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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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3 Rhinoplasty
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ab
Fig. 3.39
a Before: A 28-year-old patient with a long nose and nasal hump
b After: 12 months after septorhinoplasty
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ab
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3 Rhinoplasty
cd
Fig. 3.40
a, cBefore:A26-year-oldpatientwithawide,longnoseandnasalhump
b, d After: The same patient 12 months after septorhinoplasty and cheek remodeling
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3 Rhinoplasty
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ab
Fig. 3.41
a Before: An 18-year-old patient with a long nose
b After: The same patient 12 months after a aesthetic rhinoplasty
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ab
Fig. 3.42
a Before: A 28-year-old patient with a nasal bump
b After: The same patient 12 months after septorhinoplasty
Tips and Tricks
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In the film (time code 6:31), maximum cartilage removal is shown,
such as is carried out by Prof. Mang only in exceptional cases where
there is thick nasal skin. As a rule, removal of nasal tip and lateral
nasal cartilage should be carried out moderately, carefully , and
according to the individual. As a novice you should take care here!
Note
Nasal mucosa and the nasal valve are alwa ys maintained intact by an
experienced nasal surgeon. This is the most important point in the
method for correction of the nasal tip according to Mang.
– Basal and transversal osteotomies are only carried out once all of
the work on the soft tissue of the nose has been concluded. If this
is carried out too early, then there will be severe swelling which
makes accurate correction of the soft tissue impossible.
– Tension-free closure of the incisions is indispensable to prevent
latermalformationsandscarformation:Theextremelysensitive
region of the nasal vestibule must be reproduced in an anatomically correct manner, the function of the nasal valve must be
maintained, and a possible postoperative suction phenomenon
must be preven ted.
3 Rhinoplasty
– In patients with primarily long noses with bumps, we generally
(> 90%) use an endonasal technique.
– In patients with noses requiring revision and patients with a cleft
lip and palate, the extranasal technique is used (statistically
< 10%).
– Changing the plaster is carried out after 6–8 days; the second
plaster is removed by the patient themselves after a further 6 days.
If appropriate, changing the plaster need not be carried out; the
patient can then remove the plaster that has been applied after 10
days.
– We use 4.0 Vicryl rapid as suture material. These sutures can,
however do not have to, be removed.
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4 Rhytidectomy (Cervicobuccal Plasty)
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Standard Operation:
Extended Supraplatysmal Plane Lifting (ESP) Using the T umescence Technique
Transection ofall Osteodermal Ligaments and Dissection
of a Cervicofacial Lipocutaneous Flap Following Tumescence
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Introduction 66
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Anatomical Overviews 68
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Instruments and Medication 72
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Duplicate Patient Instruction and Photographic Documentation 77
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Surgical Planning 77
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Premedication 77
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Anesthesia with Hypotension 78
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Tumescence of the Face and Neck 78
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The Mang Method of Tumescence Rhytidectomy 82
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Liposuction and Undermining with the Suction Instruments 84
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Endoscopic Brow Lift 86
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Stage 1 Rhytidectomy (30 –40 Age Group) 88
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Stage 2 Rhytidectomy (40 –45 Age Group) 90
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Stage 3 Rhytidectomy (45 –50 Age Group) 92
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Stage 4 Rhytidectomy (50 –Plus Age Group) – Standard Facelift 96
Incision Lines 96
Dissection of the Lipocutaneous Flap 100
Dissection of the Cheeks and Neck 106
Deep Dissection and Exposure of the Platysma 110
Visualization of Osteodermal Ligaments 110
Wound Trimming and Wound Sealing with Fibrin Adhesive 114
Skin Tightening 116
Skin Incision and Placement of Key Sutures 118
Subcutaneous Wound Closure 128
Temporal Flap Resection and Sutures 130
Periauricular Wound Closure 134
Retroauricular Skin Resection, Redon Drain, and Wound Closure 136
Identical Approach on the Contralateral Side 140
Special Bandaging Technique 140
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PostoperativeCareandPrecautions 141
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Mini Lift 146
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Tips and Tricks: Rhytidectomy 161
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Tips and Tricks: M-Lifting 162
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Results 143, 159
4 Rhytidectomy (Cervicobuccal Plasty)
The symbol indicates parts of the procedures shown in the video
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4 Rhytidectomy (Cervicobuccal Plasty)
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Introduction
It is not known exactly when the first facelift was performed. This procedure has its origins in Europe in the nineteenth century. However, the
first facelifts consisted of only a minimal resection in which strips of
skin were removed in front of the ears. Over the years, the dissection
performed during facelifts has ventured into ever deeper anatomical
layers. To date, procedures involving five different anatomical levels of
dissection have been described:
1. Superficial facelift: Only a cutaneous flap with a small percentage of
fat is dissected. However, a large number of blood vessels – in particular in the subdermal plexus – are destroyed by this type of dissection.
