Facelift (Rhytidectomy) - Board Review Flashcards
What are the factors that result in the aging face?
Elastosis - resulting in the loss of collagen and elastin fibers due to:
Intrinsic factors - genetic
Extrinsic factors - actinic damage and gravity
Name 3 factors that contribute to less than ideal results in facelift
Poor elasticity
Heavy actinic damage
Deep, course facial rhytids
How does UV light in general cause skin damage?
Through generation of reactive oxygen species that damage enzymes after being absorbed by chromophores.
How does UVB cause skin damage?
direct damage; wavelength 280-325nm; responsible for most of the DNA damage to the skin
How does UVA cause skin damage?
acts through other active molecules; wavelength 315-400nm (longer than UVB), causes damage 100-1000x dose and deeper penetration
What is the mechanism of dermal damage?
Activation of three metalloproteinases capable of degrading dermal collagen matrix.
What are the endogenous changes that occur with aging (5)?
- Glycosaminoglycans and proteoglycans decrease with age
- Collagen decreases 6% per decade, dermal thinning and decreased type 3 collagen
- Decreased number of langerhans cells and keratinizing cells
- Increased flattening of the dermal-epidermal junction
- Repetitive mimetic muscle contraction contributes to the nasolabial fold depth
Describe cutis laxa
- degeneration of elastin fibers in the dermis
- skin does not spring back
- AD, AR and XL genetic patterns
- recessive form has systemic symptoms
- surgery not contraindicated
Describe Pseudoxanthoma elasticum
- two dominant and two recessive forms
- recessive form (Type II) entire skin is loose fitting
- diagnose by biopsy to r/o cutis laxa
- surgery not contraindicated if systemic symptoms not present
Describe Ehlers-Danlos syndrome
- hypermobile joints
- very thin, friable, hyperextensible skin
- subcutaneous hemorrhage
- skin can stretch 15cm but returns back
- post-traumatic bleeding
- poor wound healing (decreased production on enzyme lysyl oxidase)
- surgery contraindicated
Describe Progeria
- rare with unknown etiology, AR
- craniofacial disproportion (premature closing of epiphysis)
- baldness, pinched nose, protruding ears, micrognathia
- loss of subcutaneous fat, arteriosclerosis, cardiac disease
- do not reach reproductive age expectancy
- surgery is contraindicated
Describe Werner syndrome (adult progeria)
- hypo and hyper pigmentation
- AR
- balding, aging facies, short stature, high-pitched voice, cataracts, mild DM, muscle atrophy, osteoporosis, premature arteriosclerosis, various neoplasms, severe microangiopathy
- surgery contraindicated
Desribe Meretoja syndrome
- systemic amyloidosis
- excessive lax skin in pts >20YOA
- *facial polyneuropathy
- amyloid deposits in the perineurium and endoneurium of peripheral nerves
- surgery contraindicated
Describe idiopathic skin laxity disorders
- patchy areas of mid-dermal elastosis (MDE)
- localized fine wrinkling
- without systemic abnormalities
- pathogenesis poorly understood
- surgery contraindicated
Elastoderma
Elastoderma is a rare condition that affects the skin. People affected by elastoderma generally have increased laxity of skin covering a specific area of the body. Decreased recoil of the skin has also been reported.
Elastoderma
Elastoderma is a rare condition that affects the skin. People affected by elastoderma generally have increased laxity of skin covering a specific area of the body. Decreased recoil of the skin has also been reported.
Discuss the soft tissue perfusion of the anterior face
perfused by several small musculocutaneous perforators
Discuss the soft tissue perfusion of the lateral face
perfused by relatively few but large fasciocutaneous perforators
-these are generally disrupted with the facelift dissection, making medial dissection important to be conservative
What is the cause of the hollowed outlook in the cheek region following a facelift during which the malar fat was transposed to its preptotic locale?
Malar fat pad atrophy due to ischemia. It is perfused by the angular artery musculocutaneous perforators. If it is transposed more than 2 cm this may lead to compromise.
What is the end point to each of the dissection layers (skin and SMAS) in the cheek?
Skin: release of the nasolabial fold
SMAS: upturning of the modiolus (corner of the mouth)
Discuss some of the differenced between male and female faces and implications in the facelift
- Hemotoma (6-8%) twice as high in males
- Higher Vascularity because of the beard
- Pretragal incision indicated in men
Discuss some of the differenced between male and female faces and implications in the facelift
- Hemotoma (6-8%) twice as high in males
- Higher Vascularity because of the beard
- Pretragal incision indicated in men
Describe the SMAS (from superior to inferior, what is it contiguous with?)
- galea/frontalis
- superficial temporal fascia
- deep temporal fascia - splits into superficial and deep layers that surround the superficial temporal fat pad as they extend, the superficial layer becomes the PMF
- parotidomasseteric fascia
- deep cervical fascia
Which of the mimetic muscles are innervated along their anterior surface?
Mentalis
Levator anguli Oris
Buccinator
Describe the osteocutaneous ligaments and their significance
-Zygomatic and mandibular ligaments that are responsible for malar fat descent and nasolabial fold deepening. Volume deflation in the setting of an intact mandibular ligament can lead to marionette lines
Describe the soft tissue cutaneous ligaments and their significance
Include the masseteric cutaneous ligaments that stretch from the anterior border of the masseter to the skin and are responsible for jowling
Describe the orbicularis oculi cutaneous ligaments and their significance
They are stretched with herniation of orbital fat pad and loss of malar fat pad support following its descent. Stretch of these ligaments is associated with festoons
Name the approaches to Facelift
- Skin only
- SMAS plication
- SMAS elevation
- Lateral SMASectomy
- Minimal access cranial suspension (MACS)
- Deep plane facelift
- Subperiosteal (temporal or lower lid) - for young pts
What are some considerations for secondary facelift?
