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68 / Small-Incision Rhytidectomy
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times if possible for at least 5 days to provide support and promote adherence of the skin fl ap. The
patient wears the elastic dressing at night for an additional week. All sutures are removed 1 week postoperatively. We schedule additional postoperative
visits at 2 weeks, 1 month, 3 months, 6 months, and
1 year; although, this is tailored to each patient’s individual schedule and needs.
Complications
As with our traditional rhytidectomy technique, few
complications are typically observed in patients undergoing small-incision rhytidectomy. Occasional
accumulations of blocked or serom are easily treated by aspiration in the offi ce on postoperative day
one. Facial nerve injury is unlikely with the limited
dissection involved in this procedure, and postoperative facial weakness in the recovery area is usually
secondary to persistent activity from the infi ltrated
lidocaine. All patients should expect to have decreased sensation in the undermined area for at least
6–8 weeks following surgery. Injury or transection
of the great auricular nerve can lead to prolonged
numbness of the earlobe and postauricular area.
Tension-free skin closure ensures minimal scarring
along incision sites. Other complications are rare.
Summary
We fi nd that the small-incision rhytidectomy
with SMAS plication is a useful adjunct to a facial
plastic surgeon’s armamentarium. Patients with
active lifestyles are amenable to a procedure that
offers signifi cant surgical facial rejuvenation with
minimal risk and recovery time. The small-incision
technique is especially useful in younger patients
with early development of jowls, some submental fat, and minimal banding of the platysma.
The small-incision technique can also be benefi cial as a secondary procedure to restore correction initially achieved by an earlier rhytidectomy.
Our small-incision technique is relatively simple
and can be easily mastered with rare complications
by most surgeons.
References
1. Adamson PA, Litner JA. Evolution of rhytidectomy
techniques. Facial Plast Surg Clin N Am. 2005, 13,
383–391.
2. Passot R. La chirurigie esthetique des rides du visage.
Presse Med. 1919, 27, 258–262.
3. Mitz V, Peyronie M. The superfi cial musculoaponeurotic
system (SMAS) in the parotid and cheek area. Plast
Reconstr Surg. 1976. 58. 80.
4. Hamra ST. The deep-plane rhytidectomy. Plast
Reconstr Surg.1990, 86, 53–61.
5. Becker FF, Bassichis BA. Deep-plane face-lift vs
superfi cial musculoaponeurotic system plication
face-lift: A comparative study. Arch Facial Plast Surg.
2004, 6, 8–13.
6. Salyan Z. The S-lift: Less is more. Aesthetic Surg J. 1999,
19, 406–409.
7. Massiha H. Short-scar face lift with extended SMAS
platysma dissection and lifting and limited skin
undermining. Plast Reconstr Surg 2003, 112, 663–669.
8. Baker DC. Minimal incision rhytidectomy (short scar
face lift) with lateral SMASectomy: Evolution and
application. Aesthetic Surg J. 2001, 21, 14–26.
9. Tanna N. Review of 1,000 consecutive short-scar
rhytidectomies. Dermatol Surg. 2008, 34, 196–203.
Index
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Information in fi gures and tables is indicated by f and t.
A
adipose tissue
excision, 12, 13–16, 13f, 14f, 15f, 16f
overresection of, 16
aging
facelift duration effects, 8
facial effects, 5
as jawline disruption cause, 52
airway management, 9
alopecia. See hair loss
analgesia, postoperative, 37
anatomy, facial-cervical
occipital, 7f
postauricular, 7f
preoperative evaluation, 5–8, 6f, 7f
ancillary procedures, 8, 51. see also chin augmentation
anesthesia, 8–9, 9t, 11–12, 24
for chin augmentation, 53
for small-incision rhytidectomy, 63
angle
cervical
high, 5
in submental correction, 14–15, 17, 18f, 19
cervicomental, 41f, 42f
anticoagulant drugs, 8, 46
aspirin, 45, 46, 46f
auricular nerve injury, 46
B
bearded skin, 22, 23f
blepharoplasty, 51
brow lift, 51
buccal nerve injury, 46
C
cannulas, for liposuction, 13–14, 14f, 15f, 16f, 63, 64f
