CHAPTER 15: AESTHETICS - FACIAL Flashcards
How is facial ageing classified?
Extrinsic (gravity) and Intrinsic
Chronological ageing
- dermis thins
- reduced elastic fibres, blood vessels, fibroblasts and mast cells
- gravity - soft tissue descent, deep furrows
- muscle contraction - wrinkles
Actinic damage
- fine rhytids
- skin laxity
- dyschromia
- reduced and more disorganised collagen
What changes are seen in extrinsic ageing?
Gravity ‘Extrinsic Ageing’ • Brow Ptosis, Furrows • Glabellar Frown Lines • Infraorbital Hollowing • Malar Ptosis • Nasolabial Folds • Marionette Lines • Submental, cervical excess • (Animation creases)
What changes are present in intrinsic ageing?
Intrinsic Ageing
• Fine wrinkles – disruption of elastin network
• Coarse wrinkles – solar elastosis
• Irregular Pigmentation
Epidermis • Effacement of Rete ridges • Dermal – epidermal junction thins • Decreased melanocytes Dermis • Thins • Decreased collagen, fibroblasts, pacinian corpuscles, Langerhans cells • Altered/Lost elastic tissue Subcutaneous • Atrophy • Decreased skin adherence Photo-Ageing • Elastosis • Type III collagen predominates
What congenital conditions cause pre-mature ageing? When is surgery recommended?
Surgery recommended
- cutis laxa
- pseudoxanthoma elasticum
Surgery not recommended
- Ehlers-Danlos
- progeria
How do you assess the ageing face?
General
- skin quality, thickness, elasticity, laxity
- asymmetry, excess tissue distribution, wrinkles
- facial mvmt
- sensation
Forehead
- level of hairline, quality of hair
- ptosis
- wrinkles, glabellar lines
Mid-face
- circumoral wrinkles
- NL folds, Marionette lines
- ptosis of malar fat pads and jowls
Neck
- submental fat deposits, witches chin
- submandibular gland ptosis
- platysma bands, divarication
What are the 5 layers of the face?
- Skin
- Subcut fat
- SMAS - superficial musculo-aponeurotic system layer (continuous with TP fascia, platysma, galea)
- Muscles - 4 layers (Facial nerve runs deep to all except mentalis, levator anguli oris and buccinator)
- Deep fascial layer (parotid fascia, deep temporal fascia, cervical fascia)
Name the retaining ligaments of the face
Osseoucutaneous → b/t bone and skin
- zygoma (McGregor’s patch)
- anterior part of the mandible
Musculocutaneous → condensations from underlying muscle fascia to skin
- parotid-cutaneous ligaments
- masseteric-cutaneous ligaments
What does SMAS stand for and describe its anatomy
Superficial musculoaponeurotic system
(Mitz & Peyronie, PRS 1976)
• Layer of facial fascia contiguous with frontalis, galea aponeurotica, temporoparietal fascia (superficial temporal fascia), and platysma.
• Forms a continuous layer of superficial fascia in the forehead, temple, face and neck
• tightly adherent to the zygomatic arch, less distinct at the nasolabial crease.
• Sensory nerves lie superficial to SMAS,
• Motor branches of the facial nerve lie deep to the SMAS.
How are the muscles innervated?
Facial nerve innervates muscles of facial expression from deep surface, except
- buccinator
- mentalis
- levator anguli oris
What is the blood supply of the face?
Almost completely from external carotid artery
Anterior
- facial artery (labial branches)
- supratrochlear & supraorbital (from ICA)
Lateral
- transverse facial, zygomatico-orbital, ant auricular, submental
Forehead and scalp
- sup temporal, post auricular, occipital
What is the surface anatomy of the frontal branch of facial nerve?
runs along pitanguy’s line
0.5cm below tragus to 1.5cm above and lateral to eyebrow
At temple - nerve lies just below temporoparietal (superficial temp) fascia
Gilles lift is safe to perform b/t deep temporal fascia and temporalis muscle
What is the surface anatomy of the facial nerve?
