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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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cervicofacial branch, providing innervation to lower face and neck muscles.
The frontal and marginal mandibular nerves should be carefully avoided
during rhytidectomy, as these are the most commonly injured facial nerve
branches [146, 147].
Pitanguy’s line is used to estimate the course of the frontal facial n.
branch, using a theoretical line drawn from 0.5 cm below the tragus to 1.5
cm above the lateral eyebrow. This branch runs deep to the temporoparietal
fascia and superficial to the deep temporal fascia, and should be identified
in relation to the SMAS with rhytidectomy [148]. Surgeons use Zuker’s
point to locate the motor nerve branch of the zygomaticus major muscle,
located at the middle point on a line from helix (ear) to oral commissure.
This motor branch usually travels above the transverse facial artery, and
buccal nerve branches lie underneath the vessel [149].
The great auricular nerve is at the greatest risk of damage, emerging
between the mandibular angle and mastoid process before moving inferiorly
along the lateral sternocleidomastoid muscle [147]. McKinney’s point is
estimated at one third of the distance from the mastoid tip to the clavicular
attachment of SCM, and is used to locate the great auricular nerve as it
borders the posterior SCM. Caution should be taken to avoid the superficial
jugular vein, located approximately 1 cm anterior to this point [149]. The
marginal mandibular nerve (facial nerve branch) lies deep to the platysma
muscle, and is generally found 1–2 cm below the inferior mandibular
border [150].
4.2 Preoperative Patient Assessment
Rhytidectomy is indicated in patients who have excess skin laxity, deep
rhytids (wrinkles), and additional changes resulting from aging (volume
loss, deepening of skin folds). While the actual texture of the skin cannot be
changed with this procedure, there are additional nonsurgical rejuvenation
techniques [188]. This surgery is not designed to alter the overall
appearance of the face or stop the aging process, although it is well utilized
to create more youthful appearance of tighter skin.
Each technique has its own advantages and disadvantages, which will
be discussed in detail for each individual approach. Various tissue planes
can be utilized, depending on the depth and severity of rhytids and skin
laxity. Different approaches are detailed in Table 4, along with their various
indications [142, 151].
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Table 4 Indications for modified facelift approaches
Primary concern Indicated approach
Neck deformities (submental fat accumulation, striated or
deformed platysmal bands)
Cervical rhytidectomy
Unaesthetic jowls and neck deformities SMAS and cervical rhytidectomy,
performed concurrently
Deep nasojugal and/or mesolabial folds Deep plane or composite rhytidectomy
Descending malar fat pads and/or severe mesolabial folds Midfacial or deep plane rhytidectomy
Jowls SMAS rhytidectomy
Deformity of the eyelid-cheek junction Composite rhytidectomy
In general, contraindicating factors include smoking, chronic
corticosteroid use, and disorders impacting wound healing capability (e.g.,
diabetes). All of these risk factors can increase the risk of tissue flap
necrosis after facelift surgery. Blood thinners increase the risk of excessive
bleeding and hematoma formation, especially with rhytidectomy. Any
NSAIDS, supplements, or prescribed/OTC blood-thinning medications
should be discontinued at least 2weeks prior [142]. A thorough past
medical history and medication reconciliation should be obtained at the
preoperative consultation to identify any contraindications or underlying
psychiatric disorders. The surgeon will examine the quality, laxity, and
texture of the skin, determining severity of rhytids or previous scarring.
Skeletal resorption and volume loss/fat pad malpositioning will be noted as
well to identify an ideal surgical approach.
Analysis of the face with emphasis on hairline shape/integrity, facial
asymmetries, and contour deformities can give the surgeon a better idea of
what the postoperative outcome might look like. As with many aesthetic
procedures, photographs should be taken from lateral, frontal, and base
views before and after the procedure [151].
Some patients benefit from integrated cervicoplasty, and the surgeon
will examine the neck to assess and identify underlying structural
deformities. Severity of these deformities can be classified using the Dedo
scale [152] (Fig. 20).
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Fig. 20 Illustration of various severity with aging neck deformity [153]
4.3 Surgical Techniques
Rhytidectomy may be performed using general anesthesia (requiring
intubation), although local anesthesia with oral or IV sedation has been
indicated in the literature as a safer method of pain management. The
underlying risk of complications directly related to rhytidectomy is
unchanged, regardless of pain management technique. The skin is prepared
with iodine and injected with tumescent anesthetic solutions to mitigate
bleeding and reduce the overall amount of anesthetic used. Intravenous
antibiotic and steroid therapy is indicated for most patients to reduce
infection risk and resultant inflammation [154].
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4.3.1 Incision Patterns
The incision location and length can vary between surgeons and is
dependent on the technique which will be utilized. Traditional facelift
incisions consist of the preauricular segment and postauricular segment.
Preauricular incisions begin at the root of the helix and extend upward into
the temporal scalp along the hairline, and postauricular incisions are made
horizontally into the hair-bearing scalp to access posterior structures [155].
Preauricular incisions can be modified using a post-tragal approach
(necessitates incision to the posterior margin of the tragus) or pretragal
approach (incision anterior to the tragus into cutaneous cheek tissues). With
male patients, a pretragal approach is frequently indicated as the
repositioning of skin with flap closure places unnatural hair-bearing skin on
the tragus. The preauricular incision is illustrated in Fig. 21.
