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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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4 Rhytidectomy (Cervicobuccal Plasty)
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䊏
After tumescence has been achieved in the forehead and cheeks, the
lipocutaneous flap of the neck is separated in a fan-shaped pattern
from the platysma. The neck represents the caudal boundary here.
During this procedure, the assisting surgeon overextends the patient’s
head to protect anatomical structures such as the thyroid cartilage, the
thyroid gland, and the large vessels in the neck.
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Laterally, tumescence is carried out up to the level of the anterior edge
of the trapezoid muscle.
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The picture shows the status following tumescence of the right half of
theface;tumescencehasnotyetbeenachievedontheleftside.(Fig.4.7)
The com plications described by Ramirez following tumescence in the
facial area do not occur under the following conditions:
–e180 ml is injected on each side of the face;
– about 20 min aftertumescence, the tumefied area isundermined and
carefully suctioned with 1.5–1.8 mm facial cannulas;
– smokers undergo stringent screening todetermine their suitability
for the procedure.
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Fig. 4.7
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The Mang Method of Tumescence Rhytidectomy
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A review of more than 1000 rhytidectomy procedur es performed with
the Mang method shows that this face-lifting procedure produces better
results and fewer complications. Even the novice aesthetic surgeon has
fewer problems finding the target layer for dissection following prior
tumescence. For rhytidectomies in male patients, in particular, the
tumescence technique offers enormous advantages; the tissue is loosened, dissection is made much easier, and the tightening effect is markedly enhanced.
4 Rhytidectomy (Cervicobuccal Plasty)
The use of the tumescence technique is therefore highly advantageous
for the aesthetic surgeon learning how to perform rhytidectomies.
Thanks to the “preliminary dissection” with the suction cannula, most
of the skin can be detached bluntly with a dissection swab.
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The basic incision lines serve as guidelines; they should be modified in
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each individual case to take account of the patient’s age and the degree
offlacciditydisplayedbyhisorherskin.Sincestage4rhytidectomyis
the most frequently performed face-lifting procedur e, this method is
shown in detail in the video film.
We have developed our own cannulas (a 1.2-mm straight cannula and a
1.8-mm bent cannula) for facial suction. Using these specially designed
cannulas, we are able to carry out suction of the entire face after it
has been “watered” with appr ox. 350 ml of tumescence solution. Nine
2-mm-wide microincisions are made in the face; tumescence is then
carried out diagonal to these incisions and suction is performed selectively following a precise grid.
What is decisive here is less the liposuction than the separation of the
“ en tire facial skin from the underlying tissue and the selective, diagonal
perforation of the subcutaneous tissue. ”
4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
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Liposuction and Undermining with the Suction Instruments (Fig. 4.8, 4.9)
䊏
Using a number 15 scalpel, the surgeon makes one to two incisions in
the upper submental transverse fold. From this location, the surgeon
predissects about 2 cm with the blunt dissecting scissors.
䊏
The assisting surgeon overextends the patient’s head with one hand and
smoothes the skin of the neck with the palm of the other hand. Using
thebluntsuctionneedle,thesurgeoncannowundermine,dissect,and
remove excess fat.
䊏
During this procedure, the surgeon’s left palm presses gently on the tissue to be suctioned; at the same time he or she undermines, dissects,
and suctions with the right hand. These activities are carried out without force,as if one were guiding the bow of aviolin.
The decisive advantage of this method is that it makes the subsequent
dissection work significantly easier , since the target lay er has already
been identified by the numerous perforations, which give it the appearance of Swiss cheese. As a result, dissection can be carried out in a substantially shorter period of time and with distinctly less blood loss.
At the same time, the tightening effect exerted on the skin is intensified;
the removal of fat cells results in fibrosis and, thus, tightening of the
subcutaneous tissue.
This is especially true in the forehead region, where – similar to the procedure followed during an endoscop ic lift – the skin is detached with the
suction needle following tumescence and can then be fixed with a screw.
䊏
Following liposuction of the neck and double chin, the cheeks are
undermined in a fan-shaped pattern via an incision in the skin fold in
front ofthe tragus.
The boundaries here are the nasolabial fold, the caudal bony orbital
marginsand2cmlateraltothecornerofthemouth.Thecourseofthe
mandibular branch of the facial nerve should be avoided. From the
same incision, the lateral portion of the neck is undermined and liposuction performed up to the front edge of the trapezoid muscle.
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Suction dissection of the forehead is carried out following one lateral
incision on the right and left side, respectively, and a medial incision
about 2 cm behind the hairline. During this dissection, as during the
tumescence, the supraorbital foramen is excluded.
䊏
At the end of the suction procedure, the entire lipocutaneous flap is
detached from the underlying structures; care should be taken to preserve the supporting tissue as well as blood vessels and nerves.
If the excess facial skin is not too voluminous, which is usually the case
in patients under45 years of age,good aesthetic resultscan be achieved
with tumescence dissection alone.
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Fig. 4.8
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4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.9
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4 Rhytidectomy (Cervicobuccal Plasty)
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There are four different facelift stages; if desired, these procedures can
be combined with an endoscopic brow lift.
Endoscopic Brow Lift (Temporal Tightening) (Fig. 4.10)
The traditional rhytidectomy is frequently combined with an endoscopic brow lift. Here, again, prior tumescence of the tissue (approx.
100 ml) offers the following advantages:
– Easy and fast dissection
– Less bleeding and swelling
Following tumescence five 3-mm-long incisions are made in the haircovered scalp (i.e., at 12 noon, 2 p.m., 3 p.m., 9 p.m., and 10 p.m.); the
entire skin of the forehead (including the periosteum) is detached
under endoscopic control. The detached skin is fixated again postoperatively with a taped bandage or two 5-mm screws. The holes for the
screws can be drilled manually or with an electric drill. It is important
to use a drill with a lock to avoid perforating the skull. The screws are
taken out at the time of suture removal 10 days postoperatively.
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Fig. 4.10 ······· Tumescence margin
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– – – Suction margin
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4 Rhytidectomy (Cervicobuccal Plasty)
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Stage 1 Rhytidectomy (30 – 40 Age Group) (Fig. 4.11)
䊏
Seven incisions (3 mm) are made during stage 1 rhytidectomy performed with the Mang method. The dotted pattern shows the tumescence and/or suction carried out with the 1.2-mm or 1.8-mm facial cannula. The special feature of this technique is that, after the entire face
has been tumefied, the surgeon can find the target layer (i.e., the layer
offering the least resistance) with the blun t swab without using force;
the swab is guided gently like the bow of a violin. The enormous advantageofthistechniqueisthatinjuriestonervesandbloodvesselsare
virtually ruled out.
Endoscop ic examina tio n reveals that fat cells have been selectively
removed while the infrastructural support tissue remains intact. This is
of great importance for the fibrosation or tightening effect since it
brings about an effective tightening of facial skin without skin resection. The decisive points to be observed here are cannula diameter
(1.2 mm to max. 2 mm), correct technique (diagonal undermining),
and the selection of the rhytidectomy stage appropriate for the particular patient.
During a study carried out at our hospital, we observed that various
incision techniques can be used, depending on the patient’s age and
degree of skin flaccidity , to obtain optimal results. Moreover, all of the
rhytidectomy procedures can be performed with local anesthesia.
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Fig. 4.11 ······· Tumescence and suction margin
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