The fat responsible for drooping cheeks and deep nasolabial folds is left
in place, however , leading to poor aesthetic results.
2. Midsubcutaneous facelift: A larger percentage of fat is left in the
cutaneous flap, but a fatty layer also remains on the platysma as well.
This dissection layer does not correspond to any natural anatomical
layer either, which means that important vessels are also destroyed
when this technique is used.
3. Subplatysmal facelift: Dissection is performed directly under the
superficial musculo-apone ur o tic system (SMAS).
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4. Subperiosteal lift: Dissection is performed directly on the bone.
5. Supraplatysmal lift: Dissection is carried out directly on the SMAS.
Whereas no fat is left on the platysma with this technique, a thick, wellvascularized lipocutaneous flap is formed. This technique permits the
release of all five osteodermal supporting ligaments (i.e., malar,
parotid, masseteric, inferior distal zygomatic, and mandibular) and the
repositioning of the five facial fat compartments (malar, labial, double
chin,cheekregion,droopingcheeks).
This facelift technique is based on the simple, but logical principle that
facial aging is due to the sagging of skin and fat and not to loosening of
the SMAS; we believe that the platysmal aponeurosis is too thin to
make a significant contribution to facial ptosis. This is analogous to
ptosis of the breast, which is not caused by sagging of the pectoral muscle but to the force of gravity and the decreased resiliency of the cutaneous and glandular tissue.
This “tumescence facelift” offers great advantages. Following the application of about 250 ml of a saline solution to each side of the face
(+epinephrine+Xylonest+triamcinolonhydrochloride) to achieve
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tumescence, the entire face is suctioned with mini-needles. The great
advantage of this method is that the surgeon can locate the correct anatomical layer effortlessly. This is because the fine-suction needles which
are inserted into the tissue without pressure gravitate automatically to
the area with the lowest resistance, i.e., the fatty tissue. Whereas the
infrastructural supporting tissue remains fully intact, the SMAS is
stripped of all fat. The actual dissection work then takes place quickly
and, most importantly , with virtually no loss of blood.
We have been performing extended supraplatysmal plane (ESP) tumescence facelifts for 10 years now with outstanding results. We have standardized this method, and it is now easy to reproduce, involves practically no loss of blood, is gentle to the facial structures, and produces
good long-term results. The tumescence technique introduced here
makes dissection distinctly easier; this is a great advantage, especially
for beginners.
An important point to bear in mind is that the aim of every facelift procedure should be to attain a natural and not a mask-like appearance.
4 Rhytidectomy (Cervicobuccal Plasty)
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Anatomical Overview (Fig. 4.1)
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4 Rhytidectomy (Cervicobuccal Plasty)
1. Superficial temporal artery and vein,
frontal branch
2. Epicranial muscle, occipitofrontal
muscle, highest nuchal line
of occipital bone
3. Supraorbital artery
4. Superciliary depressor muscle
5. Supratrochlear artery
6. Aponeurotic structure of the scalp
7. Procerus muscle
8. Supratrochlear nerve
9. Superciliary corrugator muscle
10. Supraorbital nerve,
medial and lateral branches
11. Nasal bone
12. Zygomaticofacial nerve
13. Zygomatic bone
14. Zygomatic branches of facial nerve
15. Infraorbital nerve
16. Parotid gland
17. Infraorbital nerve
(anastomosis with facial nerve)
18. Levator muscle of angle of mouth
19. Masseter muscle, zygomatic process
of maxilla and lower border
of zygomatic arch
20. Buccinator muscle
21. Buccal branch of facial nerve
22. Orbicular muscle of mouth
23. Marginal mandibular branch
of facial nerve
24. External jugular vein
25. Sternocleidomastoid muscle
26. Thyrohyoid membrane
27. Transverse nerve of neck
28. Thyroid gland
29. Cricoid cartilage
30. Thyroid cartilage
31. Median thyrohyoid ligament
32. Platysma
33. Mentalis muscle
34. Depressor muscle of lower lip
35. Mental branch
of inferior alveolar artery
36. Depressor muscle of angle of mouth
37. Risorius muscle
38. Depressor muscle of septum
39. Levator muscle of angle of mouth
40. Levator muscleof upper lip
and ala of nose
41. Greater zygomatic muscle
42. Lesser zygomatic muscle
43. Levator muscle of upper lip
44. Facial artery and vein,
lateral nasal branch
45. Nasal muscle
46. Facial artery and vein
47. Medial palpebral ligament
48. Superior palpebral sulcus
49. Orbicular muscle of eye,
lateral canthus
50. Angular artery and vein
51. Orbicular muscle of eye,
medial margin of orbit
52. Superficial temporalartery and vein,
parietal branch
53. Temporal muscle
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Fig. 4.1
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