- older patients with more comorbidities (HTN most common)
- less skin to be resected
- tissues are thinner and scar tissue present
- facial nerve injury risk is the same as primary
- decreased risk of vascular injury due to delay phenomenon
- risk of hypertrophic scarring is minimal
- intraoperative bleeding and post op hematoma risk is less
Describe the effects of tissue sealants (fibrin adhesives) and PRP after facelift
Decreased rate of ecchymosis, edema, seroma formation but increased induration
Does administration of preoperative steroids decrease edema and ecchymosis?
No
Branch of the facial nerve most frequent branch injured during facelift, usually not symptomatic because of collateral innervation in 70% of patients
Buccal branch of the facial nerve
Collateral innervation seen in 15% of patients; found on Pitangy’s line from 0.5cm below the tragus to 1.5cm above lateral eyebrow. Dissection must be subcutaneous or superficial to the position of the nerve in the temporoparietal fascia and superficial to the parotidomasseteric fascia below the zygoma to prevent injury
Frontal or temporal branch
Travels along the mandibular angle, 81% travels above the border of the mandible, 19% below the body of the mandible, damage to this nerve causes loss of the depressor anguli oris and depressor labii inferioris function (causing failed eversion of the bottom lip), platysma can provide some collateral function
Marginal mandibular branch
Branch of the cervical plexus C2-C3. Located 6.5cm inferior to the external auditory meatus as it crosses the anterior belly of the SCM (McKinney’s point); the nerve runs in proximity to the external jugular vein and is invested in the superficial temporal fascia of the SCM. Provides sensation to the lobe, helix, anti-helix, and most of the cranial surface of the ear
Great auricular nerve
Branch of C2 and innervates the upper one-third cranial surface of the ear, and it may be injured as it runs along the posterior border of the SCM
Lesser occipital nerve
Branch of C2-C3 and supplies the mastoid area and posterior scalp. It is not typically injured as its course is more posterior than the traditional dissection
Greater occipital nerve
Branch of V3. Supplies the tragus and root of the helix. It can be seen running superficial to the temporoparietal fascia during subcutaneous elevation of the temporal flap during a facelift and enters the ear near the tragus
Auriculotemporal nerve
Innervates the SCM and trapezius, exits the jugular foramen and travels deep to the styloid process and then courses underneath the SCM. It exits from the posterior border of the SCM fascia within 2 cm superior to the GAN. Uncommonly injured.
Spinal accessory nerve (Cranial Nerve XI)
Where is the temporal branch of the facial nerve in the forehead above the zygomatic arch?
Deep to the superficial temporal fascia or temporoparietal fascia in the lateral forehead. This nerve innervates the frontalis.
A patient presents 1 week after facelift. Her smile is asymmetric. On full denture smile the right lip is lower than the left. What is the likely cause?
Injury to the marginal mandibular nerve on the left. May be temporary due to neuropraxia. Resolves within 6 months in 80% of patients.
Affects lower lip depressors, mentalis, and orbicularis oris
What is the most likely cause of motor dysfunction in the immediate post operative period (within a few hours) after a facelift?
Residual effects of local anesthesia. Motor dysfunction that is present a few days later may be due to traction, cautery, sutures or transection.
What is the ideal cervicomental angle and appearance ?
105-120 degrees, distinct mandibular border with sub-hyoid depression, visible SCM, and thyroid cartilage
What is the cause of an obtuse cervicomental angle?
excess loose skin, preplatysmal or subplatysmal fat, low position of the hyoid bone, retro-displaced or small chin.
What is the most common complication? Describe rate of complication and potential causes.
Hematoma. 3% in women (6-8% in men) associated with SBP >150. Stop medicines with anticoagulant effect (anticoagulants, aspirin, NSAIDs, ginko, garlic, vitamin E) 1 week prior to surgery.
Treatment of nausea/vomiting, coughing, anxiety, pain
Drains do not treat hematomas.
Describe nerve injury complications.
The buccal branch of the facial nerve is the most commonly injured nerve but it is asymptomatic. Great auricular nerve is the most commonly injured symptomatic nerve. Marginal mandibular is 3rd most common then frontal branch of the facial (but they are more noticible)
Describe the complications associated with skin slough or dehiscence
associated with excessive medial dissection of the skin flap, tension at closure, cigarette smoking (nicotine causes release of epinephrine and increase platelet adhesion and retards wound healing). Treatment is local wound care, healing by secondary intention, scar revision and reassurance
Describe allopecia complication
Tension of the closure is the usual cause, electrocautery at the level of the hair follicle, rough tissue handling, poor scalp flap design. Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair root.
Describe widened or crosshatched scar complication
Due to excessive tension. Use fine sutures (5-0, 6-0) and should be removed at 5-7 days.
Where should the post auricular incision be placed in order to make it less noticible?
In the auriculomastoid sulcus or just slightly above the sulcus on the posterior aspect of the ear
Describe how the “double chin” deformity is caused
Submental incision in the submental crease can accentuate a double chin. Placing the incision 1-2cm inferior to the crease allows undermining in the area and the scar is hidden in the mandibular shadow
Name the two ear lobe deformities and how to prevent them
Pixie ear and loving-cup deformities. Avoid excessive tension and skin excision in this area.
What is the incidence of infection after facelift?
Rare. <0.5%
