Facelift and Necklift Flashcards
Facial skeleton work is limited in facelift
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Facelifting
techniques have little effect on skin texture, elasticity, and discoloration,
but they improve folds resulting from tissue shifting and descent.
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Retaining ligaments are landmarks for facial rejuvenation procedures as they separate
facial fat compartment, are intimately related to the branches of the
facial nerve
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During facelift, the deep and superficial cheek compartments may be repositioned and/or refilled
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The mobile SMAS is softer and medial,
over to the zygomatic and masseteric retaining ligaments toward the
central face
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Sub-SMAS dissections may result in facial nerve injury ifthe deep fascia is violated
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The
deeper facial muscles include the buccinator, mentalis, and depressor
labii
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Within the
parotid gland, the branches of the facial nerves are superficial located,
to the parotid fascia
F Within the
parotid gland, the branches of the facial nerves are deeply located,
deep to the parotid fascia
they become more superficial at the
anterior boarder of the gland
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Facial nerve injury is rare in facelift surgery with an estimated incidence
of below 1 %
Permanent loss of function from injury is estimated to be around
- J % in most cases
most common
nerve injured in facelift surgery.’
The great auricular nerve is a nerve of the cervical plexus
(C2, C3)
The facial artery branches off the external carotid in the neck
and crosses over the mandible approximately 3 cm from its angle
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Branches of facial arteries
Its branches are the
submental artery, upper and lower labial arteries, angular artery, and
nasal artery
The superficial temporal artery provides blood supply to
the lateral forehead and scalp
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The infraorbital artery, another branch of the external
carotid artery (from the maxillary artery), also supplies the medial
cheek and lower lid
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The internal carotid artery and vein also contribute to the vascular supply of the face, mainly in the periocular area and forehead
through the supratrochlear and supraorbital vessels
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Patients with Fitzpatrick skin type
I-III are generally good candidates for skin resurfacing procedures
such as dermabrasion, with lower risk of postinflammatory hyperpigmentation, hypopigmentation, and blotchiness
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For patients with
skin types IV-VI, the risks are weighed against potential benefits, and
other treatments (nonablative laser rejuvenation, microneedling, and
superficial chemical peels) may be considered
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Patients diagnosed with cutis laxa has high risk of wound healing problem
F there is no underlying issue with wound healing.
The great auricular nerve branch is vulnerable whendissecting the posterior neck, as itemergesat the posterior border
of the sternocleidomastoid muscle, about 6.5 cm inferior to the exterior auditorycanal.
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Role for ant clotting drugs in face lift
Caprini scores
higher than 7, 40 mg of subcutaneous enoxaparin is used as a single
dose 8 to 12 hours postoperatively or extended to a week of treatment
according to preoperative clinical evaluation
Skin-only Lifts move the skin toward the lateral vectors
F Supralateral vectors
Skin lifts are not universally
popular as most surgeons prefer SMAS manipulation why?
because of the
the tension that is placed adjacent to or in the suture line
The elevation vector of the SMAS is usually superolateral, and the vector of the skin redraping is usually posterolateral in Dual-plane Approach
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In the high SMAS technique, the SMAS flap is elevated at or
above the zygomatic arch
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FOR high SMAS tech medial dissection with at least partial
transaction of the zygomatic and masseteric-cutaneous ligaments for
full mobilization of the cheek and jawline
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The platysma-cutaneous
ligaments are preserved why?
The platysma-cutaneous
ligaments are preserved for proper elevation and fixation of the
SMAS and to prevent the lateral sweep deformity
The subcutaneous undermining accompanies the SMAS undermining and extends anteriorly to include the area of the mandibular ligaments and the neck
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In the SMAS plication The vectors can be diagonally
oriented such as in the lateral SMASectomy technique or vertically
oriented, such as in the high SMAS technique
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The SMAS stacking procedure proposed by Rohrich
includes a limited lateral SMAS dissection and stacking of the SMAS
during plication for volume increase in the lateral cheek.
