Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4436_Библиотеки_им_академика_М_И_Перельмана
.pdf
7.3 Technique
https://t.me/medicina_free
motor nerve damage and dehiscence of the platysma over the submandibular gland where support
is of paramount importance. Superior or caudal
dissection from this zone is avoided because this
will likely end in a plane deep to the mimetic
muscles.
The midface dissection is performed next. A fluid release encompassing the entire platysma–
SMAS complex allows the most natural, vertical,
and tension-free lift. Again, the facelift retractor
and Steven’s Kaye scissors are used to bluntly dissect in an inferomedial direction directly atop the
zygomaticus muscles. The orbicularis oculi muscle
may overlay the muscles. Dissection may be carried over the plane of the lower orbicularis as well,
although the SMAS is very thin and difficult to dissect this far superiorly. The zygomatic dissection is
carried toward the nasolabial fold while using a
combination of sensation and vision to guide progress in the correct plane. Once complete, the remaining decussation zone at the junction of the
SMAS and facial platysma must be performed to
join the upper and lower dissections. This zone
may be roughly 1 to 2 cm broad, including the
zygomaticocutaneous ligaments at the lateral
superior border and the buccal retaining ligaments
following the course of the parotid duct and fat
pad at the caudal border of the zygomaticus major
muscle.
To complete the release of the SMAS–platysma
complex, the cer vical retaining ligaments are released next. Again, this is a fibrous decussation
zone between the lateral platysma and the deep
cervical fascia overlying the SCM muscle. The
superior extent is marked by the lateral platysmal
line at the gonial angle, while the inferior portion
of the dense tissues terminates at the crossing of
the external jugular vein a s it transverses beneath
the platysma. Inferior to this point, only loose connections exist. A partial incision is performed
using a no. 15 blade scalpel and serially continued
with the flap on superior tension using DeBakey
forceps. Incision is continued until the platysma
fibers begin to splay. Blunt dissection is then used
to complete the dissection and release in order to
avoid any marginal or cervical facial nerve branch
damage. Dissection must not carry past the plane
of the facial artery in order to avoid nerve damage
and platysmal dehiscence.
Irrigation is again performed at this point using
antibiotic solution followed by the dilute Dakin’s
solution. Meticulous hemostasis is then obtained
using bipolar electrocautery. The shelf along the
deep plane entry point is matured with blunt dissection to deliver a 5-mm flap for suturing. Excessive dissection may compromise blood flow to the
distal dermal–epidermal flap. Suspension is then
performed along the facial deep plane entry points
prior to finalizing the neck suspension. The most
substantial benefit of using a comprehensive release is that the angle or vector of lifting need not
be determined with guesswork or by reading
articles discussing angles of lif ting. The direction
of lifting is uniquely determined by the vector of
descent for each individual. This typically occurs in
a pendular fashion, and the vectors of descent vary
from patient to patient and from one side of the
face to the other. Hence, the suspension vector that
provides the greatest amount of lift and distraction should be used. To determine the anchoring
position intraoperatively, a horizontal mattress is
placed through the flap and elevated with one side
of the suture being pulled at 90 degrees vertical
and the other at 45 degrees. The resultant angle
typically ranges around 70 degrees, which is a useful guideline for novice facelifting surgeons. One
must gauge this vector by observing tactile feedback to move in the direction of least resistance,
without pleating on either side of the suture pull.
Of note, this vector typically pulls against a perpendicular plane that extends from the nasolabial
fold, down the prejowl fold, and continuing to the
submandibular triangle. The vectors of aging in the
face and neck equally demonstrate ptosis along
this line. The most effective and restorative technique for lifting should pull directly perpendicular to
this line.
Six points of suspension are used on the face
beginning with 2 ×3–0 nylon sutures on the facial
platysma. Drawing these sutures upward in the
proper vector will result in an immediate and visible improvement in the submandibular triangle.
These sutures are left tacked and hanging. Next,
2×4–0 nylon sutures are placed on the vertical
limb of the sailboat line of the SMAS and 2 ×5–0
nylon sutures on the horizontal limb. All sutures
are drawn superiorly and anchored to a dense point
along the border of the ear or temporal incision.
Lore’s fascia, also known as the temporoparotid or
tympanoparotid fascia is a dense fibrous region that
exists around the preauricular region and allows for
more predictable and secure lifting without any
descent of soft tissues during healing.
sutures may be used as well with minimal potential
11
Absorbable
77
Deep Plane Neck Lift Concepts and Technique
https://t.me/medicina_free
of causing an inflammatory response during the hydrolysis phase of absorption. The knots are secured
sequentially and without any tension on the SMAS–
platysma complex to avoid compromise of vascularity to the distal flap (▶ Fig. 7.3).
