Ординатура / Офтальмология / Английские материалы / Essentials in Ophthalmology Oculoplastics and Orbit_Guthoff, Katowitz_2007

A 2-mm cannula can also be inserted into the central subplatysmal space to remove a small amount of fat. The blind suctioning must remain central to prevent possible perforation of the multiple large vessels that traverse this plane.

This limited approach can also be extended to older patients with the caveat that skin elasticity must be sufficiently good to allow for smooth skin retraction. Additionally, in older patients, cervical lipodystrophy may mask platysma banding, which becomes visible following liposuction. The platysma may then need to be addressed separately.

16.4.2.2 Chin Augmentation

Chin augmentation can be used alone, or in conjunction with other facial restorative procedures. Frequently, those patients with lifelong cervical lipodystrophy will often have accompanying poor chin projection, and a chin implant can be of great benefit (Fig. 16.5). It is also useful to improve the appearance of apparent microgenia that develops with age as an adjunct to more extensive surgical procedures.

Alloplastic chin implants are available through numerous manufacturers. Different styles are offered, with selection based upon the anatomic deformity to be corrected. The most common implant material is silastic, being both versatile and well tolerated.

If chin augmentation is to be performed following liposuction, the submental crease incision is enlarged to 2 cm and dissection continued to the periosteum. The dissection is continued cephalad and centrally in the preperiosteal plane. The periosteum is incised bilaterally, and a subperiosteal dissection performed along the mandibular rim to allow placement of the wings of the implant. The central implant remains in the preperiosteal plane, where it may be less likely to induce bone resorption [47]. Care is taken not to violate the mental or mandibular nerves. Implant sizers are utilized to confirm appropriate implant size, and the implant placed. The implant is sutured to the periosteum centrally before the incision is closed in layers.

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Summary for the Clinician

■The aging face can be enhanced significantly by augmentation of subcutaneous tissue.

■Resection of skin with tightening of ligamentous attachments is a useful approach.

■Chin implants may be essential for enhancing the lower face.

16.4.2.3 Platysmaplasty

The presence of an obtuse cervicomental angle or platysma banding can be treated alone, or in conjunction with rhytidectomy procedures. In patients with modest facial aging changes for whom their primary concern is the neck, the platysma muscle can be approached from a central submental incision alone [17, 28, 41]. The procedure is frequently performed with neck liposuction, and benefits greatly from tumescent infiltration.

There is a wide spectrum of surgical alternatives to treatment of platysma bands. McKinney proposed a grading system of platysma bands to use for treatment selection [35]. Among the commonly accepted procedures are midline platysma plication, sagittal excision of redundant platysma, wedge resections at or below the hyoid, muscle flaps, and sling suspension.

When a face-lift procedure is performed, lateral SMAS tightening is often sufficient to correct modest platysma banding. Greater degrees of banding are often associated with muscle hypertrophy and shortening, producing a bowstring effect. In these cases, a submental approach is mandatory.

A central 3-mm incision is centered at, or slightly posterior to the submental crease. Under headlight illumination the skin and subcutaneous fat are elevated off the platysma muscle, extending laterally to the anterior borders of the sternocleidomastoid muscle. The platysma muscle is assessed for laxity, and redundant platysma excised. Wedge resections may be made laterally at the level of the thyroid cartilage to allow for more superior and posterior repositioning of the muscle. If subplatysmal fat is to be excised it is performed at this time, under direct visualization.

The platysma is then reapproximated centrally using permanent sutures to prevent recurrence of bands (Fig. 16.6).

Other techniques, most notably Feldman’s corset platysmaplasty [18], do not advocate platysma resection, but rather tighten the muscle

in a layered fashion. In this approach, relaxing incisions are not performed, as proponents argue that by sufficient tightening the platysma is repositioned to achieve a more defined cervicomental angle, without the need for wedge resections.

Another adjunctive technique to assist in creating a deeper cervicomental angle is the use of platysma suspension sutures. The sutures may be utilized with or without platysma resection or midline plication. Originally described by Guerrerosantos et al. [22], numerous modifications have been reported [15, 19, 20]. These sutures are especially useful in more difficult necks, with greater platysma laxity and obtuse cervicomental angles (Fig. 16.7). The sutures typically affix the platysma border to the contralateral mastoid fascia. Two or more sutures are placed, with the tension adjusted to achieve the desired result. These sutures can be utilized either alone, together with liposuction, or as part of a face-lift procedure.

