Practical Plastic Surgery

ligaments become lax, leading to inferomedial migration of the malar fat pad and formation of the nasolabial fold. The mandibular retaining ligaments arise from the parasymphysial mandibular body and insert into the skin inferior to the insertion of the depressor anguli oris. The mandibular ligaments define the anterior extent of the jowls. The zygomatic and mandibular ligaments are obstacles to surgical maneuvers intended to lift the skin flap and, therefore, both are usually divided.

Malar and Buccal Fat Pad

In a youthful midface, the superior border of the triangular shaped malar fat pad lies along the orbital rim and extends laterally to the zygoma. The lateral border can be identified by drawing a line from the lateral canthus to the lateral commissure. The malar fat pad is located beneath the skin and subcutaneous fat, but it is superficial to the SMAS. It is fibrous and fatty, and it is readily distinguishable from the overlying subcutaneous fat. With advancing age, the malar fat pad slides downward and medially, over the SMAS. Ptosis of the malar fat pad also empties the midface, producing a crescent-shaped hollow at the lower lid-cheek junction. The malar fat pad descent also contributes to the nasojugal and nasolabial folds. To a lesser extent, this displacement also results in the formation of labiomandibular folds (marionette lines) and jowls.

The buccal fat pad lies over the masseter and buccinator muscles, deep to the plane of the parotid duct and facial nerve branches. Medially, it may reach into the pterygopalatine space. It can be approached from a sub-SMAS dissection plane by separating the buccal branches of the facial nerve. Alternatively, it can be approached through the mouth by penetrating the mucosa and buccinator muscle. There are few indications to remove this fat pad because it tends to hollow the cheek giving an aged appearance.

Preoperative Considerations

All patients should receive a complete medical examination by the appropriate specialist, including complete blood counts, metabolic chemistries, EKG and, if indicated, a chest roentgenogram. Patients with diabetes mellitus, hepatic, cardiovascular, renal, or thyroid disorders must have preoperative medical clearance. Patients should be instructed to stop taking alcohol or tobacco products 3 weeks prior to surgery. Aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, Alka Seltzer® and homeopathic remedies should also be discon-

60 tinued 3 weeks prior to surgery.

One of the dreaded complications of the facelift is hematoma. Postoperative nausea and vomiting (PONV) and hypertension are believed to be contributing factors. All patients, unless contraindicated, should receive preoperative antiemetic therapy. For example, preoperative odansetron (Zofran®), 4 mg IV, has been shown to significantly decrease the incidence of PONV. Other less expensive antiemetics are also available. In addition, patients with hypertension should take their medications the morning of surgery. Any patient with even mild hypertension the morning of surgery, should be considered for antihypertensive therapy. Oral clonidine (0.1-0.2 mg) is a commonly used medication for this purpose. The night before surgery, a benzodiazepine can be given (e.g., lorazepam 2 mg) to prevent preoperative anxiety-induced hypertension.

The patient should refrain from using cosmetics, perfumes, aftershave, and moisturizers on the morning of surgery. Hair coloring should not be performed within 10 days of surgery. Make-up should be removed the night before surgery, and the

patient should be instructed to wash their face and shampoo their hair with an antimicrobial soap. It is standard to administer a single intravenous dose of preoperative antibiotics. Antibiotics are generally not required postoperatively.

Surgical Techniques

Skin/Subcutaneous Facelift

Incisions vary and depend on the technique, patient anatomy and hairline and surgeon preference. The temporal incision is generally marked in a curvilinear fashion, just within the temporal hairline and superior to the ear. This avoids any loss or elevation of the temporal hairline. The preauricular incision lies in the natural crease at the junction of the auricle and the face, following the curve of the helical root. The incision can then be continued in either the pretragal crease or behind the tragus. The inferior aspect of the incision is located at the junction of the earlobe and cheek. Curving posteriorly and superiorly around the lobe, the incision is placed in the postauricular crease. The incision then curves tangentially into the occipital hairline at the level of the inferior crus of the antihelix. This incision placement helps prevent a step-off deformity of the posterior hairline.

