KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Facelift. Flashcards
What are the layers of the face?
Similar to scalp
- Skin
- Connective and subcutaneous tissue
- Aponeurosis / muscle
- Loose areolar tissue
- Periosteum
What is continuous to the SMAS layer?
- SMAS
- galea
- frontalis
- STF / TPF
- orbic oculi & fascia
- platysma muscle
How are muscles in the SMAS layer connected to the skeleton?
Frontalis - deep galea → superior temporal line
Temporalis - orbicularis retaining ligament → orbital margin.
Platysma - masseteric ligaments.
In the face, what is found in the loose areolar layer?
- retaining ligaments
- spaces
- facial nerve branches
What are true and false retaining ligaments?
True - between dermis and periosteum.
- Zygomatic (from zygoma - McGregor’s patch).
- Orbicularis (from orbital margin).
- Mandibular (from parasymphysis of mandible).
False - between dermis and underlying fascial layers (no bony attachment)
- Platysma-auricular fascia - wide area anterior to ear, where SMAS, parotid masseteric fascia and parotid capsule fuse.
- Masseteric ligaments - from anterior border of masseter.
Why are spaces present in the face?
Areas devoid of attachments between bone and soft tissue and bound by retaining ligaments.
Soft tissue within spaces are mobile, hence malar mounds, jowls, labiomandibular folds (marionette lines).
Name the spaces in the face.
- Prezygomatic space - bound by ORL and ZRLs, laxity causes malar mounds.
- Premasseter space - bound by PAF, ML and platysma (roof). Laxity of platysma results in jowls behind mandibular ligament and labiomandibular fold.
- Masticator space - medial to masseter, degeneration of ML and platysma and inferior migration of buccal fat pad causes deepening of labiomandibular fold.
Tell me about the facial nerve
Enters face within parotid gland (protected under masseter fascia).
- Becomes more superficial to supply muscles in SMAS layer in vertical line with zygomatic, masseteric and mandibular retaining ligaments.
Frontal and mandibular branches most at risk.
What is the blood supply to the face?
ECA branches
- facial artery → paranasal, perioral and submental perforators (divided if facelift flap is dissected medial to NL fold, compromising flap).
- transverse facial artery (STA) → perforators divided when facelift flap is mobilised from malar prominence.
- middle temporal artery (STA) - supplies deep temporal fascia and fat pad, causes temporal hollowing if divided.
What is the sensory supply to the face?
Trigeminal nerve and cervical plexus.
Nerves at risk during:
Brow lift - Supraorbital and supratrochlear
Facelift - great auricular nerve (C2,3), auriculotemporal nerve (runs with superficial temporal artery), frontal nerve.
Facelift (subperiosteal) - infraorbital nerve.
Where is the great auricular nerve?
At risk when dissecting inferior to ear.
Erb’s point - posterior border of SCM and pierces deep investing fascia 6.5cm inferior to tragus.
Supplies sensation to lower pinna.
Tell me the course of the frontal branch.
Leaves parotid inferior to zygomatic arch (within parotid-masseteric fascia (4).
Passes superficial to middle 1/3 of zygomatic arch.
Travels between superficial temporal fascia (3) and deep temporal fascia (5)
Safe to dissect directly on deep temporal fascia (5) (deep to nerve).
Tell me the structural layers and the relation of the frontal branch at:
zygomatic arch
inferior temporal space
superior temporal space
Diagram pg 532
Where is the marginal mandibular branch at risk?
At risk where it is fixed against a ligament.
- Platysma-auricular fascia posteriorly.
- Mandibular ligament anteriorly.
Safe to dissect superficial to platysma.
May be located lower than 2cm below mandible due to ptosis of lower face.
Facelift history
What do they perceive problem to be? What are their expectations of surgery? Why do they want surgery? Smoke? High BP? Medication: aspirin, warfarin, clopidogrel, steroids? Medical history: healing, bleeding disorders, DM, rheumatoid. Previous facial surgery. Psychological problems.
Please examine this patient’s face (General)
Overall
- Skin quality (dermatochalasis, actinic changes)
- Pigment irregularities
- Rhytids: static and dynamic
- Facial scars
- Skin tumours
- Asymmetry
- Motor and sensory nerve function
Please examine this patient’s face (upper)
Upper third (for brow lift)
- hairline
- brow position (male, female)
- crow’s feet
- forehead & glabellar rhytids (frontalis contraction overcompensation)
- lateral hooding
Measurements
- mid-pupil to brow apex
- brow apex to hairline
Please examine this patient’s face (middle)
Middle third (for blepharoplasty)
- dermatochalasis (redundant skin)
- hollowing of orbit
- pressure on globe = medial pre-septal fat pad herniation.