cautery
bipolar, 18, 19f, 20, 27f, 33, 47–48, 65
as hair loss cause, 47–48, 50f
monopolar, 46, 47, 50f
cephalometry, 52
cervical angle
high, 5
in submental correction, 14–15, 17, 18f, 19
cervicomental angle, 41f, 42f, 52, 67f
cheek fl ap, 24
chin, aesthetic evaluation, 52, 53f
chin augmentation
as adjunct to rhytidectomy, 5, 51–57, 53t
injectable, 51
patient selection for, 52–53
preoperative preparation for, 53
surgical technique, 53–54, 55–58f
chin defi ciency, 51–52
chin implants
for prejowl defi ciency, 52–53
for retrognathia, 12, 12f, 12t
silicone rubber, 13f
chinline
preoperative evaluation, 5, 8t
in thick-skinned patients, 43f
chin supports, postoperative, 37
Chirurgie esthetique des rides du visage, Le
(Passot), 61
complications, 45–50
auricular cleft and lobe displacement,
48, 50
of deep-plane procedures, 2, 62
hair loss, 47–48, 49f, 50f
hematoma, 45–46
infections, 45, 46, 54
medication-related, 8
nerve damage, 46, 47f, 62, 68
of osseous genioplasty, 52
scars, 46–47, 48f, 49f
of small-incision rhytidectomy, 68
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concha, 23–24, 23f
consultations, preoperative, 9
contracture, 21
D
deep-plane procedures, 1–2
alternatives to, 61
comparison with superfi cial muscle aponeurotic system
(SMAS) plication, 62
complications, 2, 62
superfi cial aponeurotic system (SMAS) in, 26
dressings, postoperative
for chin augmentation, 54
removal, 37
for small-incision rhytidectomy, 65, 68
E
ear, 23
earlobe/earlobe region
positioning, 33
postauricular incisions within, 22
postoperative deformity, 47, 50
preauricular incisions within, 22
ecchymoses, 45, 46f
edema, postoperative, 62
elasticity
postoperative improvement, 38, 39f
premature loss, 5, 8
endotracheal intubation, 9, 11, 12, 53
excision
of hypertrophic scars, 47, 49f
of redundant adipose tissue, 12, 13–16, 13f, 14f, 15f, 16f
of redundant skin, 20, 20f, 29, 31f
in small-incision rhytidectomy, 61–62
superfi cial muscle aponeurotic system, 67f
expectations, of patients, 8, 8t
external auditory canal, 23, 62
F
facelift. see also Safety Facelift
acceptance of, 1
duration, 8
rationale for, 1–3
facelift candidates
“diffi cult,” 5, 8, 9t
ideal, 8, 8t
selection of, 5–8, 45
facial analysis, preoperative, 5–8
facial nerve branches
in fl ap elevation, 24, 26
mandibular, 26, 46, 47f
temporal, 11f, 24, 26, 46, 47f
facial nerve injury, intraoperative, 46, 46f, 62, 68
fat. see adipose tissue
fl aps
bilateral platysmal, 17
elevation
auricular nerve injury during, 46
intermediate 24
of postauricular fl aps, 25f, 26, 26f
of preauricular fl aps, 25f
intermediate, 29
necrosis, 45
postauricular, 22–23
alignment with hairline, 31f
elevation, 25f, 26, 26f
preauricular, 25f
retraction, 25f
forehead lift, 51
Frankfort horizontal, 52, 53f
G
general anesthesia, 9, 9t
genioplasty, 52
H
hair-bearing skin, 21–22, 21f, 23f
damage to, 47–48
temporal, 31, 33
hair coloring, postoperative avoidance of, 37
hair follicles, preservation, 32–33
hairline
distorted, 48
incisions within, 21, 21f
occipital, 23–24, 24
postauricular margin, 23
shifts in, 21
temporal, 21–22, 21f, 23, 24, 31
hair loss, postoperative, 47–48, 49f, 50f
hair transplantation, 48
head positioning
operative, 11
during postoperative recovery, 37
hematoma, postoperative, 24, 37, 45–46, 62
small-incision rhytidectomy-related, 68
treatment, 45
hyoid
anteroinferiorly positioning, 52
high positioning of, 5
hypoesthesia, postoperative, 68
I
incisions
camoufl aged, 21, 22–24, 39f, 47, 48f
for chin implant placement, 54, 55–58f
closure, 20f
curved, 21, 21f
facial, 21–24, 21f, 22f, 23f
for liposuction cannula placement, 13–14, 13f
periauricular, 63, 63f
for platysmal muscle tightening, 16–17, 16f
postauricular, 61–62
postoperative care, 37
posttragal, 33
preauricular, 33, 61–62
at preauricular superior helix, 21–22
pretragal, 22
pretrichial, 21
scars incorporated into, 12
skin overadvancement in, 49f
in small-incision rhytidectomy, 61–62, 62, 63f, 66f, 67f
in SMAS-platysmal complex, 26, 27f
submental, 12, 13f, 51
in submental crease, 13–14, 13f
Index / 71