Flap elevation proceeds in a subcutaneous plane with care taken to avoid hair follicles. Transilluminating the flap can help to maintain the proper dissection plane. Preand postauricular flaps are extended into the neck over the sternocleidomastoid muscle. The great auricular nerve emerges from the anterior border of the sternocleidomastoid muscle 6.5 cm inferior to the external auditory meatus. A separate submental incision may be used to elevate the anterior portion of the cervical flap in a preplatysmal plane. The dissection is limited superiorly by the inferior border of the mandible and inferiorly by the hyoid bone. The preplatysmal plane serves to protect the marginal mandibular nerve as it courses below the mandible. Once elevated the skin is redraped, tailored and inset under limited tension.

The subcutaneous facelift technique is simplest to perform, with the least risk of injury to the facial nerve branches. The skin-only facelift produces good results for thin women with good skin tone and underlying bone structure. It is difficult to obtain a natural look in patients with heavier faces because high skin tension produces a pulled-appearance, wider scars and alopecia. The skin-only facelift has limited application.

60

SMAS/Muscle Facelift

The SMAS facelift begins with the incisions and skin flap elevation as described above. Classically, the SMAS is elevated in the preauricular area, from 1 finger breadth below the zygoma to the lower border of the mandible. The parotideomasseteric fascia is left intact just below the dissection plane, protecting the facial nerve branches. Dissection continues anteriorly to the nasolabial fold, remembering to change the level of dissection at the lateral border of the zygomaticus major muscle. The dissection plane remains superficial to the zygomaticus major muscle and extends inferiorly to the oral commissure. Sharp division of zygomatic and mandibular retaining ligaments allows full mobilization of the skin and soft tissue, facilitating redraping.

In the neck, subplatysmal dissection can be performed to expose the triangular shaped subplatysmal fat pad. After resecting this fat pad under direct vision, the medial edges of the platysma can be trimmed and the diastasis closed. The muscle sling should be securely plicated in order to correct the platysmal banding.

After completing the dissection, the SMAS is lifted in a vector parallel to the zygomaticus major, trimmed and inset. The skin is then redraped in a vector perpendicular to the nasolabial fold. It is critical that the skin is inset tension-free. The advantage of a SMAS/muscle facelift over a skin only lift is the ability to independently control the vectors of the deep tissues and skin. Moreover, since the lift is based on the SMAS, the skin can be trimmed and inset without tension. There are many variations of this technique which include the limited SMAS, extended SMAS and lateral SMASectomy.

Deep Plane Facelift

Deep plane facelift refers to sub-SMAS dissection without significant undermining in the subcutaneous plane. The subcutaneous dissection is carried approximately 2-3 cm in front of the tragus, from zygoma to the jaw line. The sub-SMAS plane is dissected beyond the nasolabial fold, exposing the orbicularis and zygomatic muscles (the SMAS is transected at the level of the zygomaticus major muscle and the dissection continued in a subcutaneous plane). This maneuver frees the SMAS from the attached mimetic muscles, allowing the pull on the skin to be transmitted to the fold. The cheek fat is dissected free from the underlying mimetic muscles and is elevated with the skin/SMAS flap. The technique is said to diminish the appearance of the nasolabial fold. The risk of nerve injury may be greater with the more extensive dissection. There is improved vascularity compared to the subcutaneous plane facelift. However, the major drawback to the deep plane operation is the development of persistent infraorbital and midface ecchymosis and edema that greatly prolong the convalescence.

Composite Facelift

The composite facelift is a modified deep plane facelift designed to additionally address the orbicularis oculi muscle. With the addition of a lower blepharoplasty incision, the orbicularis oculi is elevated off the malar prominence. This frees the muscle of its attachments to the malar eminence, allowing mobilization and repositioning. As originally described, this dissection plane is then connected to the deep-plane dissection by an incision made between the inferior lateral border of the orbicularis oculi and the zygomaticus minor muscle. A distinct division between these muscles is not always present because they lie in the same plane. This maneuver prevents inadvertent elevation of the zygomaticus minor muscle into the com-

60posite flap. The inferior aspect of the orbicularis oculi muscle is trimmed, and the muscle is repositioned in a superomedial vector.