Botulinum toxin A (Botox) can also be used to temporarily improve muscle bands [30]. Botox is injected directly into the platysma muscle, often resulting in significant amelioration of

bands, presumably by relaxing the muscle and allowing it to retract superiorly and posteriorly. Improvement is temporary, requiring reinjection at approximately 3-month intervals.

Achieving a well-contoured neck has been an accepted priority for years. Extensive operations [12–14, 45] including resection of subplatysmal fat down to the mylohyoid muscle, resection of the anterior belly of the digastric muscles, and submandibular gland resection have been termed the “radical neck rhytidectomy” by Baker [7]. In his paper, Baker makes a cogent argument for less radical cervical surgery, noting that commonly held criteria for a youthful neck [16] are no longer valid. To attempt to achieve the “ideal neck” for all patients is both “unrealistic and poor aesthetic judgment.” Postoperative deformities resulting from more invasive neck surgery are well documented and difficult to correct.

16.4.3 Face-lift Surgery

16.4.3.1 Basics

The definition of the SMAS in 1976 by Mitz and Peyronie [37] marked the beginning of the common era of face-lift operations. Prior to this, facelift procedures involved elevation and tightening of the skin envelope alone. With greater understanding of facial anatomy, face-lift procedures became increasingly aggressive, with larger incisions and deeper planes of dissection. These procedures carried with them an increased risk of facial nerve paresis, prolonged postoperative edema, and ecchymosis [3, 24, 44]. While anatomically sound, these procedures may not offer any prolonged benefit to justify the increased risk and extended healing period [26, 27, 42, 48, 49].

The academic arguments are becoming increasingly moot. Societal shifts have made prolonged postoperative recovery unacceptable for most patients. These patients will be pleased with a more subtle result in exchange for a rapid recovery and return to normal activities. Additionally, as patients seek restoration at a younger age, more limited procedures are often more than adequate to enhance face and neck contours. The ideal procedure marries safety, efficacy, rapid recovery, and patient satisfaction.

16.4.3.2Alternative SMAS Approaches

The main alternatives in face-lift surgery have traditionally been based upon SMAS modification. More recently, incision length has also been used to stratify procedures into either standard or “short-scar” face-lifts.

In a conventional SMAS lift, the SMAS is elevated over the parotid gland and redraped in a more cephalad vector than the skin flap [46]. In extended SMAS dissection, the sub-SMAS dissection is continued to the zygomaticus major muscle, allowing for greater SMAS advancement and repositioning [8]. In the deep-plane technique [23] a single flap of skin and SMAS is elevated, which is argued by Hamra to improve malar fat pad suspension and improvement of the nasolabial fold compared with alternative approaches. When the orbicularis oculi is included

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in the deep-plane flap it is termed a composite rhytidectomy [24].

More extensive SMAS dissection places the facial nerve at increased risk and prolongs postoperative recovery time. The pendulum has swung back, and both patients and surgeons have sought to optimize efficacy, safety, and recovery with less extensive SMAS dissections. To this end, Baker developed the lateral SMASectomy technique [4].

The SMAS is firmly adherent to the parotid gland, but mobile anterior to the gland. It is the more mobile SMAS that must be elevated and tightened to achieve the desired facial contour changes. The previously described procedures in which the SMAS is formally elevated anteriorly places the facial nerve at risk. Additionally, the thin SMAS flap often tears, making it useless for elevation. Baker proposed excision of a strip of SMAS overlying the anterior parotid gland from the malar eminence to the angle of the mandible, allowing the mobile anterior SMAS to be repositioned and adhered to the fixed SMAS overlying the parotid in a vector parallel to the nasolabial fold (Fig. 16.8). The senior author (ABB) has used this technique in over 1,000 patients, and can attest to its efficacy and safety.