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Deep Plane (Composite) Approach composite flap is thick and has robust vascularization, being a good option for patients with
potential would healing issues, such as smokers and diabetic patients
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The disadvantages of composites
the skin of the neck is usually shifted into the facial skin, and adjustments of the skin and
SMAS flaps cannot be performed independently and can cause artificial facial contour
Buccal fat pad may be approached through the mouth, through
the temple, or through the sub-SMAS dissection. There is a close relationship between the buccal fat pad and branches of the facial nerve
and the parotid duct
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The most common fat injection locations
The most common fat injection locations are the midface,
temporal fossa, periocular and perioral areas. Facial lines can also be
treated with fat injections
Harvesting
cannulas vary from 2.1 to 2.4 mm in diameter, and injection cannulas
vary from 1.2 to 0.7 mm in face fat graft
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Microfat utelized small gauge harvesting cannulas (0.7 mm)
F small gauge harvesting cannulas (2.0-2.4 mm)
Nanofat is a fat grafting derivate from emulsification of microfat
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There are limited amount of fat cells in the nanofat solution
F There are no viable fat cells in the nano fat solution
Nanofat should
not be used for volume enhancement, but as an adjuvant to skin quality improvement.
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Preparation of the fat through decanting, straining, washing, or
centrifugation procedures seems to be equally effective for fat survival
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Time from harvesting to injection seems to be the crucial point
for optimal fat intake. The quicker the fat injected after harvesting
the better the result.
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The use of
fat grafting can enhance results of face lift but has drawback what is it?
increase operating room time,
postoperative bruising, and swelling. Obtaining fat from multiple
sites may be needed for thin patients and may help prevent donor-site deformities
all facelift procedures will have some effect on the neck
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The goal of neck rejuvenation
to modify and improve the submental area and cervicomental angle.
The amount of fat in each plane varies according to patient’s
weight and anatomy and is usually more abundant in the central submental area.
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Liposuction for the neck is ideal for
patients who have good skin tone and elasticity.
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Small cannulas (size 2-3) are recommended to
prevent excessive resection of fat and surface irregularities
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the platysma decussation types
Type 1 is the most common (75%) with limited submental decussation. Type 2 (15%) shows decussation from the mandibular symphysis to the thyroid cartilage
Type 3 (10%) shows no decussation.
In submental plasismoplasty The borders of the muscle can be simply approximated or overlapped with or without transverse partial or complete platysma transection to weaken the platysma bands
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Transections usually start
centrally at the level of the cricoid cartilage and extends laterally
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Absorbable sutures only used
for plication through simple or continuous running sutures.
F Absorbable and permanent sutures may be used
for plication through simple or continuous running sutures.
structures that influence the neck shape and aesthetics are
located deep into the platysma muscle
the subplatysmal fat, the
anterior belly of the digastric muscles, and the submandibular glands
The anterior belly and
posterior belly of each digastric muscle form two sides of the submental triangles
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The facial
artery and vein and the marginal mandibular branch of the facial nerve
crosses the submandibular glands superficially outside its capsule
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The safest approach
to the gland is intracapsular resection to avoid neurovascular injury
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When prominent, the anterior belly of the digastric can be partially or totally excised without
noticeable loss of function
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In an anterior neck, the superficial and deep planes of the
neck can be resected
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Candidate for direct Anterior Neck Resection
usually males or older
patients of both genders who tolerate a central and more visible scar,
who are not suitable for longer operations or prefer a less extensive
procedure
The use of drains under the skin flap is a common practice for neck
and facelift
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Drains have not
shown to prevent hematomas or seromas but are advocated by many
authors, why?
to help decrease the amount of swelling and bruising after a
facelift and help the patient return quickly to social activities
low salt intake in the postoperative period help with swelling
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The same study found male
gender an independent factor for hematoma
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Body mass index >= 25
and combined procedures increased the infection risk
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postoperative hematoma incidence in female and male
postoperative hematoma
is variable due to lack of consistent classification, usually reported
to be 4% to 8% for men and 1 % to 3% for women
Minor hematoma is defined as a collection of blood that does not require surgical evacuation but is amenable to treatment by bedside aspiration,
with volumes under 30 cc
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Minor hematomas consequences
Minor hematomas can lead to persistent face and neck edema, nerve compression, skin necrosis, and
unpleasant aesthetic results
expanding hematoma is a serious
complication with an incidence of 1.8% that requires immediate
recognition and treatment due to impending risk of skin necrosis,
airway obstruction, and death.
