What is the blood supply to the face and main branches central middle outer/lateral scalp/forehead

External carotid Internal carotid (ophthalmic artery -\>eyebrow, lid, forehead, scalp) Central: angular, Nasal, S&I labial, Middle: facial, M&P jugular, submental, infraorbital Lateral: S&I masseteric, transverse facial, Zygomatico-orbital Scalp forehead: STA, SO, post auric, occipital

Facial Aging & Rhytidectomy Flashcards by Kathryn isaac

What are the five anatomical layers of the face

Skin: firmly attached to the underlying SC w cutis retinacula
Subcutaneous/Superficial fat compartments (5)
- Nasolabial
- Medial Cheek
- Middle Cheek
- Lateraltemporoparietal (cheek)
- Inferior orbital
Superficial musculoaponeurotic System
- = superficial fascia and mimetic muscle
- continuous w plastysma (superficial cervical) fascia, TPF, galea
- Fixed over the parotid, mobile medial to parotid and fuses again medially at NLF
Parotidomasseteric fascia - Deep facial fascia
- continuous w superficial leaflet of DTF, into neck as deep cervical fascia
- Neurovascular structures are in and deep to PM fascia
Bone/periosteum

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Name the muscles in the face (4 layers)

Zm, Oo, DAO
Risorius, Plastysma, DLI
ZM, LLSAN, LLS, Ooris
Mentalis, LAO, Buccinator * innervated on superficial surface

+ procerus

+ depressor supercilli

LLSAN, LLS, Zn, ZM (from medial to lateral)

Mentalis, DLI, DAO (from medial to lateral)

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What is the blood supply to the face and main branches

central
middle
outer/lateral
scalp/forehead

External carotid

Internal carotid (ophthalmic artery ->eyebrow, lid, forehead, scalp)

Central: angular, Nasal, S&I labial,
Middle: facial, M&P jugular, submental, infraorbital
Lateral: S&I masseteric, transverse facial, Zygomatico-orbital
Scalp forehead: STA, SO, post auric, occipital

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Describe the course of the facial branches

Frontal
- Course; 0.5cm below tragus to 1.5cm above lat brow (pitangays line). AT midpoint b/w tragus and lat canthus, nerve crosses arch
- Inf to arch: deep to PM
- At arch, on periosteum+sup.leaf of DTF
- Sup to arch, deep to TPF
Zygomatic
- deep to PM, above masseter
- VULNERABLE at anterosuperior parotid, deep to orgin of Z.M at 3cm anterior to tragus
Buccal
- vulnerable at anterior parotid, deep to PM
Marginal Mandibular
- exits anteroinferior parotid - deep to PM, deep cervical fascia
- always deep to plastysma, protected by deep cervical fascia
- posterior to facial vessels, nerve lies inferior to mandible
- anterior to facial vessels, nerve lies superior to mandible
Cervical
- penetrates deep cervical fascia, runs deep to plastyma at a pint 1/2 b/w mastoid/mentum at angle of manidble

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Describe the course of CN11

exits jugular foramen
runs along posterior deep surface of SCM
leaves posterior SCM 7-9cm above clavicle to travel on deep surface of trapezius

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What si the anaotmic landmark for he Greater auricular nerve and what is the consequence of its injury

6.5cm below EAC, ont he superficial surface of SCM, traveling form posterior to anteriro to course with the EJV
injury results in numbness of loule, inferior auricular region

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What provides the sensory innervation to the face

external nasal
infratrochlear
supratrocheal
supraorbital
infraorbital
zygomaticofacial
zygomaticotemporal
mental
buccal
auriculotemrpoal
GAN
LON
GON

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What are the 7 facial danger zones

GAN : 6.5 cm below EAC
- posterior to SMAS
- =>numbness inferior 2/3 rd of ear, cheek, neck
Temporal: 0.5cm below tragus to 1.5cm above lat brown
- deep to SMAS
- =>paralysis of frontalis
Marginal mandibular: 2cm posterior to oral comissure, midmanidble
- deep to SMAS (platysma)
- =>paralysis lower lip
Zygomatic+Buccal : triangle formed by points on malar, oral commisure, posterior angle mandible
- deep to SMAS
- =>paralysis upper lip cheek
Supraorb/supratroch: SOR at midpupil
- anterior to SMAS
- =>numbness forehead, nose, scalp, upper eyelid
Infraorbital: 1cm below IOR at midpupil
- anterior to SMAS
- =>numbness side of nose, upper lip, lower eyelid
Mental: midmandible bwlow 2nd premolar
- anterior to SMAS
- =>numbness to half lower lip/chin

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Name the facial retaining ligaments of the face (furnas,stuzin)

