and midportion of the zygomatic arch run in a more superficial fashion, endangering injury during long-skin flap dissection [50]. Muzzafar et al. and Mendelson et al. also demonstrated that releasing retaining ligaments in the prezygomatic space through extensive subcutaneous dissection can potentially cause nerve injury to the motor branch of the orbicularis oculi [48, 49].

Unlike the SFR, deep plane rhytidectomy does not involve aggressive undermining of the skin. Deep plane facelifts incorporate a sub-SMAS composite musculocutaneous advancement flap. The results of the deep plane facelift in the lower face (namely the jowls and neck) are very consistent because the SMAS serves as a carrier of the facelift. Midface enhancement, including the nasolabial folds, using the deep plane facelift is more controversial. Owsley and others have shown that the SMAS must be completely released beyond the melolabial fold over the zygomaticus muscle to truly obtain satisfactory nasolabial effacement [51–54]. Not only can a lengthy anteromedial dissection cause extensive postoperative edema, but it can also significantly endanger the branches of the facial nerve. Furthermore, the deep plane facelift does not address lipoatrophy associated with the aging process much like the SFR. Today, facial rejuvenation techniques are also less focused on effacing the nasolabial folds and more focused on volume restoration of the midface. While controversy exists as to the best technique to achieve the best outcome, the deep plane facelift may have better outcomes in older patients with extensive rhytidosis [55, 56].

Rhytidectomy procedures, including the SFR technique, are not without shortcomings. The SFR does not address several important issues, such as the double cheek convexity, infra-orbital rim hollowness, tear trough deformity, facial volume loss, and deep nasolabial folds. Injectable fillers (calcium hydroxylapatite, hyaluronic acids), subcutaneous volumizers (poly-L-lactic acid), fat grafting, and/or implants may need to be performed to address the aging process of the midface [57].

Over the past decade, patient demands for decreased postoperative recovery time has stimulated the resurgence of “limited,” “mini,” or “endoscopic” facelifts. In our experience, “mini” facelifts appear to be ideal only for a select group of patients with minimal signs of facial aging or those requiring minor revision touch-ups [56, 58–60].

28.3Key Anatomic Features

Knowledge of the anatomy is critical for any surgical procedure to obtain outstanding results while avoiding inadvertent complications. The anatomical relationships of the tissues serve as the basis for rhytidectomy. The facial musculature in the face, midface, and neck is surrounded by the SMAS that

extends to the preparotid region and continues with the neck platysma inferiorly and frontalis superiorly. In the anterior neck, the platysma may or may not interdigitate to form a sling. Laxity and/or dehiscence of this anteriorly in the neck can cause neck banding.

The SMAS is the key structural layer of tissue in rhytidectomies. Because of the inherent characteristic of creep phenomenon in the skin and rebound characteristics, skin-only rhytidectomy does not yield long-lasting results. Only when the SMAS layer is incorporated into the procedure are the effects of rhytidectomy longer lasting. The SMAS layer is connected to the skin in the middle and central portion of the face by strong dermal filaments such that lifting and pulling the SMAS layer, while still integrated to the platysma and facial muscles, lift and reposition the skin satisfactorily. The continuity of the skin and SMAS layer as a functional unit is also necessary to maximize the safety and longevity of rhytidectomies [31–34, 36]. This is a critical point because if the two are separated, the SMAS will lose the functional support of the skin layer. This principle guides the surgical outcome in short-flap and deep plane rhytidectomies [15–20]. Longflap SMAS and extended SMAS facelifts, on the other hand, detach the skin from the SMAS layer and disrupt the skinSMAS attachments.

In addition to the facial anatomy, a strong grasp of the fundamental knowledge of the neurosensory and neuromotor branches of the face is critical to avoid complications of mimetic dysfunction. Following rhytidectomy, temporary paresthesias and loss of sensation are expected in the auricular region. The trigeminal nerve (cranial nerve V) supplies cutaneous sensation to the face, head, and neck. Any type of rhytidectomy requires elevation of the preauricular and postauricular skin, which interrupts innervation in these regions of the face. Return of sensation is expected within the first 6–8 weeks if no damage is rendered to the major branch of the greater auricular nerve, but can occasionally take longer. If the sternocleidomastoid fascia is violated with damage to the greater auricular nerve, immediate nerve anastomosis is recommended and permanent loss of sensation is uncommon.