The cervical platysma is suspended next. The
intent is to lift this as vertically as possible while internalizing the insertion point and providing depth
beneath the gonial angle. The tacking point of the
platysma superiorly should mirror the insertion
and angle of the posterior belly of the digastric. A
vector of roughly 85–90 degrees in the vertical
plane should be followed. Forty-five degree or lateral pull will result with lateral distraction of the submentum rather than tucking and internalization of
the submandibular triangle contents. This will appear as a digastric and submandibular gland bulge
postoperatively. The tacking point of the platysma
superiorly should move as vertically as possible
while tucked deep to the gonial angle and pulling
from a point above the horizontal plane of the
hyoid. The most effective point of insertion thus lies
at the anterior border of the mastoid bone. To gain
adequate exposure, a crevasse is formed vertically
along the anterior border of the mastoid. The mastoid crevasse provides greater depth, a higher anchoring point for more vertical elevation, a secure
point of attachment to avoid drooping or medialization of the posterior hairline, and a continuous line
of depth from the hyoid extending to the mastoid
once the platysma is pulled into place.
9
This also
provides a method of creating depth around the gonial angle without cutting away tissue, which could
damage the greater auricular or facial nerve. The
parotid gland is also re-compartmentalized and left
unexposed, slimming the entire jawline and avoiding risk of gustatory sweating. The crevasse is
formed using monopolar needle tip electrocautery
along the vertical line of the anterior border of the
mastoid bone extending from the conchal bowl
superiorly to the insertion of the SCM inferiorly. The
dissection typically carries 5 to 7 mm deep and 15 to
20 mm in height. A 2-mm back and fore cut may be
made at the superior extent if needed. This is a safe
zone to incise and excava te as the anterior branch of
the greater auricular nerve typically lays 8 to 12 mm
anterior and the posterior branch 4 to 10 mm posterior to the anterior mastoid line (▶Fig. 7.4).
Prior to securing the platysma, the muscle is
pulled superiorly and deep around the gonial
angle, and a partial myotomy is performed. The myotomy is placed along the inferior border of the gonial angle to permit stretching of the muscle around
the mandible, which provides greater relative depth
Deep sutures
ab
Fig. 7.3 A demonstration of the “sailboat” modification of the deep plane entry point. This modification allows for greater
preservation of vascularity to the skin along with preservation of volume and lymphatic flow in the area of the flap.
(a) Design of this modification, whereby the entry point follows the shape of the hairline and periauricular incisions on the
face. (b) Once lifted, the flap preserves the greatest volume right over the cheek, the area where greatest preservation of
volume is valuable. The lower platysmal sutures have some tension because they are not connected to skin.
78
Lift
7.3 Technique
https://t.me/medicina_free
Partial
platysmal
mytomy
a b
the mastoid
Posterior
fascia
Incision
Platysma
inset
Great auricular nerveMastoid
Line of hyoidT-incision over
Platysma muscle
Anterior fascia
Parotid gland
Sternocleidomastoid
muscle
cd
Platysma inset
into T-incision
Inward vector,
toward the airway
60°
Deep
sutures
Lift
Medial vector,
pushing into the
anterior wall of
the mastoid tip
Upward vector,
into the neckline
Fig. 7.4 (a– e) A demonstration of the Crevasse techniqu e as described, with an incision in the mastoid fascia to allow
for inset of the platysma, as well as a true deepening of the neckline, bringing the tissues up and in to better expose
the mandible and ja wline. This helps tuck the parotid and the submandibular glands into place, in essence restoring
the balance of the lower face by recreating the platysmal sling and reorienting the vectors in alignment with the
digastrics.
(Continued)
79
Deep Plane Neck Lift Concepts and Technique
https://t.me/medicina_free
Anterior border
of mastoid
Mastoid process
Posterior digastric
muscle belly
e
Lateral facial sling
on hyoid bone
Platysma muscle
Fig. 7.4 (e) (Continued)
Anterior digastric
muscle belly
while still encapsulating and slimming the area
around the parotid gland. Next, the platysma is purchased with a 2–0 Mersilene horizontal mattress
suture at a point roughly in line with the horizontal
plane of the hyoid. A second supporting suture is
placed just inferior to this. The superior suture is
then lifted as vertically as possible while securing
to the superior and internal border of the mastoid
bone. Tension with lifting is permissible along the
platysma as it has been detached from the skin and
has no risk of vascular compromise.