Pitanguy’s line - 0.5cm below tragus to 1.5cm above lateral eyebrow, deep to parotid
Facelift - pertinent points in history
smoking BP controlled? anticoagulants conditions predisposing to delayed healing previous surgery
Avoid facelifts in
- increased bleeding risk, hypertensive, aspirin, steroid, warfarin
- smokers
- poor skin quality / keratoses
- thick sebaceous skin, deep creases
- collagen / connective tissue diseases
- unrealistic expectations, prev dissatisfied facial surgery
what sensory nerve is at risk of damage in facelift?
Great auricular nerve
- br of cervical plexus
- emerges posterior to SCM 6.5cm below tragus (Erb’s point)
- supplies sensation to lower 1/2 of ear
What should be documented in examination for facelift?
- Distribution of excess tissue, and wrinkling.
- Quality of the skin
- Facial asymmetry
- Facial power
- Position of earlobes
- Quality/condition of hair → if preop hair loss likely to get ↑ post op
- Best vector to tighten the face
- Photographs
- Pre-op facial nerve function
What are the vectors of pull in facelifts
SMAS fixed
- vertical: improve jawline & perioral creases
- diagonal: improve neck & submental crease
Skin fixed
- posterior
- vertical
Key pts of skin fixation: 1cm above ear & apex of post auricular incision
What incisions are used for facelifts?
Temple
- in front of hairline - for repeat lifts, pts with short sideburns
Pre-auricular
Post-auricular
- high: mod skin redundancy
- low: mod-severe skin redundancy
- occipital hairline: excessive skin redundancy
Describe MACS facelift
Minimal access cranial suspension (Tonnard)
Anterior hairline incision and limited skin undermining
• 3 sutures (0 PDS - changed from 2/0 prolene because of palpable/visible knots)
1. Cervico-mental
2. Jowling/Cheek
3. Malar/Lower Lid (extended MACS - midface lift, excise excess lower lid skin (pinch blepharoplasty)
Name the different types of facelift techniques, and explain 1 you are familiar with
Skin only face lift
SMAS lift (Skoog) • SMAS and skin lifted as single unit
Skin and SMAS lift
• Skin of cheek is undermined first then the SMAS is dissected as a separate flap. Extent of SMAS flap may go as far medially as the NL fold
• Zygomatic and Masseteric ligaments are released to increase the mobility of the SMAS flap. The dissected SMAS layer is tightened and secured anterior to the ear. The excess SMAS can be used to augment the zygomatic arch.
Composite facelift (Hamra)
Deep plane face lift (Foundation facelift - Pitman)
Mid-face suspension
• Deep tissues of the mid-face are dissected through a lower bleph or temporal incision. A suture is placed through the soft tissue of the cheek and passed up to the temple. The midface is elevated by tightening the suture and securing it to the superficial layer of the deep temporal fascia.
Non-endoscopic, subperiosteal face lift
Endoscopic face lift (subperiosteal)
Short scar facelift with lateral SMASectomy (Baker 2001)
What other adjuncts are there to facelift?
Browlift
Botox to central forehead furrows instead of excision
Neck liposuction / lift
Micro fat grafting (harvest & inject with extra fine cannula)
Laser resurfacing
Submandibular gland excision
Chin implant
Malar augmentation - plicated SMAS, implant, filler, resuspend malar fat to lat orbit or temp fascia
Lip enhancement
NL fold - Release dermal attachment, filler
How do you avoid unfavourable results in facelift surgery?
Unnatural pulled-up appearance
→ excessive skin tension / poor choice of vector
Visible scars
→ poor placement / tension
Ear → tragus deformity, pixie ear deformity
→ tension
Hair → hairline distortion / displacement, alopecia → incise parallel to hairline, dissect deep to follicles, avoid tension
Haematoma → use tumescent soln NO ADRENALINE, fibrin glue sealant, suction drains, raise BP before closure
What are the complications of facelift?
