. Never is there a “pulled” appearance. At all times, from consultation onward, a realistic expectation by the patient is fostered.

38.8 Discussion

There has traditionally been an aura of uncertainty regarding the deep plane face-lift. This historically was propagated by those who felt the procedure subjected the patient to riskier anatomic dissection with subsequent prolonged healing. The same group felt the long-term results did not warrant the perceived additional risks.

The past decade has shown an acceptance of the procedure, particularly for the patient with the heavier neck, flatter midface, deeper nasolabial fold, and fuller jowl. It is especially beneficial with the patient who also has malar festoons. These patients benefit from the additional elevation of the lateral inferior orbicularis over the bony rim, which complements elevation of the