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for submental liposuction, 51
temporal, 21–24, 21f, 22f, 23f, 61–62
through platysmal muscle, 17–19, 18f
typical sites, 11f
infections, postoperative, 45, 46, 54
inferior alveolar nerve, 54
infra-auricular cleft, loss of, 48, 50
J
jawline
importance of, 51
poor, 51
pre- and postoperative comparisons, 38f, 41f
jowl region
liposuction in, 15
preoperative laxity location, 11
preoperative marking, 12
submandibular, 12–13
L
Le chirurgie esthetique des rides du visage (Passot), 61
lidocaine:epinephrine, 9t, 11–12, 53, 63, 68
liposuction
cervicofacial, 62
incisions for, 13–14, 13f, 51
in jowl region, 15
in small-incision rhytidectomy, 66f, 66t
subcutaneous plane for, 14, 15f
submental, 12, 13–16, 13f, 14f, 15f, 16f, 62, 66f, 66t
in chin augmentation, 53–54
in small-incision rhytidectomy, 63
local anesthesia, 9, 9t, 11–12
“lunchtime procedures,” 1
M
macrogenia, vertical, 52
malar eminence, projection, 24
male patients, 5
facial hair-bearing skin in, 22, 23f
malocclusion, 52
mandible, in liposuction, 15
mandibular area, elasticity, 39f
mandibular line, pre- and postoperative comparisons, 38f, 40f,
42f
marginal mandible nerve injury, 15
medications, as postoperative complication cause, 8
melolabial fold region, injectable augmentation of, 51
melolabial grooves/creases, deep, 8t
menton, 52, 53f
mentoplasty. See chin augmentation
microgenia defi nition, 52
midface laxity, pre- and postoperative comparisons, 38f, 39f
minilifts, 1, 9
minimal incision facelifts, 1–2
minoxidil, 48
monitored anesthesia control (MAC), 9
m-plasty, 24
N
nasion, 52, 53f
nasolabial fold region, injectable augmentation of, 51
nasolabial grooves/creases, deep, 8t
neck
short, wide, 5
soft-tissue laxity, 41f
neck line, in thick-skinned patients, 43f
nerve injury, intraoperative, 46, 47f, 54, 62
non-steroidal anti-infl ammatory drugs (NSAIDs), 45, 46
O
obese patients, 43f
obesity, facial, 5, 6, 8t
occipital region, anatomy, 7f
occlusion, evaluation, 52
orbital rim region, dissection to, 47f
orthognathic surgery, 52, 53
oxygenation, 9t
P
Passot, Raymond, 61–62
patient expectations, 8, 8t
patient selection
for facelift, 5–8, 45
for small-incision rhytidectomy, 62–63
physical evaluation, of facelift candidates, 5
“pixie ear,” 47, 50
platysmal bands
pre- and postoperative comparisons, 39f
preoperative marking, 11, 12
in small-incision rhytidectomy, 63
“verticality” of, 18–19
platysmal complex, confl uence with superfi cial muscle
aponeurotic system (SMAS), 26, 26f, 27f, 29
platysmal corset maneuver, 19–20, 19f
platysmal fl aps, bilateral, 17
platysmal medial margins
advancement and suturing, 19–20, 19f
exposure, 16–17, 16f, 17f
identifi cation, 17, 18f
undermining, 16–17, 17f
platysmal plication, 12, 18
in chin augmentation, 53–54
in small-incision rhytidectomy, 63, 66f
platysmal tightening, 16–20, 16f, 17f, 18f, 19f, 20f
pogonion, 52, 53f
bone resorption at, 54
postauricular fl aps, 22–23
alignment with hairline, 31f
elevation, 25f, 26, 26f
postauricular region
anatomy, 7f
dissection in, 26, 26f
incisions in, 22–24, 23f
sutures in, 37
postauricular sulcus, 22–24, 23f, 63f
postoperative care, 37–43
in chin augmentation, 54
in small-incision rhytidectomy, 65, 68
posttragal advancement, 48f
posttragal area, sutures in, 37
preauricular region
fl ap elevation in, 25f
incisions in, 22, 22f
preauricular superior helix, incisions at, 21–22
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preoperative evaluation
of chin augmentation candidates, 52
of facelift candidates, 5–8, 45
preoperative preparation
of facelift patients, 11–12
of small-incision rhytidectomy patients, 63
pretragal region, incisions in, 22
pretrichial area, incisions in, 21
ptosis, of submaxillary gland, 5, 8f
“pulled” appearance, 42f
R
redraping, of skin, 29
in small-incision rhytidectomy, 61–62, 65, 65f
redundant adipose tissue, excision, 12, 13–16, 13f, 14f, 15f, 16f
redundant skin, excision, 20, 20f, 29, 31f
redundant SMAS tissue, excision, 29
retrognathia
chin implant correction, 12, 12f, 12t
defi nition, 51–52