Intraop
- facial nerve injury
- 0.8% temp, 0.1% perm
- buccal br most injured - asymptomatic
- marginal mandibular nerve (crosses post. facial vein)
- bleeding
Early
- haematoma (8% M, 4% F) - hypertension, NSAIDs, male, anterior platysmaplasty, smoking, physical exertion
- skin necrosis (1-4%, esp smokers)
- infection
- altered sensation (GAN, infraorbital nerve)
- salivary fistula
Late
- alopecia (1-3%)
- unacceptable scarring
- hyperpigmentation
General
- DVT, PE (see later)
What is the important anatomy of neck lift?
Platysma - paired flat muscle
origin: pectoralis & deltoid fascia
insertion: mandible and SMAS
lies b/t superficial and deep cervical fascia
action: lip & angle depressor, wrinkles neck
innervation: cervical branch of facial
blood: submental and substernal
Variations
I interdigitate within 2cm of inf border of mandible (75%)
II interdigitate at level of thyroid cart (15%)
III no interdigitation (10%)
Neck lift assessment
Youthful neck
- distinct inferior mandibular border
- cervicomental angle = 105-120 deg
- visible subhyoid depression, thyroid cartilage bulge and anterior SCM borders
Assess
- skin quality and excess, jawline, jowls
- wrinkles - static and dynamic
- fat - subcut, pre/subplatysmal
- platysma static and dynamic banding, divarication
- chin projection
- submandibular gland and digastric muscles
- mandibulocutaneous ligament - jowls
What are the principles of neck lift?
Divarication of the platysma
Improve appearance by →
- submental defatting
- plication of the medial borders of the platysma muscles
- resection or division of the prominent bands
Laser resurfacing can be performed at the same operation (unless extensive undermining)
How are platysmal bands managed?
McKinney PRS 1996
- due to lateral laxity of muscle (not free medial edges)
- submental incision
- midline stabilisation
- liposuction of subplatysmal fat
Neck lift procedures
- Liposuction - incision: submental / below earlobe, 2-3mm hole cannula, suction assisted
- Submental neck lift - extend neck, incision just posterior to submental crease, excise interplatysmal fat, release mandibular ligaments, +/- resect digastric muscle partially, intracapsular submandibular gland resection,
- Short-scar face and neck lift - (pts with jowling but no excess neck skin) SMAS / platysmal flap dissected and elevated up
SSFL w/o submental incision - lateral pull
SSFL w submental incision - direct view - Full-scar face and neck lift, incision extended into retroaurciular region.
FSFL w/o submental incision - lateral pull
FSFL w submental incision - direct view
Platysma is (see Janis pg 842)
- imbricated / plicated
- incised (sectional myotomy of medial edge)
- suspended (from inf border of mandible)
- corset platysmaplasty (ant edges pulled together, +/- lateral plication over submandibular gland)
How is patient managed postop?
What are the risks of neck lift surgery?
analgesia, antiemetics, drains, simple dressings / ointment avoid overflexing neck neck strap (<4wks) antibiotics, ROS D7 no heavy lifting 6wks
- haematoma 4% female, 8% male
- great auricular nerve & marginal mandibular nerve damage
- infection
- skin sloughing esp retroauricular
What is the anatomy of the forehead and brow muscles?
Frontalis
- continuous w galea → supraorbital dermis, orb oculi, supraorbital rim periosteum
- elevates eyebrows
- frontal br of facial nerve
Corrugator supercilii
- supraorbital rim → medial eyebrow
- vertical creases
Depressor supercilii
- med supraorbital rim → medial brow dermis
- oblique creases
Procerus
- upper lat cartilages & nasal bones → glabellar skin
- oblique & horizontal creases
Orbicularis oculi
- medial: brow depression
- lateral: brow depression and crow’s feet
Orbit retaining ligaments (of Knize) - upper face / brow retaining ligaments, centred over zygomaticofrontal suture must be released for long lasting lift
What nerves supply sensation to the forehead?
supratrochlear - midline (sup to corrugator)
supraorbital - most of forehead (deep to corr)
infraorbital - nasofrontal jtn
What is the ideal brow height and shape?
The brow
Arches above the supraorbital rim in ♀ and at the rim in ♂ (young - more lateral)
Begins = same vertical line as alar base
Terminates laterally = oblique line from alar base → lateral canthus
Apex = lateral limbus of the eye. (more lateral = cross, more medial = sad)
What are the different techniques for brow lift?