The facial nerve is one of the most critical anatomic structures in facelift surgery. Originating in the pons, the facial nerve exits extracranially through the stylomastoid foramen to enter the parotid gland, where it first divides into an upper and lower division before further subdividing into five main branches: frontal, zygomatic, buccal, marginal mandibular, and cervical branches (Fig. 28.2). Branches of the facial nerve course superficially once past the parotidomasseteric fascia. Due to the extensive arborization of the facial nerve, permanent iatrogenic facial paralysis is uncommon in the zygomatic and buccal region. However, the frontal and marginal mandibular are often terminal branches with limited arborization and injury to them has the highest risk of leading

Fig. 28.2 The facial nerve. The facial nerve bifurcates in the parotid into an upper and lower division. It then divides into five main branches: frontal, zygomatic, buccal, marginal mandibular, and cervical

to permanent paralysis (0.53 and 2.6%) [38, 61, 62]. The marginal mandibular nerve is of risk as it courses over the mandibular margin. Deep plane elevation underneath the SMAS layer in the midface endangers facial nerve branches innervating the orbicularis, zygomatic, and buccinators muscles. Of the facial nerve branches, the frontal branch is the most commonly injured branch as it runs in the danger zone. The branch courses superficially at the level of the zygomatic arch, extending just beneath the subcutaneous tissues underneath the SMAS layer before reaching the frontalis muscle. To prevent injury to this region, it is critical that the surgeon comprehends the anatomical relationships of the layers of the face and temporal region. At the level of the zygomatic arch, the level of dissection needs to be either thin subcutaneous (traditional rhytidectomy) or subperiosteal (endoscopic midface lift) or else transection of the nerve will result. Innervation of the frontalis muscle is unpredictable following injury.

Lastly, attention towards the underlying bony framework of the face and neck is extremely important to maximize satisfactory results in cervicofacial rhytidectomy. Attention should be particularly focused on the key skeletal regions of the malar and submalar regions, dental occlusion, chin projection, and hyoid position. Patients

with visible loss of elasticity in the jowl regions, as well as neck skin and platysma, are ideal for rhytidectomies. Patients with malar prominence, submalar fullness, and good chin projection will obtain enhanced results from SFR. If these areas are deficient, skeletal and/or volume enhancements should be considered prior to the rhytidectomy. Individuals with poor chin projection and prominent prejowl sulcus may require chin augmentation in order to obtain ideal results. Finally, patients with a low and anteriorly positioned hyoid bone will not obtain satisfactory results in the neck [63]. Unfortunately, the hyoid cannot be repositioned during rhytidectomy, thus limiting maximal results.

28.4Preoperative Assessment

Individuals who are seeking periorbital rejuvenation must be also analyzed for lower and midfacial aging changes. Patients who are good candidates for periorbital rejuvenation often require simultaneous lower facial rejuvenation in order to create a balanced esthetic outcome. The typical facelift patient is one who is over 45 years old and is concerned with jowl formation, neck banding, and midface volume loss. During the preoperative consultation, an accurate assessment of the patient’s concerns and expectations need to be understood and discussed. Often this discussion is facilitated with the use of mirrors and morphing equipment to allow the patient to clearly understand the aging process and potential surgical benefits. A comprehensive facial analysis with a clear understanding of the goals is mandatory for successful results.

Facial analysis needs to focus on four key components of the aging process: cutaneous photodamage, facial laxity, musculo-skeletal-lipoatrophy,anddynamicrhytids.Restoring a youthful appearance often requires more than just surgical intervention. It is the combination of surgery with other modalities that yield optimal results. A discussion of skin care, including an antiaging regimen, sun protection, and tobacco cessation, needs to be thoroughly addressed to enhance long-term results. Then, nonsurgical procedures, such as skin resurfacing, soft tissue fillers, and neuromodulators (botulinum toxin-A), are considered. The consultation then focuses on areas that will benefit from facial plastic surgery. To achieve a balanced and natural appearing esthetically pleasing outcome, all regions of the face need to be properly evaluated. Table 28.1 highlights the surgical and nonsurgical options discussed during the consultation process. Should the patient be a surgical candidate, a second consultation will be used to further discuss the risks, alternatives, and perioperative course of the surgical procedures. Photographs should be reviewed in detail with patients during the consultations.

Table 28.1 Comprehensive facial evaluation

Upper-third

Upper blepharoplasty

Endoscopic browlift

Neuromodulators

Dermal fillers and fat grafting

Middle-third

Dermal fillers, volumizers, fat grafting

Lower blepharoplasty

Endoscopic midface lift

Malar and submalar implant

Skin resurfacing

Lower-third

Short-flap SMAS rhytidectomy

Dermal fillers, volumizers, fat grafting

Chin and prejowl augmentation

Table 28.2 Medications to avoid preoperatively

28.5Preoperative Care

Rhytidectomy may be performed under IV sedation or general anesthesia. To optimize results, patients are encouraged to avoid certain medications, especially blood thinners and herbal products, starting 2 weeks prior to surgery (Table 28.2). The patients are started on Arnica and Bromolin approximately 3 days prior to the surgery to reduce perioperative bleeding, edema, and ecchymoses as well as psychologically prepare patients for the upcoming surgery.