Subperiosteal Lift

The subperiosteal lift is another type of deep plane facelift. Through a coronal approach, subperiosteal undermining is carried out around the orbital rims, over the zygomatic arch and body, over the maxilla and down to the piriform aperture. After undermining, the tissue is advanced superiorly and sutured to the temporal fascia. In older patients with skin laxity, the procedure is combined with a preauricular incision. Patients frequently have marked facial edema for several weeks after surgery and a mask effect for several months. Risk of injury to the frontal branch of the facial nerve was high in the initial series but has been minimized with a deep approach to the zygomatic arch. Many surgeons prefer this technique for patients 45 and under who desire facial implants. There is more swelling with the subperiosteal lift than with more SMAS lifts.

Postoperative Care

In the recovery room following surgery, the patient should be evaluated for pain, nausea, or vomiting. If present, pain medication and antiemetics should be administered. The blood pressure must be frequently monitored and precisely controlled with antihypertensives. Patients should rest, but need not stay in bed. While in bed, the patient’s head should be elevated. Drains are usually removed the morning after surgery. For at least 2 weeks after surgery, the patient should refrain from physical exertion, bending or heavy lifting, sexual activity, driving and flying. The patient should continue to abstain from alcohol and tobacco products, aspirin, nonsteroidal anti-inflammatory agents, anticoagulants, vitamin E, multivitamins, Alka Seltzer® and homeopathic remedies for 3 weeks. A shower and hair washing are permitted on the day after surgery, but no hair brushing or make-up applications are permitted for 10 days. The patient should avoid sun exposure until the scars are mature. Preauricular/temporal sutures are generally removed in 5-7 days and postauricular sutures are removed in 2 weeks.

Complications

Hematoma

Men generally have twice the incidence of hematoma after facelift surgery as women (8% versus 4%). This may to be due to the hair follicles in a male’s beard. Secondary facelifts have a lower incidence of bleeding.

Skin Slough

Skin slough occurs most often in the postauricular region, and it is more common in patients who smoke. Patients should refrain from smoking at least 3 weeks before and 2 weeks after the operation. Another risk factor for skin slough is acne scarring. The subdermal acne scar is hypothesized to compromise blood flow to skin flap. Good judgment is necessary to determine the amount of skin undermining that can be safely performed in higher risk patients. Skin slough is usually treated by allowing the wound to heal by secondary intention.

Nerve Injury

The most commonly injured nerve during a facelift is the greater auricular nerve. Patients undergoing a subcutaneous rhytidetomy have a facial nerve injury risk of 60 0.5-2% (mean of 1%). Patients who undergo a SMAS-based lift have a facial nerve injury risk of 2-9% (mean of 4%).

Alopecia

Hair loss is uncommon during a face lift (1.2%). Suture line alopecia tends to occur in areas of inappropriately high tension. Elevation of the sideburn or notching of the postauricular hairline is more common, particularly during a secondary lift. Both of these complications can be avoided by careful planning.

Scarring

Scarring is present in every facelift. Well-designed incisions closed without tension produce the best scars. Patients with a family or personal history of hypertrophic scarring or keloid formation or risk factors for excessive scarring after a facelift should be counseled preoperatively.

Infection

Infections occur very uncommonly (0.18%) during facelifting due to the robust blood supply of the face.

Pearls and Pitfalls

A thorough understanding of the nerves encountered during rhytidectomy in the face and neck is essential for avoiding the most dreaded complications of this procedure.

The frontal division of the facial nerve lies within the temporoparietal/SMAS fascia. Dissection in the vicinity must be either extratemporoparietal/extra-SMAS or subtemporoparietal/sub-SMAS. In the subperiosteal approach, dissection should proceed deep to the deep layer of the temporal fascia. The zygomatic branch of the facial nerve lies deep to the zygomaticus major muscle. Sub-SMAS dissection at this point causes trauma to the nerve, as does blind incision of the zygomatic ligaments. The marginal mandibular branch of the facial nerve usually is not visualized during facelifting. In sub-SMAS dissection in the lower face, it is safer to stay above the mandible posterior to the facial vessels. Use appropriate caution with electrocautery hemostasis around vessels in the SMAS since electricity may be transmitted to nerves causing injury.