At this point, the facial soft tissues along with
the cervical contents have all been lifted and skin
simply needs to be trimmed without excess and
without tension. The peak of the skin flap that began at the helical root is lifted in the same vector
as the SMA S was lif ted in. Biplanar or multivector
lifting should be avoided as this will leave excess
in some areas and age poorly. A tacking suture is
thrown using a 4–0 nylon suture without any
tension. Tenets of redistribution of tension have
proven repeatedly to cause scarring with other
facelifting techniques. The skin overlying the temporal tuft is then trimmed, avoiding removal of
skin anterior to the temporal tuft, which would
cause undue tension, scarring, and hair loss. The
anterior limb of the temporal t uft is a zone of redistribution, and interrupted or vertical mattress
sutures should be used. A 10-Fr round drain is
then placed in the neck, remaining only overnight,
to lessen bruising and provide negative pressure
for skin adherence. The postauricular flap is then
elevated and tacked to the highest incision point in
the postauricular crease. Again, this is elevated in
the same vector of lifting and where maximal vertical and horizontal distraction is noted. The skin
flap posterior to this suture over the mastoid bowl
should be pulled vertically and trimmed. Inadvertent lateral or superolateral lifting will result in a
dog-ear and an excessively long incision that must
be chased along the posterior hairline. Of note, the
posterior hairline continues inferior and posteriorly along the scalp hairs at the base of the occipital bone and not the nape hairs, which are inferior
to this. Finally, the skin around the ear is trimmed,
again without any tension and with the neck skin
kissing the base of the earlobe. The zone around
the anterior earlobe is also a point of redistribution and closure should be performed by zipping
downward from the tragus to the base of the earlobe to avoid pleating within the lobe. Following
closure, the flaps are milked to remove any fluid.
Two percent nitroglycerine cream or ointment is
placed along the lateral skin flaps to reverse the
effects of epinephrine and overall ischemic time as
well as to lower the postoperative blood pressure.
80
Video 7.1 Deep plane neck lift.
https://t.me/medicina_free
A cotton-cushioned cling wrap is p laced overnight to provide minimal compression and avoid
accumulation of fluid in the dead spaces. This is
removed the next morning, and no further compression is required. A summarized version of the
deep plane face and neck lift technique is shown
in ▶ Video 7.1.
7.3.2 Internal Neck Lift
The internal neck lift combined with the RF treatment in our practice is called a “weekend lift.” The
procedure typically takes 1 hour and may be performed under local or deep sedation anesthesia.
Incisions are placed similarly in the submental
crease for submental access and from the frontal
base of the earlobe extending halfway up behind
the ear. These incisions improve access without
leading to visible exposure. They are good options
for patients seeking lifting of the neck who do not
require any substantial improvements above the
jowls or removal of skin. The jowls may improve
from a combination of RF skin tightening and offloading of the jawline. The concept of off-loading
is noted during facelifts as the brow may rise in
the absence of the downward tension from a ptotic
cheek. In the neck, the effect may be observed as
the jowls and jawline lift slightly in the absence of
neck drooping. Downtime and incisions are minimal using this technique.
A submental incision is performed to mirror the
procedure described for the deep plane face and
neck lift. Once the submental work is complete,
the lateral access points are opened by placing an
incision around the earlobe extending up the postauricular crease to the point where the mastoid
flattens at the insertion of the temporalis muscle.
Subcutaneous dissection is performed to connect
7.4 How to Avoid Bad Results/Common Pitfalls
the lateral and central cavities. The lateral platysma
is then marked along the line of the cervical
retaining ligaments extending from the lateral border of the platysma over the mandible superiorly
down to the crossing point of the external jugular
vein. The line is put on tension and scored using a
no. 15 blade scalpel until the internal side of the
deep cervical fascia is seen. Blunt dissection is then
performed for 3 to 4cm.
The cavity is then irrigated and hemostasis is
obtained. A very gentle partial myotomy may be
performed to allow the platysma to wrap around
the gonial angle if needed. Full myotomy must be
avoided as the deep side has not been fully dissected to avoid nerve injury. The platysma is then
suspended in a similar fashion as described earlier.
The contralateral dissection and elevation must
then be performed prior to skin closure to avoid
unnecessary trimming of skin while the neck is
pulled to one side. After both sides have been lifted
and the position of the neck has been neutralized,
the skin is closed. Minimal skin excision may be
performed as needed. Drains are inserted overnight as well.