In the preoperative area, a marking pen is used to identify the incision areas as well as important landmarks for the SFR, blepharoplasty, and endoscopic browlift in the upright position as the landmarks can be distorted once supine.

Fig.28.3 The preparation. Autoclave tape is applied to the hair 2–4 cm posterior to hair line. Sterile towel is then stapled to the autoclave tape and the endotracheal tube is wrapped in a sterile manner

Table 28.3 Sequential order of procedures

Transconjunctival lower blepharoplasty

Endoscopic brow lift

Endoscopic midface lift

Upper blepharoplasty

Lower pinch blepharoplasty

Submental liposuction

Platysmaplasty

Chin implant

Rhytidectomy

Patients are given an opportunity to visualize the proposed incisions with a mirror.

28.6Surgical Preparation and Technique

Patients can elect either general anesthesia or IV sedation. If general anesthesia is chosen, the endotracheal tube is sutured to the bottom teeth in the midline. Cefazolin and steroids are administered intravenously, and a foley catheter and lower extremity pulsatile compression stockings are placed. 1% lidocaine with 1:100,000 epinephrine is infiltrated using a 3-cc syringe and 27-g needle for the face or brow or a 1-cc syringe with 30-g needle for blepharoplasty prior to prepping and draping the patient. This will maximize time for vasoconstriction to occur. Next, autoclave tape is placed circumferentially around the head 2–4 cm behind the hairline to properly secure the hair away from the surgical field (Fig. 28.3). The entire face and anterior hairline are prepped using diluted betadine. A sterile blue towel is used as a head drape and secured to the autoclave tape via staples. The endotracheal tube is wrapped in a sterile manner using either blue towels or drapes.

Some patients elect to undergo multiple procedures simultaneously and Table 28.3 outlines the recommended order.

Fig. 28.5 Platysmaplasty. Platysmaplasty allows the lateral SMAS/ platysma imbrication to lift the neck as a sling and create a more defined cervicomental angle. Three to six buried interrupted 3–0 Mersilene sutures are utilized to plicate the muscles together. The first suture is placed at the most anterior portion of the platysma

Prior to each portion of the procedure, a second round of local anesthetic using 1% lidocaine with 1:100,000 epinephrine can be considered depending on the time since the initial injection. The face procedures generally begin with suctionassisted lipectomy of the submental region if the patient has liposis. Either a stab incision or a 1–2-cm incision is made in the submental crease. Platysmaplasty or chin implants would require the longer incision to be made. A 1-mm liposuction cannula with multiple ports is used for suction-assisted lipectomy and is inserted deep to the dermis. Multiple passes of

the cannula is performed rapidly in a folding fan-shaped fashion (Fig. 28.4). Caution is used to avoid overzealous fat removal to prevent the potential complication of cobra neck deformity. Attention should be directed towards avoiding the body of the mandible to prevent inadvertent marginal mandibular nerve injury.

Approximating the platysma creates a better-defined cervicomental angle by imbricating the lateral SMAS and platysma to lift the neck. If plastysmaplasty is to be performed, an Aufricht retractor is placed in the incision to visualize the platysma (Fig. 28.5), which is facilitated by vertical spreading with facelift scissors. Once the medial borders of the plastyma are identified, subcutaneous dissection is performed laterally. A small strip of the platysma muscle is excised medially to allow adhesion of the two sides after they are reapproximated. If necessary, backcut of the platysma in a horizontal fashion can be performed at the level of the cervicomental angle. Preplatysmal fat can be judiciously removed in a direct manner as needed at this point. The muscles are plicated using buried interrupted 3–0 PDS (Ethicon, New Brunswick, NJ) with the first of 3–6 sutures placed at the most anterior portion of the platysma extending down to the level of the cervicomental angle. Chin augmentation usually is performed at this point if indicated.