In the neck the cervical branch of the facial nerve lies deep to the platysma muscle and is in no danger in a supraplatysmal dissection. The great auricular nerve lies deep to the superficial layer of the deep investing fascia on the sternocleidomastoid muscle as it traverses from posteroinferior to anterosuperior to emerge in the vicinity of the infra-aural region, where the skin is firmly attached to the sternocleidomastoid muscle. Caution with the infraorbital nerve must be exercised during dissection in the subperiosteal plane in the region.

Suggested Reading

1.Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64:781.

2.Barton Jr FE. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 1992; 90:601.

3.Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83:11.

4.Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 1990; 86:53.

5.Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976; 58:80.

606. Pitanguy I, Silveira Ramos A. The frontal branch of the facial nerve: The importance of its variations in face-lifting. Plast Reconstr Surg 1966; 38:352.

7.Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg 1992; 89:441.

identified and preserved. The corrugator supercilii and procerus are easily visualized and may be divided to address horizontal or vertical rhytides in the medial orbitital region, the so called “frown lines.” Finally, 1-2 cm of excess scalp is excised from the incisional edge of the flap and a layered closure is performed.

Pretrichial and Trichophytic Browlift

These techniques seek to minimize or eliminate disturbance to the hairline. The pretrichial incision is carried out at or just anterior to the hairline while the trichophytic incision lies a few millimeters posterior to the hairline. Careful beveling of the incision and minimal use of electrocautery are critical to avoiding unsightly incisional alopecia. The plane of dissection and remainder of operative technique are essentially those of the coronal browlift; however great care must be taken with closure as the scar is far more likely to be visible, especially if the patient’s hairline recedes with time.

Temporal Lift

A temporal approach can be of great benefit in patients with isolated lateral brow ptosis or hooding. The incision is performed in the temporal region, running anterosuperior to posteroinferior across the temporalis muscle, similar to the Gillies approach to zygomatic arch repair. Dissection is carried out in a similar fashion to the coronal technique, in the plane between the temporoparietal fascia and the superficial layer of the deep temporal fascia, protecting the frontal division of the temporal branch of the facial nerve which courses through the superficial temporal fascia. Dissection continues inferomedially to the supraorbital rim and arcus marginalis. The superficial temporal fascia is then anchored superolaterally to the deep temporal fascia achieving the desired degree of elevation. Excess skin is excised, and skin is closed in a layered fashion.

Midforehead Browlift

This technique places the incision directly in the middle of the forehead, concealed within an existing forehead crease. It is useful for the patient seeking correction of severe brow ptosis or asymmetry for whom the appearance of horizontal forehead rhytides is of secondary concern. Either a single incision extending the full length of the forehead or two fusiform incisions above each brow are performed centered on a prominent forehead crease. Asymmetric positioning of these incisions can assist in their camouflage as natural wrinkles. In contrast to the coronal,

trichophytic and pretrichial techniques, the plane of dissection is subcutaneous, 61 superficial to the frontalis muscle and is carried down until the orbicularis oculi are visualized. The galea may be incised 2-3 cm superior to the orbital rim and excess

galea excised or redraped and anchored to underlying periosteum. Excess skin is excised and closed in a layered fashion.

Direct Browlift

Direct browlift refers to a skin and subcutaneous tissue-only technique which directly addresses positioning of the brow. A fusiform incision is made superior to each brow. Dissection is carried out in the subcutaneous plane with preservation of underlying muscular and neurovascular structures. Long term fixation is achieved through placement of sutures anchoring the superior aspect of the incision to the periosteum. Meticulous skin closure is essential as the scar is located in a very visible location.

380 Practical Plastic Surgery

Endoscopic Browlift

Minimally invasive surgical techniques have revolutionized all aspects of surgical practice, and aesthetic plastic surgery is no exception. Endoscopic browlift techniques allow results comparable to traditional incision techniques without the risks of incisional anesthesia and alopecia associated with longer scars. Although techniques are rapidly evolving, the typical approach utilizes one midline coronal incision located along the traditional coronal browlift course and two temporal incisions placed along the traditional temporal browlift incision line (along a line drawn from the lateral ala throught the lateral limbus).