In performing face-lift surgery we have found the tumescent infiltration technique extremely useful. Cervical contouring, including liposuction and/or platysmaplasty, is performed initially based upon preoperative assessment. After flap elevation the SMAS strip is excised as described by Baker, taking care to be superficial over the zygoma to prevent injury to the zygomatic nerve. The anterior SMAS is fixed to the posterior SMAS using absorbable sutures. This prevents the later complication of externalization of permanent sutures we have encountered. At this point in the procedure the cervicofacial flaps are rotated, trimmed, and fixed into position.

Ivy et al. in 1996 published results of 21 patients who underwent face-lift surgery, with different procedures performed on each side [27]. These included conventional SMAS lift, lateral SMAS­ ectomy, extended SMAS lift, and composite rhytidectomy. At both 6 and 12 months, differences between the facial sides were not identified. Those who championed more extensive approaches argued the study was flawed [25], although other studies mirror these results in comparing more and less extensive SMAS dissections [42, 48, 49].

The most recent survey of face-lift surgeons revealed no consensus regarding the ideal procedure [36], emphasizing that each surgeon must develop a technique that best fulfills their own criteria for a successful procedure.

16.4.3.3 S-Lifts

One of the most interesting developments over the past 10 years has been the increased acceptance of shorter incisions, often accompanied by limited SMAS modification, for appropriate patients. Younger patients with more modest jowling and neck laxity do not require traditional retroauricular incisions to achieve excellent results. The retroauricular incision can result in visible or hypertrophic scarring, hairline distortion and skin necrosis, all limitations to hair styling. Additionally, more limited dissection decreases postoperative ecchymosis, edema, and healing time. As skin incision and dissection decrease, patient goals of rapid recovery are more readily attained.

The concept of limited surgery is not new. The first description of small-incision face-lift surgery dates back to 1919 [39]. In 1983, Ansari used the term “S-lift” to describe an S-shaped incision extending from the sideburn or temporal hair bearing scalp to just posterior to the earlobe [1, 2]. The incision was repopularized by Saylan in the late 1990s [43]. Saylan described a conservative skin flap of 5–7 cm, with U and O sutures used to plicate the SMAS and fixate it to the zygoma. The procedure carries a high rate of satisfaction with minimal complications and brief recovery.

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and it is the vertical component of the lift that tightens the submentum, this would be expected. The retroauricular flap is required, however, for patients with greater degrees of cervical skin laxity. We now perform the S-lift with SMASectomy in over 50% of our patients undergoing face-lift surgery (Fig. 16.9) [34].

Summary for the Clinician

■A variety of techniques can be employed to tighten the SMAS with an S face-lift and/or a SMASectomy.

16.4.3.5Face-lift with Soft Tissue Augmentation

The face-lift techniques described above are all based upon traditional models of facial aging. Where does soft tissue deflation fit in? Surgeons as early as the mid-1990s were reporting on combined face-lift and autologous fat transfer techniques [21]. Over the past 10 years we have continued to utilize this combination modality in our quest to achieve optimal results (Fig. 16.10). Our enthusiasm for this composite technique is tempered by the recognition that it is accompanied by increased edema and ecchymosis, often prolonging recovery time significantly. The edema is often most evident at the lid–cheek junction, perhaps secondary to lymphatic compromise. The edema typically resolves over a period of weeks to months.

16.4.3.4 S-Lift with SMASectomy

The next progression was to couple the S-lift incision with a SMASectomy. Baker reported a series of 749 patients in 2001 using this technique he termed the “short scar face-lift” [5, 6]. The senior author (ABB) has used this technique in over 500 patients, and like Baker, has found equal success with short and standard incisions in midface elevation, jowl repositioning, and submental skin tightening. As the SMASectomy technique has its greatest effect upon the midface and jowl,

16.4.4 Autologous Fat Transfer

Advocates of the theory proposed by Coleman that facial aging is primarily the result of facial deflation believe that true restoration can only be achieved through volume augmentation. It is not, however, the ideal procedure for everyone. Patient expectations of rapid recovery with minimal edema and ecchymosis are not met by large volume fat transfer. These procedures often require up to a month or longer before patients

are secure to return to a social setting. Additionally, results are often more subtle than excisional surgery, and many patients desire a greater degree of change. In our practice, younger patients are often well-served by focused autologous fat

transfer, while patients with greater degrees of aging are best treated with a combination of facelift and volume restoration.

The technique for successful autologous fat grafting is beyond the scope of this chapter. The

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