The classic long flap technique is safe and easy to learn. It is coupled with SMAS imbrication proportionate to what the patient would benefit from as determined in consultation. It offers significant improvement to the neck and lower third of the face. Its shortcoming would be the limited correction of the ptotic midfacial tissues. Extensive skin undermining can lead to vascular compromise and flap necrosis. Excessive closure tension and hematoma can exacerbate these unfortunate sequelae.

The developments of more extensive SMAS procedures were the result of efforts to minimize the aforementioned problems. The “sub-SMAS rhytidectomy” expands on simple imbrication by extending the dissection anterior to the parotid gland. The “extended sub-SMAS” approach takes the dissection to the lateral edge of the zygomaticus muscle. This technique redistributes some tension forces from the skin to the SMAS, but does not totally negate the flap risk associated with the wide undermining. The fact that the SMAS is attenuated at the level of the melolabial fold reflects this procedure’s inability to enhance the midface as reliably as it does the neck and jawline.

Subsequently, efforts continued to attempt to improve the malar complex. In 1988, Faivre [22] described the deep temporal lift. Temporal soft tissues were elevated in the submusculoaponeurotic plane and fixed to the temporalis muscle. This produced correction of temporal, lateral brow, and jugal ptosis. Similarly, Psillakis et al. [23] reported a subperiosteal approach to the midface. The ptotic malar skin, fat, and muscle were mobilized and suspended by anchoring the periosteum overlying the lateral orbit, malar arch, and zygoma. This procedure was ideally suited for midfacial ptosis without lower face rejuvenation requirements. Disadvantages included prolonged midfacial swelling, lateral canthal elevation, widening of the midface, and the necessity of performing a standard rhytidectomy to correct lower third aging features.

The 1990s saw debate surrounding appropriate vectors of midfacial elevation, and proper plane of dissection. The infraorbital approach was added to the temporal lift as a viable technique [24]. Proponents favored the vertical vector of this approach as compared to the superolateral pull observed with the temporal lift. This dissection was either performed in the subperiosteal plane or in the plane deep to the suborbicularis oculi fat pad (SOOF) via a blepharoplasty incision. Elevated tissue is suspended to the infraorbital rim.

40.4 Deep-Plane Rhytidectomy

The latest frontier of facial rejuvenation has been the deep-plane rhytidectomy as described by Hamra [17]. This procedure modifies Skoog’s technique by including superolateral elevation of the malar fat pad in addition to the lower facial tissues. Hamra previously described a tri-plane rhytidectomy in which he combined midfacial subcutaneous elevation with subplatysmal elevation of the lower face and a pre-platysmal neck dissection.

In the deep-plane technique, the amount of skin undermining is limited to the amount suitable for redraping, once the SMAS has been elevated and repositioned. The dissection is performed deep to platysmal SMAS, also cheek fat. It is carried medially over the zygomaticus major and minor muscles, to a point lateral to the melolabial fold. The mobilized fat pad is suspended to the body of the zygoma in a superolateral vector. Hamra’s work has been instrumental in the understanding and refinement that have dramatically improved the results in selected patients.

Hamra [18] continued to adapt this process through the description of the “composite rhytidectomy.” This modification includes superolateral advancement of the orbicularis oculi muscle to improve the inferolateral descent of the malar crescent or malar festoon. This denotes the most inferior extent of the orbicularis oculi muscle in the midface. This procedure creates a musculocutaneous flap pedicled on the facial artery perforators inferiorly and the angular and infraorbital vessels superiorly. The orbicularis mobilization is performed through a subciliary approach. This approach may cause orbicularis weakness, abnormal alteration of lower lid position if not performed correctly.

The deep-plane technique provides a robust cervicofacial flap that restores youthful contours. It is technically challenging and poses an increased risk of nerve injury, especially to those facial nerve branches which course deep to the SMAS to enter the mimetic muscles from their undersurfaces. Their remains a lack of long-term follow-up studies that conclusively demonstrate a definitive long-term improvement when the deep-plane technique is employed. Short-term reduction in tension of the undermined flap is established.

Many expert facelift surgeons have reported the evolution of their technique to include the deep-plane lift. Kamer [25] reported substantial improvement upon moving to the deep-plane lift, with fewer tuck-ups

required for loss of correction. It appears that the technique achieves a more natural, long-lasting improvement in the midface, jawline, and neck.