Fig. 21 Preauricular incision [156]
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Postauricularly, the incision is continued superiorly along the auricular
sulcus to the level of the helical rim, then inferomedially into the hairbearing scalp. Inferomedial continuation can help mitigate the resultant
cone-like appearance after wound closure and contracture of healing tissues
[155]. The S-lift incision limits the tissues which can be lifted to the
midfacial region, although a postauricular scar is completely avoided with
this approach [157] (Fig. 22).
Fig. 22 Short scar rhytidectomy (originally described by Passot) has been refined, due to the limited
dissection planes and resultant tension. It is used in the MACS-lift when superficial tissue lifting is to
be performed [158]
After the surgeon has determined which incision pattern will be used
and the patient’s skin is marked, the flap can be lifted and dissected from
the underlying tissues. A scalpel is used to make a beveled incision parallel
to the hair follicles (avoiding disruption of hair growth) to the subcutaneous
tissues. Once completed, scissors are used to carefully dissect in the
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subcutaneous plane, creating a skin flap which will be repositioned [142,
151].
With SMAS facelift, the subcutaneous tissues will be dissected in the
lateral face, stopping about 6 cm anterior to the tragus. Deep-plane facelift
necessitates additional dissection, continuing subdermally to the
mandibular-lateral canthal line and proceeding deep to the SMAS [142,
151].
4.3.2 Minimal Access Cranial Suspension (MACS) Rhytidectomy
MACS-lift is well utilized to elevate subdermal tissues, using 0polydioxanone purse-string sutures as opposed to more invasive elevation
and suspension. As an additional benefit, this procedure can be performed
through short incisions along the temporal face/ear. Simple MACS-lift can
correct the lower face via tightening of neck jowls and refinement of the
cervicomental angle. Alternatively, an extended MACS-lift is well utilized
to reduce the appearance of excess laxity at the lower eyelids, midface, and
nasolabial rhytids [159].
Incisions for the simple MACS lift are less extensive compared with
other techniques, beginning just anterior to the earlobe (lobule) and
stopping at the lateral canthus (eye). Blunt dissection using finger
separation creates a pocket just above the deep temporal fascia (superior to
the facial nerve) (Fig. 23).
Fig. 23 Simple MACS-lift: suture placement and incisional pattern [160]
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Purse string sutures are placed in a circular pattern, and apply
circumferential tension when closed, allowing for reduction of excess
tissue. A thinner loop of sutures is made along supra-parotid tissues,
incorporating the superior platysma fascia and inferior temporalis fascia.
Another purse string suture can be placed in a broad, oblique fashion to
incorporate SMAS above jowls and temporalis fascia. This loop acts to
suspend the tissues and improve mandibular definition [161].
With extended MACS-lift, a third purse-string loop brings the malar fat
pad closer to deeper temporal fascia and lateral orbit, reducing the
appearance of melolabial folds [144]. With both MACS-lift approaches, the
vertical axis of tension differs from oblique or horizontal skin tightening
used in the other facelift techniques. The preplanned suture placement is
demonstrated in Fig. 24 [161].
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Fig. 24 The three locations of suture placement for an extended MACS-lift [158]
4.3.3 SMAS Rhytidectomy
Mitz originally described the technique of SMAS rhytidectomy, and it has
been used since to manipulate subcutaneous tissues, subsequently reducing
laxity and deep rhytids. Augmentation of the SMAS is accomplished via
plication (folding onto itself) or imbrication (removal of excess tissue).
Plication involves careful removal of superficial adipose tissue from the
preauricular region, requiring careful avoidance of superficial facial nerve
branches. Excess SMAS tissue is then grasped and folded onto itself. The
folds are secured with sutures, applying tension in both lateral and
superolateral vectors for additional security [151, 158].
Imbrication utilizes an inverted L-shaped incision into the SMAS,
which is made about 1 cm anterior to the ear. Careful blunt dissection below
the SMAS reduces risk of damage to the protruding facial nerve when
undermining the tissues. Excess tissues are removed, and the SMAS is then
advanced and secured with sutures. Tension can be oriented superolaterally
in the temporal region for upper facial rejuvenation. If the patient specifies
jowls as their primary concern, the SMAS is advanced laterally and
transposed in the postauricular region. The lateral tension with suture
closure allows for tightening along the margin of the mandible [151, 158]
(Figs. 25 and 26).
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Fig. 25 An illustration of the dissection plane and area of tissue to be plicated or imbricated with the
SMAS Facelift technique [158]
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Fig. 26 An illustration of the plication technique and incision points [158]
SMAS facelift is usually performed in conjunction with platysmal
elevation and plication, as the newly augmented face should match
surrounding tissues for best results. The submental skin is incised, and
dissection is performed in the supraplatysmal plane to meet the previously
dissected supra-SMAS pocket. The platysma will then be elevated and
sutured to the surrounding muscles, allowing for lateral attachment to
anterior sternocleidomastoid fibers. If necessary, the platysma is sutured to
the hyoid bone for additional stability. Lastly, bilateral platysma fibers are
cinched along the midline of the neck before an anchoring suture is placed
into mastoid periosteum, as shown in Fig. 27 [176].
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