The dissection is similar to the open coronal and temporal browlift techniques. The central dissection may proceed in the traditional subgaleal plane or alternatively in the subperiosteal plane, which some find to provide a more bloodless dissection and a better optical cavity. The supraorbital notch serves as the landmark to identify and preserve the neurovascular bundles. The corrugators and procerus musculature may be disrupted as in the open technique. Methods include sharp or blunt transection, thermal injury through electrocautery, or laser ablation. A superolateral orbicularis myotomy may be performed to maximally release the brow for elevation.

Laterally the dissection through the temporal ports proceeds along the traditional plane between the superficial temporal fascia and the superficial leaf of the deep temporal fascia until one reaches the supraorbital rim and arcus marginalis. Proceeding superomedially, the two dissections are joined at the conjoint tendon where the lateral dissection is transitioned to the deeper subperiosteal plane of the central dissection. Care is taken in this area to identify the so called “sentinel vein” which identifies the course of the temporal branch of the facial nerve that lies directly above the vein in the superficial temporal fascia.

Fixation of the soft tissues along vectors providing ideal superolateral elevation of brow structures is a matter of rapidly evolving debate. Techniques and materials include soft tissue suture fixation, permanent or absorbable cortical screws with suture or staple fixation, cortical bone tunnels and various tissue glues. Regardless of fixation method, proper mobilization of the soft tissues during dissection is critical, and the ideal fixation method is likely of secondary importance so long as it provides a reliable result and is easily accomplished through the limited incisions of the endoscopic technique.

Complications

Swelling and bruising should be expected, although the incidence of both can be minimized through judicious use of electrocautery and careful adherence to relatively avascular tissue planes. Hematomas may occur in the setting of inadequate

hemostasis or in the failure to recognize a potential bleeder due to intraoperative vasospasm or vasoconstriction from the use of local anesthetics containing epinephrine. Patients should be warned of the risk of incisional alopecia and anesthesia. Both can be minimized by limiting thermal injury associated with electrocautery and taking care to minimize tension along the suture line during closure. Standard perioperative antibiotics may be administered to limit the incidence of wound infection although the rich vascular supply of facial skin makes this a rare complication even in the absence of such prophylactic measures. In addition to incisional anesthesia, risk of injury to major sensory or motor nerves must be related to the patient. Careful dissection along safe tissues planes and avoidance of excessive tissue traction minimize these risks. In the absence of complete transection, most nerve injury is transient, and patients may be reassured that partial or complete return of function is typical. Finally, as in any elective aesthetic procedure, the patient should be counseled on the inherent unpredictability of the final outcome and the very real possibility of underor overcorrection, asymmetry, hypertrophic scarring and other aesthetic considerations which are a function of the body’s inherent response to the surgery out of the control of the surgeon.

Pearls and Pitfalls

•The highest brow peak in women is between the lateral limbus and lateral canthus, whereas in men it is more directly above the pupil, less of a peak and roughly at the level of the orbital rim.

•Vertical glabellar wrinkles are due to the corrugators, whereas horizontal wrinkles are primarily due to the procerus.

•Excessive resection of the procerus, corrugator and frontalis muscles can result in visible depressions in the center of the forehead and glabellar regions.

•For patients who have a very high hairline preoperatively, the pretrichal approach will preserve the hairline without elevating it further.

•For patients with any lateral ptosis, insufficient release of the orbital retaining ligaments (dermal to periosteal adhesions) will result in under correction of the ptosis and a likely dissatisfied patient.

•If an upper blepharoplasty is planned along with the browlift, much of the dissection can be performed through the upper bleph approach. After dissection above the supraorbital rim and development of the subperiosteal plane, the periosteum can be released from the bone and the muscles readily divided under

Suggested Reading

1.Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg 1994; 18(3):269.

2.Core GB, Vasconez LO, Graham IIIrd HD. Endoscopic browlift. Clin Plast Surg 1995; 22(4):619.

3.Freund RM, Nolan IIIrd WB. Correlation between browlift outcomes and aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg 1996; 97:1343.

4.Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg 1995; 22:639.