Osteocutaneous (Direct)

Zygomatic RL*
- along arch/body, posterior to Zm, 4.5cm ant to tragus
- suspends malar fat pad
- deep to ZRL is zyg/buccal branches, parotid duct, trasnverse facial artery
Mandibular RL*
- along parasymphysys and anterior 1/3 of body
- posterior limit of MRL defines anterior border of jowl

Indirect cutaneous (between deep and superficial fascia)

Parotid-preauricular CL (Lore’s fascia)
Parotid-Masseteric CL*
Superior temporal line CL
Platysma CL
orbicularis RL (orbitomalar ligament)

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WHat is contained in the buccal fat pad

Zygomatic, buccal branches superficial
parotid duct

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What is macgregors patch?

Malar fat pad

= 3 superficial fat compartments

= Nasolabial, medial cheek, inferior orbital

descends with age and deflates

= deepened NFL and jowls

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Describe facial aging by decade and by structure

30s - eyelid, crow feet

40s - NLF, glabella, forehead

50s - neck, jaw, jowls, nasal tip

60s- deepened wrinkles and sagging

Skin: thining epidermis, atrophic dermis, less collagen 1

Soft Tissue - deflation, descend, deterioration

Middle 1/3 NL and mrionette groove
Lower 1/3 jowl, witchs chin

Bone - retrusion of IOR and maxilla anteriorly and height

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What are rhytids and examples of each type

Creases in the skin due to intrinsic changes in skin structure and perpendicular to muscle movement

Dynamic - animation creease
Static fine - disrupted elastin network
Static coarse - deep caused by solar elastosis

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What changes occurs histologically to skin with aging

Loss of cells
- melanocytes
- langerhans
Loss of structure
- DE papillae
- reticular dermis
Loss of substances
- ground substance
- elastin
- collagen type 1 (more t3:t1)
increase size of sebaceous glands

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What changes occur with photoaging

telangiectasia
dyschromias:hypo/hyperpigment
atrophy
erythema
static rhytids: fine and deep

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What genetic syndromes predispose to facial aging and who are good and poor surgical candidates?

POOR CANDIDATES FOR SURGERY

Ehlers -Danlos
- abnormal production of lysyl oxidase -> required for collagen crosslinking
- = capillary friability, poor wound healing
Progeria
Adult Progeria (Werner’s)
Cutis Laxa (AR or Xlinked only)
- deficiency of lysyl oxidase

Good or select

Cutis Laxa (AD)
Meretoga syndrome
- amyloidosis of facial skin and facial nerve
Pseudoxanthoma elasticum
Idiopathic skin laxity

Describe your Pre-operative Facial Analysis

HISTORY

Desires and Expectations
Full PMHx, previous treatments
Effect on skin aging: Sun>Smoking>Weight change

PHYSICAL

Skin: quality, photoaging
Facial Proportions
- Midface width (line thorugh infraorb rim)
- Facial Length (height from malar projection to inferior jowl)
- Facial Fullness (distribution)

UPPER 1/3

PERIORBITAL ZONE (FOREHEAD, BROW, MIDFACE)

Brow position
Glabella rhytids
Forehead rhytids and height
Temporal
- crows feet
- atrophy
Lateral canthus position
Upper lid ptosis, pseudoptosis, skin, fat
Lower lid laxity, position, lid-cheek jx
- Tear trough
- Festoon
Malar projection, fat pad descent
- negative/positive vector

MIDDLE 1/3

PERIORAL ZONE

NLF
Angle of mouth
Upper lip
- height
- volume loss & periooral rhytids
Lower lip
Chin
- labiomental crease
- ptosis (witchs chin)
- jowls
Nasal tip
Ear lobule

LOWER 1/3

NECK

Platysmal banding, transverse cervical bands
Jawline
Submandibular ptosis

Describe your surgical goals of facial rejuvenation

Correction of Ptosis and Laxity
- general skin laxity
- malar
- Jowls
- Labiomental crease
- NLF
- Neck definition
- Jowls
Alter face shape form rectuangular to conical
Bidirectional advancement of skin and SMAS

What are options for non-surgical facial rejuvenation

Sunscreen (prevention)

Anti-UVA (titanium dioxide, Zn oxide)
Anti- UVB (‘, PABA, salicylate)
Retin-A (vitamin A and derivative)
- stimulates collagen synthesis, inhibits MMP
- 0.025% topical nightly
Exfoliants
- alpha hydroxyl acids
Bleaching agents
- hydroquinone
HRT (estradiol retards loss of collagen)
(probably should include):
filler: synthetic, autogenous
laser
chemical peel