rhinoplasty, 51
rhytidectomy
with chin augmentation, 51–57
complete, 1
rhytidoplasty. See facelift
S
Safety Facelift, 2f
advantages, 2
fundamental steps in, 2
modifi cation to small-incision technique, 62–68
patient selection, 5–8, 45
pre- and postoperative comparisons, 37f–43f
surgical technique
excision and closure, 29–33, 30f, 31f, 32f, 33f
facial incisions, 21–24, 21f, 22f, 23f
fl ap and superfi cial aponeurotic system elevation, 24–29,
25f, 26f, 27f, 28f, 29f
fl ap elevation, 24
preoperative preparation, 11–12
submental correction, 12–20, 13f, 14f, 15f, 16f, 17f, 18f,
19f, 20f
“Satan’s ear,” 50
“satyr’s ear,” 47
scars, incisional, 21, 23–24
contracted bowstring, 24
hypertrophic, 46, 47, 49f
irregularization of, 23–24
poorly-positioned, 48f, 49f
wound closure tension-related, 49f
scissor dissection and excision, 63, 64f, 65f
secondary facelifts, 1–2
shampooing
postoperative, 37
preoperative, 11
shaving patterns, 22
sideburn hair, 21–22, 23f, 31
skin thickness
medium, 40f
thick, 43f
thin, 42f
“S-lift,” 62
small-incision rhytidectomy, 61–68
background, 61–62
complications, 68
patient selection, 62–63
postoperative care, 65, 68
stepwise technique, 66–67f, 66t
surgical technique, 63–65, 63f, 64f, 65f, 66–67f
smoking cessation, 8, 45
staples, 32–33
removal, 37
sternoclavicular mastoid muscles, 14–15
stomion, 52, 53f
“stretched” appearance, 29, 42f
subcutaneous plane
in liposuction, 14, 15f
in small-incision rhytidectomy, 63, 64f
subfollicular plane, 21
submaxillary gland, ptosis of, 5, 8f
submental area, postoperative “cobralike hollowness” in, 16
submental correction, 12–20
cervical angle in, 14–15, 17, 18f, 19
chin augmentation, 12, 12f, 12t, 13f
liposuction, 12, 13–16, 14f, 15f, 16f
with overresection of fat, 16
platysmal band correction and plication, 12
platysmal band “verticality” breakup, 18–19
platysmal corset maneuver, 19–20, 20f
platysmal muscle exposure, 16–17, 16f, 17f
platysmal muscle tightening, 16–20, 16f, 17f, 18f, 19f, 20f
redundant skin excision, 12, 20, 20f
submental fl ap creation, 17
submental crease
incisions in, 13–14, 13f
preoperative marking, 12
submental fat, 12
preoperative marking, 11
submental fl aps, 17, 18f
submental region elasticity, pre- and postoperative comparisons,
38f, 39f
subnasale, 52, 53f
subperiosteal pockets, 12, 51
in chin augmentation, 54, 56f
sulcus, postauricular, 22–24, 23f, 63f
sun-damaged skin, 5, 8
superfi cial muscle aponeurotic system (SMAS), 1
anatomic description, 62
closure, 29
confl uence with platysmal complex, 26, 26f, 27f, 29
dissection beneath, 62
elevation, 26–29, 28f, 29, 46
in small-incision rhytidectomy, 63, 64f
excision, 67f
exposure, 26, 27f, 28f
exposure to, 24
imbrication
advantages, 62
in small-incision rhytidectomy, 62, 65, 66f
two-vector approach, 62
without postauricular incisions, 62
incision line, 30f
plication, 26, 62
dual-suture, 62
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redundant, excision of, 65
in small-incision rhytidectomy, 62, 63, 64f, 65, 66f
two-vector approach to, 29–33, 30f
undermining, 29f, 67f
surgical technique, 11–36
sutures
absorbable, 37, 51
for chin implant placement, 51, 54, 57–58f
for fl ap positioning, 31–32, 32f
H-polydioxanone, 19
in platysmal muscle medial margins, 19
for plication, 26
removal, 37, 68
in small-incision rhytidectomy, 63, 65, 66f, 67f, 68
in SMAS, 26, 28f, 29
“splitting,” 26
3-0 PDS, 26, 28f, 29
T
temporal region
fl ap elevation in, 25f
hair loss in, 49f, 50f
incisions in, 21–24, 21f, 22f, 23f, 61–62
skin overadvancement in, 49f
triamcinolone, 47
tuck-up procedures, 9, 9t, 62
two-vector approach, 29–33, 30f
U
ultraviolet light exposure, postoperative avoidance of, 37
V
vitamin E, 46
“V” scar irregularization, 23–24, 23f
W
weight loss, preoperative, 5
“windblown look,” 29
wound closure, tension on, 29, 46–47, 48, 49f, 50
Y
younger patients, small-incision rhytidectomy in, 61
Z
zygomatic arch
fl ap elevation at, 24
redundant excision in, 29
in superfi cial aponeurotic system (SMAS) undermining, 29f
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