Prior to or following the procedure, Profound RF
is used to tighten the skin quality of the face and
neck. This contributes to an overall improvement
in appearance and reduces the chance of irregularities or redundancy in the neck skin. Results improved over 12 months as increasing amounts of
elastin, hyaluronic acid, and collagen are formed.
Standard dressings are then applied overnight, including head and neck wrap with light compression (▶ Fig. 7.5).
7.4 How to Avoid Bad Results/
Common Pitfalls
It is crucial to completely release the deep structures.
Partial release will lead to a poor or compromised
result, and will often l ead to unnatural-looking
necks, or animation deformities. The steps above
allow the avoidance of these problems. Additionally, overtightening the platysma centrally may
lead to the inability to laterally tighten the neck
appropriately.
be avoided to minimize chance of irregularit ies,
vascular compromise, and postoperative neovascularization. Limiting or hiding incisions in face
and neck lifting may inadvertently lead to more
scarring, limitations in lifting, and poorer overall
12
Excess skin dissect ion must also
81
Deep Plane Neck Lift Concepts and Technique
https://t.me/medicina_free
Lateral access
incision
Submental
incision
Blue lighted
Platysmal
window
ba
facelift retractor
Fig. 7.5 (a,b) A demonstration of the modifications to incisions for the direct neck lift or “weekend lift” procedure,
which is essentially a minimal access incision from the submentum along with a postauricular incision, which comes
around the front of the earlobe and up approximately 4 mm. This incision is for access to the deep neck, not for excess
skin removal. It is a good option for young patients with deeper neck struc ture ptosis and good skin and is best
performed in conjunction with radiofrequency microneedlin g either before or after the procedure.
results. Tension must be avoided in the deep
plane closure as well as in the skin closure. Soft
tissues will eventually drop if any tension is
present. Performi ng a deep plane lift permits
dissociation of the SMA S from the mimetic musculature, avoiding the often-overlooked dynamic
facial changes and untoward pull lines seen in
some SMAS plication techniques.
7.5 Case Examples
7.5.1 Case 1
(▶ Fig. 7.6)
This 56-year-old patient was treated with a
deep plane face and neck lift in combination with
a blepharoplasty and modified lip lift. Note the
deepening of the jawline and improvement in the
lateral photographs. Shown is a 1-year result.
7.5.2 Case 2
(▶ Fig. 7.7)
This 58-year-old man elected to have a deep
plane face and neck lift to improve the excess skin
and laxity of the jawline. His postoperative views
demonstrate improved balance and facial harmony. This is a 6-month result.
7.5.3 Case 3
(▶ Fig. 7.8)
This 34-year-old patient presented with excess
heaviness in the lower face. She was treated with a
combination of a lower face and neck lift through a
limited preauricular incision with minimal skin resection. This was performed in concert with Profound RF microneedling to improve skin texture
and collagen. This is a 10-month result.
82
7.5 Case Examples
https://t.me/medicina_free
Fig. 7.6 (a– e) 56-year-old patient pre- and post-deep plane face and neck lift, upper and lower blepharoplasty and lip lift.
83
Deep Plane Neck Lift Concepts and Technique
https://t.me/medicina_free
Fig. 7.7 (a– e) 58-year-old patient pre- and post-deep plane face and neck lift.
84
7.6 Expert Commentary by Dr. Slavin
https://t.me/medicina_free
Fig. 7.8 (a– c) 34-year-old patient pre- and post-deep plane internal neck lift and Profound radiofrequency.
7.5.4 Case 4
(▶ Fig. 7.9)
This 51-year-old patient had a full face and neck
lift with blepharoplasty to address the signs of
aging. She has great improvement in jawline and
the depth of her neckline from the lateral view.
7.5.5 Case 5
(▶ Fig. 7.10)
This 37-year-old patient had a limited incision
weekend lift performed with deep plane neck lift
in combination with a symmetrizing modified lip
lift procedure. Post-op, the neck is lighter and
more balanced, and all of her features are more
natural and balanced.
7.6 Expert Commentary by
Dr. Slavin
We commend the authors on an excellent chapter.
The authors’ description of their deep plane techni-
que successfully rearranges soft tissues (and skin)
to a degree that less extensive techniques may not
85
Deep Plane Neck Lift Concepts and Technique
https://t.me/medicina_free
Fig. 7.9 (a– e) 51-year-old patient pre- and post-deep plane face and neck lift and upper blepharoplasty.
86
Соседние файлы в папке Библиотека им академика М.И. Перельмана