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Measurement to decrease the incidence of hematoma
Strict blood pressure control in the operating room (SBP < 150 mm Hg) is a widely recognized preventive
intervention(Antihypertensive clonidine has been used successfully
in the postoperative period to keep SBP under 140 mm Hg)
The use of fibrin glue,
absence of epinephrine in the local anesthetic solutions,
and compressive dressings have been reported to be beneficial but are
not completely effective in preventing hematomas.
use of quilting sutures is a promising strategy in prevention of hematoma in the face by reducing the rate of hematoma to zero in the published series
The great auricular nerve is the most
commonly injured nerve and will lead to numbness of the lower part
of the ear and earlobe
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Nerve compression by sutures during platysma
suspension can also cause numbness and chronic pain.
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Injury to the marginal mandibular branch of the facial nerve
results in weakness of the ipsilateral lower lip depressors (denervation of thedepressor anguli oris). It also affects the ipsilateral mentalis
muscle
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complete nerve transection is more common than Neurapraxia in this area
F Neurapraxia is more common than complete nerve transection in this area and can return within a few days to 3 to 6 months
temporary paralysis of the facial nerves due to
injection of local anesthetic in the dissected area
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incidence of skin slough after facelift was 7.5% in smokers compared to
2.5% in nonsmokers
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skin necrosis and poor
wound healing after cosmetic surgery
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Can smoke cessation ameliorate the risk if wound healing
At least 4 weeks of abstinence from smoking
reduces respiratory and wound-healing complications
Causes of poor wound healing
Smoking
Poor planed flap that result in closure under tension
ethnicity
Complication of previous facelift surgery
The “pixie ear” deformity
“joker lines’: “lateral sweep”, postauricular banding,
facial deformities related to abnormal SMAS and skin traction,
suturing points, or non correction of facial deflation
augmentation with autologous fat transfer can significantly improve
structural bony deficiencies and is included frequently to enhance
results in facial rejuvenation surgery
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the SMAS as a superficial
fascia investing the face and the superficial mimetic muscles. It is contiguous with the galea aponeurotica, the temporoparietal fascia, parotid
masseteric fascia, platysma muscle, and superficial cervical fascia
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The fixed SMAS is firm and
lateral over the parotid gland. The mobile SMAS is softer and medial,
over to the zygomatic and masseteric retaining ligaments toward the
central face
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The most superficial layer ofmuscles is intimately related to the
medial extension ofthe SMAS. Traction and suspension ofthe SMAS
will also suspend the muscles
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The great auricular nerve is a nerve of the cervical plexus
(C2, C3) that provides the dominant sensory innervation to the ear
(lobule, concha, and posterior auricle)
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The transverse facial artery branches off the superficial
temporal artery at the level of the external auditory meatus and travels anteriorly supplying the lateral face and lateral orbital area
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Aesthetic analysis is done by dividing the face into horizontal thirds and vertical fifths
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The frontal branch is vulnerable to injury as it crosses
the zygomatic arch 2.5 cm anterior to the external auditory meatus deep into
the temporoparietal fascia
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The SMAS can be elevated as a flap (high SMAS technique), can be
resected (SMASectomy), or can be plicated with or without tissue
stacking
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In the high SMAS technique, the SMAS flap is elevated at or
above the zygomatic arch with medial dissection with at least partial
transection of the zygomatic and masseteric-cutaneous ligaments for
full mobilization of the cheek and jaw line
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The subcutaneous undermining accompanies the SMAS undermining and extends
anteriorly to include the area of the mandibular ligaments and the
neck
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The lateral SMASectomy technique was popularized by Baker
includes resection of a diagonal strip of SMAS from the malar eminence to the angle of the mandible, parallel to the nasolabial fold with
posterior SMAS plication. The edges of the fix and mobile SMAS are
brought together with sutures for elevation of the jowls and cheek
In the SMAS plication technique, there is no flap elevation or
resection of SMAS. The edges of the fixed and mobile SMAS are
simply plicated together with sutures
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In the minimal access cranial suspension lift (MACS lift) developed by Tonnard, large purse-string suture loops are used to suspend the SMAS platysma in a cranial position instead of using the traditional individual plication sutures placed parallel to the nasolabial
fold
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The deep plane approach The skin flap dissection in front of the ear is limited and there
the transition into a skin-SMAS flap starts laterally, over the deep
parotid fascia
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In selected patients, other facial sub-SMAS procedures are needed
to adjust facial volume and shape.* These include buccal fat pad excision or suspension and trimming of the parotid gland to reshape the
face.