Coronal
Endoscopic (Vasconez 1994 - subgaleal)
Supraciliary
(skin only - melon slice excision)
What are the indications for brow lift?
Brow ptosis (lateral hooding of upper eyelids)
Transverse furrows
Prelude to upper lid blepharoplasty
Facial palsy (with skin excision)
How do you do a coronal brow lift?
Subgaleal / subperiosteal plane
How do you do an endoscopic brow lift?
Prep - tie hair, mark nerves, infiltration subperiosteal & hydrodissect
5 Y shaped incisions (2cm limbs)
Obwegeser - elevate at subperiosteal plane blindly until 2cm superior to orbital rim
Put scope in centrally, start elevating laterally → medially (assistant’s finger on orbital rim)
Avoid nerves
2 further lat incisions → develop plane over deep temp fascia w tenotomies to conjoined tendon. Stay in safe zone
Under brow - use no. 7 up-cutting elevator to divide periosteum
3/0 vicryl - Y→V closure = elevation
Galea pulled up (+/- anchored to calvarium w mitek or drilled holes)
Botox corrugator & procerius - not excise
What post-operative measures are taken?
Dexamethasone intra & postop
Antibiotics
Head bandage 2 days
ROS 2 wks
What are the complications of brow lift?
haematoma alopecia / hairline distortion frontalis paralysis numbness (posterior to scar = normal) asymmetry implant infection
How do you assess upper and lower lids for blepharoplasty?
Upper Lid
- ptosis
- lagophthalmos
- skin laxity, lateral hooding, dermatochalasis, crow’s feet
- supratarsal fold position
- fat herniation
Lower Lid
- skin: redundancy, crow’s feet
- lower lid tone: Snap test
- globe position (exop / enophthalmos)
- scleral show (due to tarsal laxity, exophthalmos, middle lamellae contracture)
- lower lid lines / grooves / swellings
- Palpebral bags
- fat protrusion / herniation due to attenuated orbital septum - Tear trough
- groove / depression at the boundary of eyelid and cheek (septal reset or fillers) - Festoons
- redundant folds that hang from canthus to canthus (skin, muscle +/- orbital septum, fat)
Distinguish malar bags from palpebral bags
- Bell’s phenomenon
- Visual acuity
- Facial nerve function
- Schirmer’s test
What questions are important in blepharoplasty?
General: Age, smoking, diabetes, aspirin/coagulopathy, prev scars quality
Specific
- Contact lense wearing
- Dry Eyes → sicca syndrome
- Diplopia
- Glaucoma
Lower eyelid blepharoplasty
A: subciliary incision
skin flap is elevated +/- strip of muscle.
(Initially skin only to leave a cuff of muscle overlying the tarsus).
3 fat pads accessed through small incisions in orbital septum. (avoid over-resection → sunken appearance)
Lower eyelid skin re-draped and excess excised
suture
B transconjunctival approach
C Septal reset
Tear trough correction - release orbitomalar ligament to release arcus marginalis (like underwire in bra!)
What is important in examination?
eyebrow position eyelid pathology excess eyelid tissue fat pads lagophthalmos Marginal reflex distance MRD 1 = corneal light reflex → upper eyelid MRD 2 = corneal light reflex → lower eyelid facial nerve function trough deformity palpebral bags=fat herniation/ muscle festoon malar bags = chronic regional oedema eyelid snap-back test compensated brow ptosis Bell's phenomenon exclude enophthalmos visual fields, visual acuity Schirmer's test Dermatochalasis = eyelid skin redundancy & herniated orbital fat Blepharochalasis = AD condition
What are the complications of blepharoplasty surgery?
Intra-operative, Early, Late Infection Gritty/sticky eyes Reoperation (inadequate correction) Ptosis (injury to levator) Injury to Internal Oblique → diplopia looking down and out (most commonly injured) Scleral show Ectropion Risk of blindness = 1 in 40 000 Retrobulbar haematoma = surgical emergency → orbital decompression by lateral canthotomy & cantholysis to release blood. Acetazolamide and mannitol
Describe the procedure of a traditional blepharoplasty
Do brow lift first
Mark patient in upright position
Mark lower incision (9-10mm above lash line) → avoid supratarsal fold (connects levator)
Mark upper border of skin excess by pinching with forceps.
