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Fig. 28.15 (continued) (f) using curved iris scissors. The newly positioned facial skin over the tragus is aggressively thinned (g). A Vicryl suture is used to create a pretragal cleat; it penetrates the dermis of the facial skin and secured to the pretragal tissue (h). The third anchor point (AP-3) is the apex of postauricular incision (i). Excess occipital skin is excised with the help of a hook (j). The occipital hairline is aligned with deep dissolvable sutures. The intervening tissue between
AP-2 and AP-3 is draped over the ear lobule (k). The inferior border of the lobule is then used to make a split into this intervening skin. The apex of this incision becomes the anchor point of lobule attachment (AP-4). The excess skin between AP2 and AP-4 is excised. In the postauricular area, the skin between AP-3 and AP-4 is also trimmed conservatively. The preauricular incision is closed with a 6–0 Nylon in a running locking manner (l)
procedure to promote vasoconstriction and limit perioperative ecchymoses. As discussed in earlier sections, volume restoration is a key component of facial rejuvenation and most patients at this point will undergo multilevel fat grafting, most commonly in the midface and prejowl sulcus regions. At the conclusion of all the procedures, a circumferential pressure dressing is placed and the patient is transported to the recovery room.
28.7Postoperative Care
It is recommended that patients stay in an after-care facility for 24–48 hours where registered nurses can provide personal postoperative care, although patients can choose to recover at home if assistance is available. Patients are encouraged to elevate their heads and use cool compresses
for the first 72 hours to minimize perioperative ecchymoses. Antibiotics, analgesics, sleep, and anti-nausea medications are prescribed for the recovery period.
Patients are seen on postoperative day No. 1 for dressing and drain removal as well as wound inspection. Hydrogen peroxide and antibiotic ointment are generously and continuously applied to keep the wounds clean and moist for the first 5 days. A Velcro head wrap is used continuously while the patient is at home during the first postoperative week. Patients are allowed to take light showers starting on the postoperative day No. 2. The preauricular sutures and all staples are removed on the seventh postoperative day and Steri-strips (3M, St. Paul, MN) are applied. The patients return around the fourth postoperative week for follow-up. At this followup visit, if indicated, dermal fillers, volumizers, and neuromodulators are used to address the midface as well as any perioral and periorbital rhytids (Figs. 28.16–28.18).
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Fig. 28.16 Preoperative (a–c) and postoperative (d–f) photos of a patient who underwent short-flap SMAS rhytidectomy, upper blepharoplasty, and multilevel fat grafting.
Table 28.4 Potential complications
Cervicofacial hematoma
Alopecia
Poor scarring
Contour irregularities
Skin slough
Infection
Numbness
Need for revision surgery
Facial nerve injury
28.8Potential Complications
Potential complications associated with the SFR are listed in Table 28.4. While the rate of cervical hematoma, postauricular
skin necrosis, alopecia, and numbness is tantamount to other facelift techniques, our experience has shown that the SFR has a lower risk of facial hematoma, flap necrosis, and facial nerve palsy. The rate of revisional surgery has been observed to be similar to other SFR techniques.
28.9Future Considerations
With the advent of less invasive facial rejuvenation options, patients’ demand for minimally invasive procedures have skyrocketed over the past decade. This trend is expected to continue into the twenty-first century. The future of facial rejuvenation will likely depend on a combination of surgical and nonsurgical modalities to yield ideal results. While the advent of longer lasting fillers, volumizers, and noninvasive
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Fig. 28.17 Preoperative (a–c) and postoperative (d–f) photos of middle-aged female with aging face who underwent short-flap SMAS rhytidectomy, multilevel fat grafting, and blepharoplasty
tightening technology may diminish those interested in receiving surgery, time-tested surgical procedures, such as facelifts, blepharoplasty, fat grafting and brow lifts, will continue to be critical methods for maximizing facial rejuvenation results.
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