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Fig. 27 An illustration of platysmal plication, with pink and green lines demonstrating the location
and extent of suture placement [158]
4.3.4 Deep Plane Rhytidectomy
This approach has been used for decades and continues to be a well-utilized
procedure for dramatic facial rejuvenation of melolabial folds and malar fat
pad repositioning. Subcutaneous dissection is performed in the same
manner as SMAS rhytidectomy, followed by deeper dissection below the
SMAS. An incision will be made through the SMAS tissues at the malar
eminence and extended to the mandibular angle, as well as below the chin.
Blunt dissection is used to separate the SMAS from underlying fascia
within this plane, starting at the parotidomasseteric fascia and continued
anteriorly. Dissection should not proceed past the malar eminence
superiorly or mandibular angle inferiorly [163].
Once the SMAS has been lifted from underlying tissues, the surgeon
should identify the zygomaticus muscle. The superficial layer of this muscle
is separated and dissected toward the melolabial folds, mobilizing the malar
fat pad. The tissue flaps and fat pads will then be advanced posteriorly and
superiorly and secured. Additional care should be taken with fat pad
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repositioning to ensure symmetrical and aesthetically appropriate results
[163].
The subcutaneous rhytidectomy is an additional surgical technique
originally published by Lexer, utilizing minimally invasive dissection in the
subcutaneous plane to lift the superficial skin layers [161]. There is no
alteration of the SMAS, and the excess skin can be removed and reattached.
It is best utilized in thinner individuals who have minimal skin laxity and no
severe aging changes to the underlying facial skeleton, muscles, and fat
pads. We invite the interested reader to independently investigate this
technique in [162].
After advancement and excision of excess tissue using the
aforementioned variable techniques, the flap is secured using 2–4 sutures or
staples along the incisional opening. Thinner, 6–0 sutures can be used to
close the flap around the auricular region, and closure around the hairline
may utilize staples or absorbable sutures. Bilayered sutures can be utilized
to reduce tension of superficial tissues, which may induce a pixie-ear
appearance or produce unattractive widening of the scar. The resultant dead
space is implicated with hematoma formation and fluid buildup. Use of
drains can help to reduce bruising but is not shown to be effective in
reducing risk of hematoma. Placement of a “hemostatic net” (quilting
sutures dispersed throughout the dissected plane) has been shown to reduce
hematoma risk in all patients when compared with a control group [164,
165].
Fibrin tissue sealants are another option to mitigate fluid buildup and
reduce open planes of tissue. While there is no conclusive evidence to
determine its efficacy in hematoma reduction, fibrin glue is well utilized in
prevention of drainage, ecchymosis (bruising), or facial edema [166].
Directly after the procedure, surgeons treat the wound with antibiotic
ointment and apply pressure dressings, which help to mitigate the formation
of hematomas. Drains are removed after 24hours if placed, as well as the
compressive dressings.
Patients are cautioned against strenuous activities throughout the
healing process, and instructed to sleep with their head elevated. Pressure
on the sinuses should be avoided, such as with nose-blowing, until the
tissues are sufficiently stabilized [167].
4.4 Complications and Outcomes
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The vast majority of individuals undergoing rhytidectomy are older than 50,
and one third fall above age 65. There have been numerous studies
conducted to determine whether age incurs additional risks to patients
undergoing rhytidectomy, although the data is inconclusive. Despite a
higher risk classification by American Society of Anesthesiology standards,
different age groups experience similar rates of postoperative and
intraoperative complications [168, 169].
The most common complication of rhytidectomy is hematoma
formation, which occurs more in male patients compared with female
patients [170]. This risk is additionally increased in patients who are current
tobacco users, use NSAIDS/blood thinners regularly, or are chronically
hypertensive. Severe hematomas can be detrimental to the vascularity of the
transposed skin flap, leading to necrosis in some cases. Hematoma
formation generally occurs in the first 24h after surgery and should be
surgically corrected to avoid long-term disfiguration and pigmentation
abnormalities [171]. Use of perioperative clonidine has been shown to
reduce the risk of hematoma formation for male patients, and postoperative
intravenous administration of labetolol and hydralazine is effective for both
genders [172–174]. In a study conducted by Jones et al., the use of
tumescent solutions without epinephrine has been shown to eliminate the
risk of hematoma requiring surgical excavation [175].
Residual effects of injected anesthesia can produce temporary muscle
weakness and facial asymmetry, although this should resolve within a few
hours. If these defects persist, they may be attributed to thermal injury from
vessel cautery, poor suture placement/use of traction, or damage to the
distal SMAS. Usually, nerve damage from these events resolves in
4months, although patients should monitor for any additional symptoms
[176]. The likelihood of injury to sensory or motor nerves is often related to
the surgical technique. Temporary facial nerve injury is indicated by
transient muscle weakness, and this risk is increased with use of high lateral
SMAS facelift. The relative risk of permanent nerve injury remains
consistent regardless of technique utilized [177].
Hematoma formation may increase the risk of skin necrosis, although
this is a very rare complication. Active tobacco use is by far the most
common risk factor for impaired healing, and additional risks include
excessive tension at the site of flap closure, thin flaps, active excessive skin
dissection/undermining past the nasolabial folds. These factors are much
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more likely to impair the wound healing and induce minor skin slough after
surgery [178–180].
Infection after surgery is relatively rare and can often be attributed to
Staphylococcus aureus bacteria. The length of the surgery is an indication
for antibiotic prophylaxis, and some surgeons will swab the nose for MRSA
cultures to identify whether Vancomycin should be used as a prophylactic
antibiotic treatment. Generally, non-MRSA carriers are treated with
intravenous cephalosporin one hour prior to surgery [181, 182]. Rarely,
patients may develop deep vein thrombosis and pulmonary embolus,
although data from 2020 suggests that only 0.01% of patients are affected
[183]. If the parotid gland is damaged during the operation, patients are at
risk of developing parotid fistulas (sialoceles). It should be noted that very
few cases have been reported, with only 24 documented in the literature as
of 2012 [184].
FACE-Q is a questionnaire administered to patients to assess their
satisfaction with appearance and functionality, as well as the impact on their
life (social, psychological) and daily activities. There are different sets of
questions targeted to each specific cosmetic procedure. In general, patients
are very satisfied with the results of rhytidectomy, and very few experience
severe or life-threatening complications. Multiple reviews show that over
80% of patients are satisfied with their appearance after surgery, and report
feeling/looking 6–8years younger. Of all patients surveyed, more were
satisfied with the appearance of the nasolabial folds, cheek, and jawline
compared to the neck. Overall, more than 90% were satisfied with their
decision to pursue this procedure [185, 186].
Superficial (subcutaneous) facelift surgery does not produce consistent
aesthetic improvement in the long term, due to the subsequent loosening of
skin and underlying subcutaneous tissue ptosis [187]. MACS-lift is an
improved minimally invasive technique with less scarring, allowing for
hairstyle flexibility. The relatively quick recovery period and ability to
correct deeper subcutaneous tissues in the neck and face lends to improved
patient satisfaction. Figure 28 shows one male patient’s results of
simultaneous facelift and platysmal plication [159].
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Fig. 28 Facelift and platysmal plication was performed in the male patient, with the (a) preoperative
appearance and (b) postoperative results [158]
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