Once the adjunct procedures are completed, attention is then directed toward performing the rhytidectomy. Starting with a 2–3-cm incision in the anterior temporal hair tuft (Figs. 28.6 and 28.7), the incision is slightly curved posteriorly to meet the root of the helix. The temporal hairline incision should never be at the junction of the nonhair-bear- ing region as it has a high chance of being visible even with meticulous closure. From the root of the helix, the incision will continue along the preauricular contour down to the tragus inferiorly. The incision is then created in the retrotragal region in women, before following the natural crease just anterior to the lobule and then posteriorly onto the postauricular conchal bowl. In men, a pretragal incision is

created to avoid placing the sideburn hair inside the ear. The postauricular incision is continued about 3 mm onto the conchal bowl to the junction of the helix and the occipital hair tuft before continuing into the occipital hair tuft for an additional 3 cm. The occipital incision is at a 45° angle and does not follow the hairline because of increased visibility.

Fig. 28.6 The incision and area of dissection in short-flap rhytidectomy. The temporal and occipital incisions are limited. A retrotragal route is utilized. The facial region is dissected for 4–5 cm. The neck is widely dissected to the submental region

The postauricular incision is generally well camouflaged because of the inconspicuous location and heals unnoticeably. Occasionally, a short-scar facelift using a limited postauricular incision can be performed in a select number of patients.

A Brown Adson and No. 15 scalpel are used to begin the flap elevation in the subcutaneous plane at the temporal hair tuft and midface region (Fig. 28.8). Once the plane is identified, double prong skin hooks or 4-prong cat-paws are placed to aid the remainder of the undermining performed with Metzenbaum scissors. During the subcutaneous elevation, countertraction of the skin on the opposite side of the flap by the assistant is critical to preserve the appropriate plane of dissection. Of note, a thick skin flap is dissected at the level of the tragus, just above the perichondrium measuring approximately 8–10 mm. The facial skin is significantly thicker than the native tragal skin and obliteration of the pretragal notch is a telltale sign of facelift procedures. Aggressive thinning of the skin at the end of the procedure significantly limits postoperative tragal fullness, leading to a more appealing esthetic result.

The extent of facial skin undermining is minimal in the SFR. Skin elevation is performed for only 4–5 cm in the facial region. This limited skin dissection is the most important variation of the SFR as compared to other SMAS facelift procedure. Note that the most inferior aspect of the facial dissection at the angle of the mandible is not performed until the posterior neck elevation is completed. The temporal and zygomatic arch regions need to be dissected with extreme care in the subcutaneous plane, as it is very easy to dive down to a deeper plane where the frontal branch can be easily injured (Fig. 28.9).

Once the facial skin elevation is completed, the postauricular and cervical dissection is initiated. The posterior occipital area is elevated initially with a No. 10 or 15 blade (Fig. 28.10). This dissection is more fibrous and difficult than the anterior dissection. The subcutaneous plane is more

Fig. 28.9 Danger zone for the frontal branch of the facial nerve. Typically, four rami of the frontal branch of the facial nerve pass over the zygomatic arch. The most anterior rami runs about 2 cm posterior to the anterior zygomatic arch. The branch is almost always anterior to the superficial temporal vessels

difficult to ascertain. Supercut facelift scissors are utilized to complete the cervical dissection. Extensive cervical dissection may be necessary for individuals with significant neck

skin laxity. The lateral cervical dissection is united with the central dissection that was created for the platysmaplasty and suction-assisted lipectomy. The inferior limit of the dissection is 4–5 cm below the angle of the mandible and at the level of thyroid notch. The surgeon must be cognizant of the external jugular as well as the great auricular nerve as they can be easily injured. Complete cervical dissection is necessary in patients with significant laxity to obtain exceptional results.

Once the cervical and facial dissections are completed independently, the interconnection region at the level of the angle of the mandible is elevated in a subcutaneous plane while the other areas are retracted (Fig. 28.11). Skin hooks are used in the facial and cervical regions to retract the ear and skin in the opposite direction to ensure a continuous level of dissection in the same plane. Furthermore, this technique allows increased protection of the marginal mandibular nerve. The anterior limit of this dissection is approximately 4–5 cm to preserve the continuity of the skin and SMAS layer as a functional unit as previously discussed. Facial liposuction is not recommended because of unpredictability of results.

Following complete elevation of the subcutaneous tissue in the facial and postauricular regions, the SMAS just anterior to the preauricular incision is grasped using a Brown Adson and excised using facelift scissors (Figs. 28.12 and 28.13). The SMAS is removed from the level of the root of the helix extending inferiorly to the infraauricular platysma. The SMAS could be safely undermined to the level of the anterior border of the parotid. For patients with significant facial laxity, the sub-SMAS dissection can be carried out bluntly past the anterior border of the parotid. This should be done with extreme caution. The edges of the SMAS are then imbricated with multiple buried 3–0 PDS sutures to suspend the continuous skin and SMAS layer in a posterosuperior direction

(Fig. 28.14). The direction of the SMAS suspension will depend on the patient’s level of laxity and must be customized for each individual.

