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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)
https://t.me/med1917
Stage 2 Rhytidectomy (40 – 45 Age Group) (Fig. 4.12)
This procedure is performed in younger patients aged 40 years and
above, in whom only the nasolabial and cheek regions have to be
raised.
䊏
This kind of facelift is carried out with a local anesthetic at an outpatient facility.
䊏
Following tumescence and undermining, an approx. 2-cm-long incision
is made along the temporal hairline; it is continued in the preauricular
area up to the lower margin of the tragus. Along this t-shaped incision
line only about 3–5 cm of the lipocutaneous flap are detached in the
preauricular region.
䊏
This small flap is subsequently pulled up almost vertically; it is then
attached to the part of the scalp located cranially to the flap with a
sharpBackhaushook.Theexcessflapisremovedalongthetemporal
hairline. The excess preauricular skin is also removed with the Mang
dissecting scissors.
During any face-lifting procedure, it is important to place the patient’s
head in the center line before tightening the skin in order to achieve
symmetrical results.
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Fig. 4.12 ······· Tumescence and suction margin
https://t.me/med1917
– –– Preparation margin
–––– Incision line
4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
https://t.me/med1917
Stage 3 Rhytidectomy (45 – 50 Age Group) (Fig. 4.13–4.14)
Thismethodisusedinpatientsaged45yearsandolder.Duringthis
procedure, the nasolabial fold and the sagging skin in the mental and
submen tal regions, i.e., “drooping cheeks,” are tightened.
In this age group, lateral facial skin is typically less tight. Drooping
cheeks are a problem. The tightening effect attained with suction and
undermining alone is no longer sufficient; the incision lines must be
extended to achieve good resul ts. The dotted area represents the facial
area that is tumefied and undermined. The incision lines demarcating
the detached area show that this is a minimally invasive procedure.
䊏
We do not make any incisions behind the ear or in the occipital region.
This is very important for people of both sexes with short hair and for
women with upswept hairdos.
䊏
An S-shaped incision is made in the temporal hair region; it is routed
around the auricular lobe and then continued for 2 cm in a retroauricular direction.
䊏
A lipocutaneous flap with the approximate dimensions 4–8 cm is
excised; a technique of sharp dissection followed by blunt dissection is
used here.
䊏
Subsequently, the temporal vascular bundle is exposed and ligated at
the upper pole of the ear. Afterwards, the surgeon goes into the layer
between the two fascial sheets of the temporal muscle above the ligature. As a result, dissection is being performed one layer deeper here
than in the preauricular region; this protects the hair roots.
䊏
Following wound edge trimming, precise hemostasis, flushing with triamincinolene hy dr ochloride 40 (1 ml diluted in 20 ml of 0.9% saline),
and adjustment of the patient’s head to bring it into the center line, the
lipocutaneous flap is pulled cranially in the direction of the ear line (!);
at this location, the cranial end of the flap is attached to the stationary
portion of the scalp with a sharp Backhaus hook.
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Fig. 4.13 ······· Tumescence and suction margin
https://t.me/med1917
– –– Preparation margin
–––– Incision line
4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
https://t.me/med1917
䊏
The“earline”isastraightlineconnectingthelowestpointofthe
auricular lobe with the highest point of the helix. This line shows the
direction of rotation during the facelift procedure (craniofacial rotation
at a 30° angle).
䊏
Afterwards, an incision is made in the excess skin above the tragus with
the dissecting scissors; the skin is then attached with a 3/0 Resolon
interrupted suture. Additional fixation sutures are placed on the upper
and lower auricular poles. The Backhaus hook can now be removed
and the remaining excess skin resected.
䊏
Following repeated hemostasis, wound closure is carried out in two
layers.
During every wound closure, care should be taken that the cutaneous
sutures are not under tension. For this reason, the tension is distributed
among the primary sutures. Only after the wound has been closed
subcutaneously with 3–4/0 PDS sutures is the skin closed with intracutaneous or continuous sutures.
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Fig. 4.14 The “ear line”
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4 Rhytidectomy (Cervicobuccal Plasty)
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4 Rhytidectomy (Cervicobuccal Plasty)
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Stage 4 Rhytidectomy (50-Plus Age Group) – Standard Facelift (ESP Lift)
䊏
(Fig. 4.15–4.53)
During the ESP tumescence rhytidectomy, the skin is detached from
the entire face and neck following prior undermining with 1- to 2-mm
cannulas and tumescence. In this traditional rhytidectomy, the incision
lines depend on the hairline: the incision is made along the hairline in
the temporo-occipital region in patients with a high hairline and in the
hair-bearing scalp in other patients. A thick lipocutaneous flap is dissected directly above the mimicry muscles and the platysma; the skin is
then tightened by craniofacial rotation (30°). A piece of skin up to 6 cm
long is removed.
When this technique is used, no tightening of the SMAS or platysma is
necessary. A 5-year observational and comparison study conducted at
our hospital showed that excellent results are achieved by using the
tumescence-suppo rted ESP technique as a routine measure.
96
The standard facelift procedure is as follows:
䊏
Following tumescence and undermining with 1- to 2-mm facial
cannulas, disinfection, and suction, a metal comb is used to comb and
part the patient’s hair in preparation for the incision (Fig. 4.16). No hair
must be shaved or cut off.
Incision Lines
䊏
These are first drawn with a sterile marking pen.
An important point to bear in mind is that the incision line can – and,
in fact, must – vary, depending on the patient’s individual hairline.
We show here the incision lines made on a patient with a normal
hairline.
······· Tumescence
https://t.me/med1917
and suction
margin
– – – Preparation
margin
–––– Incision line
4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.15
Fig. 4.16
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4 Rhytidectomy (Cervicobuccal Plasty)
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䊏
Using a number 15 blade, the surgeon starts the incision in the preauricular region. While he pulls the patient’s ear in a dorsal fashion, the
assisting surgeon stretches the patient’s facial skin slightly. Now the
incision is continued temporally to the upper curve of the S in the hair
region; the assisting surgeon gently pulls up the hair lying in front of
the incision. The incision is then continued around the auricular lobule
about 2 mm above the retroauricular fold cranially; from here it proceeds above the mastoid into the hair-covered portion of the neck in a
zigzag pattern. (Fig. 4.17)
䊏
The assisting surgeon now inserts the long two-pronged hook in the
retroauricular incision and pulls the auricle slightly to the front. Using
the number 15 blade and then the surgical tweezers, the surgeon can
now detach the skin flap over the mastoid. The tendon of the posterior
auricular muscle and the insertion of the sternocleidomastoid muscle
are exposed. Dissection is continued caudally along this important
anatomical line until the great auricular nerve is reached.
䊏
Dissection must always be carried out under tension.
(Fig. 4.18)
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Fig. 4.17
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4 Rhytidectomy (Cervicobuccal Plasty)
Fig. 4.18
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