Medially - not medial to canthus (cause tight web).
Laterally - to a wrinkle line
Leave 30mm b/t lashes & lower eyebrow margin to avoid lagophthalmos
- LA, head up
- excise marked skin
- excise strip of orbic (max 3mm)
- fat pads accessed thru orbital septum higher up to avoid levator injury, separate stab incisions (beware lacrimal gland laterally! Consider glanduloplasty).
- Gentle pressure on globe to allow fat to herniate out. Resect w diathermy & transect
- Meticulous haemostasis to avoid retrobulbar haematoma
- Oppose muscle with monocryl
- Close skin with 6/0 prolene over and over
How do you treat lower lid laxity?
See Ectropion section
Tarsal shortening (Kuhnt Szymanowski)
Canthoplasty (tarsal strip procedure)
Canthopexy (retinacular suspension)
What is the skeletal structure of the nose?
Upper 1/3
- paired nasal bones, frontal bone (nasal process) & maxilla (frontal process)
Middle 1/3
- upper lateral cartilages (inf = int nasal valve)
Lower 1/3
- lower lateral cartilages (alar)
(a) medial crus (columellar)
(b) middle crus (tip)
(c) lateral crus (fan upwards & laterally)
Septum - quadrangular cartilage (ant), ethmoid (perpendicular plate) (sup), vomer (inf)
What is important in the history for rhinoplasty?
Previous trauma / surgery Breathing problems Nosebleeds Allergic rhinitis Olfactory disturbances Regular headaches Profession depends on a sense of smell (eg wine tasting) Nasal drugs (Cocaine) Drug history - aspirin, warfarin, steroids PMH - DM, hypertension, smoking
What important examination findings are in rhinoplasty?
- Overall shape of the face, proportions and symmetry of nose to 1/3s of face
- width of alar base ( = intercanthal distance)
- width of bony base (75% of alar base width)
- Does nose match ethnicity of patient?
- Proportions of underlying skeleton (malar, chin, teeth)
- Dental occlusion - Skin quality and thickness on nose, telangectasia
- Nasal lines
- nasal deviation
- aesthetic lines (medial supraciliary ridges to tip defining points)
- dorsum (hump, saddle deformity, supratip deformity) - Tip
- alar rim symmetry
- lateral projections of left and right domes
- tip defining points
- supratip break
- columellar break
- tip projection = tip to alar cheek junction
- tip rotation = columellar / NL angle (M 90, F 100) - Intra nasal inspection
- Nasal septum and turbinates
- External nasal valve test = block each nostril
- Internal nasal valve test = Cottle sign (present when lateral cheek traction opens the nasal valve and improves air entry into the nose)
What should be covered in pre-op counselling
- Won’t improve crows feet lateral to orbit
- GA / LA, incisions, technique
- Post Op → bruising, eye pads, avoid straining/bending, NSAIDs, apply damp eye pads at night
- Pink scars
- Time off work
What the risks of rhinoplasty?
bleeding, haematoma, epistaxis
infection
scars
cosmetic disappointment - under / overcorrection
asymmetry
septal perforation
saddle nose (over resection of dorsum)
supratip deformity (too much alar cart left behind)
internal valve narrowing (esp w infracture)
airway obstruction
persistent nasal tip oedema and numbness
altered sensation (infratrochlear, infraorbital, external nasal nerves)
altered sense of smell
What steps are there in rhinoplasty?
Submucous resection (SMR)
Hump resection (rasp) → open roof deformity
Osteotomy - intranasal / transcutaneous (postage stamp)
Infracture
Cartilage grafts - rib, conchal bowl, diced
Correction of nasal tip (see next card)
What preop & prep procedures are there?
Photograph
Nasal packing, LA with adrenaline
Shave nasal hair
Open / closed approach