- lower eyelid laxity and wrinkles
- festoons = redundant orbicularis muscle
- palpebral bags = post-septal fat bulge
- Medial and lateral canthal laxity, Snap test.
- Bell’s reflex
- Visual acuity, Schirmer’s test (ophth review).
For facelift - malar projection - earlobe position Signs of midface ptosis - elongation of lower eyelid - scleral show - mid-cheek groove - tear trough (nasojugal groove): fromed by junction between palpebral and orbital orbicularis. Located just inferior to medial canthus and nasolacrimal crest → along orbital margin (palpebromalar groove). - malar mounds (bags / crescents): triangle bulges of skin and fat overlying malar prominence (NOT malar fat pads).
Please examine this patient’s face (lower)
Lower third
- Nasolabial folds
- Perioral rhytids
- Labiomandibular folds (Marionette lines)
- Jowls
- Mandibular progection & dental occlusion.
Please examine this patient’s face (neck)
Neck
- loss of definition of mandibular border
- blunted cervicomental angle (normally 105-120 degrees)
- excess fat
- platysmal bands and divarication
What do you propose for this patient?
Propose surgical plan based on findings and patient’s wishes.
- Consider most appropriate vector of lift.
Consider ancillary procedures (e.g. resurfacing for perioral rhytids, Botox for glabellar lines).
Name the features of facial ageing.
Diagram pg 536
How do you counsel a patient for facelift surgery?
What it does not correct / limitations (upper 1/3s, perioral rhytids, NL fold)
Incisions
Post-op recovery - dressings, bruising, swelling, home POD 1, avoid exercise, head up.
Complications
What are the complications of facelift surgery?
Immediate
Sensory nerve damage
- GAN (<7%)
- facelift flap numbness (12mth recovery)
Motor nerve damage
- facial nerve (2.6% persistent) - marginal mandibular, frontal, buccal.
- haematoma (F 1-3%, M7-9%), risk factors: hypertension, anticoag, smoking, male, NSAIDs, open platysmaplasty.
Early
- Skin necrosis (1-3%)
- Infection.
- Parotid gland pseudocyst.
- wound dehiscence.
Late
- alopecia (<2%).
- trounblesome scars (visible, hypertrophic, keloid, pixie ear, steps in hairline).
- asymmetry.
- skin pigment changes.
How do you classify the different techniques of facelift surgery?
Subcutaneous
- skin only
- traditional SMAS dissection
- extended SMAS dissection
- SMASectomy
- SMAS plication
- MACS suture suspension (minimal access cranial suspension)
Sub-SMAS (‘deep-plane’)
Subperiosteal
Can you tell me about facelift surgery involving SMAS manipulation?
Traditional
- inverted L incision of SMAS.
- transverse incision inferior to zygomatic arch.
- vertical preauricular incision extended down to anterior border of SCM.
- anterior dissection past parotid.
- SMAS is redraped in posterosuperior vector.
- platysma is sutured over mastoid.
- decreases jowling and defines angle of mandible
Extended
- transverse incision above zygomatic arch.
- anterior dissection over zygomaticus major.
- gives malar augmentation.
SMASectomy
- A strip of SMAS is excised along a line connecting angle of mandible and lateral canthus, and cut edges are sutured together.
- Platysma is sutured over mastoid.
SMAS plication
- plication sutures same as above without excision, upper dog ear augments malar, lower dog ear excised usually.
- facial nerve at risk if sutures are too deep.
Suture suspension (MACS)
Tell me about MACS facelift
Minimal access cranial suspension
- Tonnard and Verpaele (Gent, Belgium 2002).
- soft tissues are suspended from deep temporal fascia above zygomatic arch by 2-3 purse-string suture loops.
Vertical lift may cause ruching of excess skin around earlobe and elevate temporal hairline (prevented by hairline incision rather than within hair).
What is a sub-SMAS facelift?
Skoog
- cheek dissection is deep to SMAS, no dissection above SMAS.
- better vascularity to flap, but risk CN VII damage).
Composite rhytidectomy (Hamra) is a modification of Skoog (includes orbicularis oculi in flap)
What is a subperiosteal facelift?
Tessier
Craniofacial incisions originally: coronal, lower eyelid, upper buccal sulcus. (Endoscopic)
Advantages: CN VII protected.
Disadvantages: does not address skin excess and laxity.
What procedures can be done for the malar fat pad?
Elevation of malar fat pad restores fullness, via
- Temporal incisions
- Lower eyelid incisions
- Classic facelift incision
Tear trough deformity - fat grafting.
How can the neck be improved?
- Submental defatting (submental incision or liposuction).
- Medial platysma plication (submental incision)
- Suture lateral platysma to platysma-auricular fascia or mastoid (facelift incision)
- Resection / division of prominent platysmal bands
- Suspension of ptotic submandibular glands
(excising skin at nape of neck has been described!)