40.5 Adjuvant Procedures

There has been a trend to performing total facial rejuvenation in a single session. The ability to deal with the upper, middle, lower thirds of the face, as well as the neck in a single operation has been afforded primarily due to the improvements in anesthesia technique. Combining brow lift, blepharoplasty, deep-plane rhytidectomy, platysmaplasty, and some form of skin exfoliation provides a consistent, reproducible, safe method of facial rejuvenation which affords a longlasting natural result for which the patient will have a high level of satisfaction. Surgeon skill is the main factor that dictates the ability of completing this combination in less than 6–8 h. Many surgeons will keep their full facial rejuvenation patients overnight to ensure patient comfort and safety.

The addition of fillers and neurotoxins at the time of surgery is also an acceptable adjuvant as patients seek to maximize their experience. These are typically performed at the start of the procedure to enhance the surgeon’s aesthetic advantage. On an individual basis, concurrent procedures should be performed only if benefits outweigh any added risk and patient safety is not compromised. Patient satisfaction will reflect the highest intersecting points of safety and efficacy. The surgeon’s comfort level will dictate which procedure will best accomplish this goal.

References

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41.1 Introduction

Morbid obesity is a worldwide problem, with 1.7 billion people considered overweight [1]. Approximately twothirds of adults in the USA are overweight, and half are obese [2]. In 1991, the National Institute of Health established indications for bariatric surgery, BMIs >40 or >35 with significant comorbidities, and these guidelines may be further liberalized. According to Buchwald et al., patients who undergo bariatric surgery lose 61.6% of their actual excess body weight and a majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experience complete resolution or improvement of these comorbidities [3]. Overall 5–10 weight loss retention rates vary from 30% to 80%. Despite the drastic improvement in health, twothirds of massive weight loss patients are unhappy with their appearance secondary to copious sagging skin [4] and may experience dysphoria, depression, and discrimination. According to the American Society of Plastic Surgeons, 47% of these (roughly 150,000) patients underwent body contouring procedures in 2007 after significant postsurgery weight loss [5].

Bariatric surgery leads to significant (mostly trunkal) weight loss, with relatively less weight loss in the face

A.P. Sclafani ( )

Division of Facial Plastic Surgery, The New York Eye & Ear Infirmary, 310 East 14th Street, New York,

NY 10003, USA and

Department of Otolaryngology, New York Medical College, Valhalla, NY, USA

e-mail: asclafani@nyee.edu

V. Mehta

Department of Otolaryngology, The New York Eye & Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA e-mail: vmehta@nyee.edu

and neck. However, this small but disproportionate fat reduction can cause secondary facial and cervical aesthetic deformities. The loss of cervicofacial fat often leaves the patient with noticeable soft tissue volume deficiencies and skin laxity. These post-bariatric changes result in a “hollowed,” prematurely aged appearance (Fig. 41.1a). Specifically, patients will often present with prominent nasolabial and nasojugal grooves, lip atrophy, and a turkey-neck deformity. Although the truncal skin excess can be significantly more dramatic, many patients report that the facial changes are of greater concern as they cannot easily be hidden with clothing. Similar to HIV-associated antiretroviral therapy (HAART) patients, this weight loss is often (ironically) perceived as an indication of chronic illness. Often, these patients pursue cosmetic facial surgery prior to addressing other body contour issues. As more Americans undergo weight loss surgery, it is useful to identify and address the operative and perioperative challenges that affect this unique and growing population. The mechanics, physiology and demographics of these patients differ significantly from the typical patient with an aging face. Understanding these variations is the key to successful and safe cervicofacial rejuvenation in the massive weight loss patient.

41.2 Pathomechanics

Fundamentally, postbariatric contouring surgeries focus on skin laxity and fat loss. An analysis of the biomechanical properties of skin following weight loss showed decreased stiffness, increased laxity, greater

Reprinted with permission of Springer

Fig. 41.1 Postbariatric surgery patient. (a) This patient appears prematurely aged, with significant malar flattening and midfacial volume loss, as well as lateral cheek and cervical skin redundancy. (b) Six months after endoscopic brow-lift, submen-

tal liposuction and SMAS face-lift with volume enhancement of the midface. The natural structural features of the midface are highlighted postoperatively. A minor revision procedure was performed subsequently to further improve the lax cervical skin