At this point, the excess skin is then redraped and excised to complete the rhytidectomy. The goal of skin redraping is to minimize tension in the facial region, while distributing any potential tension in the postauricular region of the occipital hair tuft. This portion of the procedure is critical for the outcome. A Brown Adson forcep is used to aid in the calculation of excess skin excision followed by placement of multiple anchor points to reapproximate the skin in the facial region (Fig. 28.15). Any intervening excess skin is then removed. The skin is then closed in two layers, with the helical root serving as the first major anchor point (AP1). Once AP1 has been determined and set using a 3–0 PDS suture, any excess temporal hair tuft superior to this point is excised using a No. 15 scalpel. The hair bearing temporal region is then closed using staples in a superior to inferior fashion to prevent potential “dog ear” deformity. Because the temporal incision is limited, no significant alteration in hairline positioning is experienced.

Fig. 28.11 The upper facial dissection and cervical dissection are joined. Once the cervical and superior facial dissections are completed, the lower facial subcutaneous elevation at the level of the angle of the

Fig. 28.12 Outline of the SMAS excision. A segment of SMAS is excised 1–2 cm anterior to the preauricular incision at the level of the root of the helix and extends inferiorly down to the infraauricular platysma (a, b)

Fig. 28.10 Postauricular skin flap elevation. This posterior dissection is more fibrous and difficult than the anterior dissection. Facelift scissors and double-pronged hooks are utilized to complete the cervical dissection. The inferior limit of this dissection is 4–5 cm below the angle of the mandible. An extensive cervical elevation is performed in order to join the submental dissection

mandible is performed (a). Hooks are placed on the facial and cervical regions as the ear and facial skin are retracted in opposite direction (b). The dissection is usually carried out for 4–5 cm (c).

Fig. 28.14 SMAS imbrication. The anterior segment of the SMAS is elevated up to the anterior border of the parotid gland (a, b). The SMAS is imbricated with buried 3–0 Mersilene sutures (c). Multiple buried

horizontal mattress sutures are placed. A posterosuperior vector is used for the SMAS imbrication.

The level of the antitragus serves as the second anchor point (AP2). Once AP2 has been placed, the intervening skin between AP1 and AP2 is judiciously excised to avoid overexcision of the skin, which can lead to a widened scar and displacement of the tragus anteriorly. A natural pretragal cleat should be surgically fashioned to conceal the facelift incision. This is easily completed by using facelift scissors and curved iris scissors to thin the newly positioned facial skin draped over the tragus. A buried, interrupted 4–0 PDS suture is then placed into the dermis of the skin flap to artificially recreate the anatomic tragal notch and to prevent inadvertent anterior displacement of the tragus during healing. The third anchor point (AP3) is placed toward the apex of the postauricular region. A single hook is then placed at the distal edge of the occipital incision to allow realignment of the skin and allows identification of the excess occipital skin that needs to be excised. Following excision, the occipital hairline is loosely approximated using deep dissolvable sutures followed by placement of staples to close the hairbearing occipital hair tuft. The tissue between AP2 and AP3

is draped over the ear lobule to assess the amount of skin to excise. Facelift scissors are then used to carefully incise the postauricular excess skin, as the apex will become the anchor point of the lobule attachment (AP4). The excess skin between AP-2 and AP-4 is excised using a No. 15 scalpel to score the skin followed by excision using tenotomy scissors. Aggressive skin removal will lead to pixie ear deformity; therefore limited tension at AP4 is critical.

Prior to closure of the epidermal layer in the preauricular region, there should be a lack of tension following closure of the dermal layer. Should any tension be noted, additional subdermal absorbable sutures should be placed. Mediumsized Jackson-Pratt drains are placed prior to closure. Alternatively, Tisseel Fibrin Sealant (Baxter, Mississauga, ON, Canada) can be used to eliminate the need for drains. The preauricular incision is closed using a running locking 6–0 Nylon or Prolene suture between AP1 and AP4. In the postauricular region, a 4–0 plain gut suture is used to close the skin. The submental incision is closed with a 6–0 Nylon suture. Ice, placed in sterile gloves, is used throughout the

Fig. 28.15 Skin tailoring. Several anchor points are utilized for tailoring the skin (a–c). The root of the helix (AP-1) serves as the first anchor point (d). Once this location has been set, excess temporal hair tuft

superior to AP-1 is excised and staples are used for closure. The second anchor point (AP-2) is at the level of the antitragus (e). The intervening skin between the first and second anchor point is removed