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Microfat can be used
for facial volume restoration and is the preferred method used by the
authors for volumization
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Exact fat grafting survival is still uncertain,
with reported rates of fat grafting survival varying from 40% to 80%
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differentiate between subcutaneous fat and deep fat during the clinical
exam
the submental fat is pinched and the patient is asked to grimace
to contract the platysma muscle. If the amount of fat does not change
with contraction, it indicates that most of the fat is subcutaneous and
liposuction is a good option for fat removal.
Small cannulas (size 2-3) are recommended to
prevent excessive resection of fat and surface irregularities.
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The platysma is a pair of superficial muscle of the neck that originates
from the pectoralis major muscle fascia and inserts into the mentum
and the inferior mandibular border
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Stuzin discussed the importance of the platysma retaining ligaments in the aging neck
These ligaments are a series of fibrous
bands connecting the mandibular symphysis to the thyroid and once
attenuated contribute to platysma descent, band formation, and the
oblique cervical angle of the aging neck
Submental necklifting consists in treatment of the central neck
through a submental incision
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The submental
incision is placed just posterior to the submental crease
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Anterior platysmaplasty consists of suturing the medial platysma
borders from the submental area to the thyroid cartilage for tightening
of the neck
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Transections usually start
centrally at the level of the cricoid cartilage and extends laterally, but
this maneuver can also be performed from lateral to medial through
the facelift incision.
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The anterior bellies extend from the posterior mandibular symphysis to the lesser cornu of the hyoid bone
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Partial but not complete subplatysmal fat
is known to avoid submental depression
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Enlarged submandibular glands can be
visualized laterally to the anterior belly of the digastric muscles.
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In an anterior neck, the superficial and deep planes of the
neck can be resected.
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straight resections are avoided to prevent banding and scar contraction. Most incision patterns are variations of z-plasty in the midline
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Visible scars, hypertrophic scars, and long lasting scar erythema
are some of the downsides of this approach.
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Facial dressings and head wrapping are commonly used after face
and necklifts and removed 24 h after surgery. After this, a compressive, nonbinding chin strap or garment is recommended for a couple
of weeks
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the incidence of facelift complications that need
hospitalization within 30 days of surgery is 1.8%. Hematoma (1.1%)
and infection (0.3%)
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Smoking can increase the chance of skin necrosis and poor
wound healing after cosmetic surgery
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The “pixie ear” deformity is a known tell-tale sign of previous
facelift
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It is caused by tethering and forward rotation of the base of
the lobule due to excessive tension during wound closure and distortion of natural axis of rotation of the lobule
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the timing for a secondary facelift is in average a
decade after the first procedure
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Ancillary procedures such as skin
resurfacing and fat grafting are often added to primary facelifts to
improve outcomes.
F Ancillary procedures such as skin
resurfacing and fat grafting are often added to secondary facelifts to
improve outcomes.
Beale at al proposed the “five Rs” or tenets for
performing a sound secondary rhytidectomy
(1) resect skin/scar, (2)
release abnormal vectors, (3) refill by fat grafting, (4) reshape with
SMAS procedures, and (5) redrape skin
Hematoma that requires surgical evacuation in the
operating room has an incidence of 1.8%
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Transection of the great auricular nerve percentage
incidence of up to 2.6%