Describe the incision options for a cervicofacial rhytidectomy

Temporal - want normal hairline relation to ear
- Hairline (if >4cm b/w lateral orbit and hairline)
- In Hair (3cm in temporal scalp extending superirly from root of ear (if <4cm =>hairline will be posteriorly positioned postop)
- **look at amount of hair sitting in front of ear as it will be back 2-3cm depending on laxity
Preauricular - want normal camouflage of color/texture, prevent tragal distortion
- Anterior to tragus - if preauric rhytid, male
- Tragal edge - if no preauric rhytid
- posterior margin
Perilobular
- incision 2-3mm below crease (lob-cheek jx)
Post-auricular
- inciion directly in auriculomastoid groove then turn posterior at upper level of EAC
Occipital
- along hairline within inferior incison turned back into hairline at jx of thin/thick nair
Submental incision
- plan w posterosuperior traction on cheeks - placed parallel and posterior tosubmental crease

List the techniques for cervicofacial rhytidectomy

Skin only
Skoog (skin+SMAS as a single unit)
Subperiosteal
Endoscopic (Byrd)
SMAS + Subcutaneous
SubSMAS + Subcutaneous

List the variations for the SMAS techniques

SMAS (5 variations)

Plication (no elevation)
Imbrication (advanced and overlapped)
MACS (minimal access cranial suspension)
- subcut separation, SMAS suspension to DTF
Lateral SMASectomy
- strip excised along anterior parotid
SMAS stacking
- SMAS incised and two edges stacked

List the variations for the SubSMAS techniques

SubSMAS = deep plane, deep SMAS (5)

Low SMAS - below arch, treats only lower face
High SMAS *BARTON
- above arch, treats midface and lower face
Extended SMAS (Stuzin)
- into upper mid cheek to release ORL and superior malar fat pad. Risk o.o branches
Composite SMAS (Hamra)
- Skin +SMAS raised as single unit
Lamellar SMAS
- bidirectional elevaiton and adv.

List and describe minilift procedures

Webster lift
- short ant and post scar w only SMAS plication
S-Lift (Ansari)
- temporal + preauric incision w SMAS plastysma plication
Short scar lift (Baker)
- S-lift variation w lateral SMASectomy

Describe features of a youthful neck

* cervicomental angle 105-120 * defined dpression subhyoid, visible anterior SCM, thyroid bulge * distinct inferior mandible border

Describe your neck analysis

* Skin * excess posterior to SCM and below thyroid * Platysma * banding static/dynamic * Fat * subplatysma vs subcut (pinch then ask to animate) * Submandibular gland-bulging worse w neck flexion * Digastric - bulging below mandible * Chin - ptosis/projection * Mandible CL

Describe options for Neck rejuvenation and Plastysma procedures

**_Cervicoplasty_** **Neck rejuvenation** * **Submental** * ****in combo w CF lift * submental fat exicsion and mandible CL release * +/- plastyma procedure as required * **Short scar face & Neck** * ****temporal + preauric incision * SubSMAS dissection b/w adherent and mobile SMAS * **Fulls scar face and neck** * ****standard full CF incision (temp to occip) * same Sub smas elevation * smas anchored to Mastoid **Platysma correction - if bands worse w animation** * **Midline Platysma** * **Plication of diastasis** * **horizontl incision across sling** * Lateral platysma suspension

What are complications of a Cervicofacial rhtidectomy and managment of compx

* Ischemia of skin flaps * release suture, allow granulation, STSG 6ks later, then scar revision * Hematoma * RFs: NSAIDs, smoking, postop HTN, male * systemic issues, pain.n/V, anxiety * pressure dressing, suction, evacutation and electrocautery * Infection * open sutures and track down to abscess to drain, IV abx . If no response treat w fluconazole for yeast * Nerve injuries * wide conspicuous scars * inadeaute lifting, overlifting * tragal defomrity, distorted earlobe * alopecia

Whata re options for malar enhancement

* Malar fat compartment suspension (to DTF) * Malar augmentation (fat or filler)

What are options for improvement of NLF?

* Release CL * indirect CL masseteric * direct OCL zygomatic * resuspend malar fat pad and SMAS on zygomatic eminence * Malar fat pad undermined medial to ZM (mild) or to level of NLC(severe) * SMAs release from ZM attachment and pulled superior * Dermal fat grafting * direct excision

What are options for improvement of jowls

* CF rhtidectomy * buccal fat pad excision (fat pad of **Bichat)** * suture sling submandibular

What are options for improvement of chin ptosis

* resuspension/augmentation * release of submental crease and mandible CL * direct excision of skin ST redundancy

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Facial Aging & Rhytidectomy Flashcards

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