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FRCS Plastic Surgery > KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Facelift. > Flashcards

KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Facelift. Flashcards

0
Q

What are the layers of the face?

A

Similar to scalp

  • Skin
  • Connective and subcutaneous tissue
  • Aponeurosis / muscle
  • Loose areolar tissue
  • Periosteum
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1
Q

What is continuous to the SMAS layer?

A
  • SMAS
  • galea
  • frontalis
  • STF / TPF
  • orbic oculi & fascia
  • platysma muscle
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2
Q

How are muscles in the SMAS layer connected to the skeleton?

A

Frontalis - deep galea → superior temporal line
Temporalis - orbicularis retaining ligament → orbital margin.
Platysma - masseteric ligaments.

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3
Q

In the face, what is found in the loose areolar layer?

A
  1. retaining ligaments
  2. spaces
  3. facial nerve branches
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4
Q

What are true and false retaining ligaments?

A

True - between dermis and periosteum.

  1. Zygomatic (from zygoma - McGregor’s patch).
  2. Orbicularis (from orbital margin).
  3. Mandibular (from parasymphysis of mandible).

False - between dermis and underlying fascial layers (no bony attachment)

  1. Platysma-auricular fascia - wide area anterior to ear, where SMAS, parotid masseteric fascia and parotid capsule fuse.
  2. Masseteric ligaments - from anterior border of masseter.
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5
Q

Why are spaces present in the face?

A

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).

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6
Q

Name the spaces in the face.

A
  1. Prezygomatic space - bound by ORL and ZRLs, laxity causes malar mounds.
  2. Premasseter space - bound by PAF, ML and platysma (roof). Laxity of platysma results in jowls behind mandibular ligament and labiomandibular fold.
  3. Masticator space - medial to masseter, degeneration of ML and platysma and inferior migration of buccal fat pad causes deepening of labiomandibular fold.
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7
Q

Tell me about the facial nerve

A

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.

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8
Q

What is the blood supply to the face?

A

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.
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9
Q

What is the sensory supply to the face?

A

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.

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10
Q

Where is the great auricular nerve?

A

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.

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11
Q

Tell me the course of the frontal branch.

A

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).

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12
Q

Tell me the structural layers and the relation of the frontal branch at:
zygomatic arch
inferior temporal space
superior temporal space

A

Diagram pg 532

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13
Q

Where is the marginal mandibular branch at risk?

A

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.

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14
Q

Facelift history

A 
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.
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15
Q

Please examine this patient’s face (General)

A

Overall

  • Skin quality (dermatochalasis, actinic changes)
  • Pigment irregularities
  • Rhytids: static and dynamic
  • Facial scars
  • Skin tumours
  • Asymmetry
  • Motor and sensory nerve function
16
Q

Please examine this patient’s face (upper)

A

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
17
Q

Please examine this patient’s face (middle)

A

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).
18
Q

Please examine this patient’s face (lower)

A

Lower third

  • Nasolabial folds
  • Perioral rhytids
  • Labiomandibular folds (Marionette lines)
  • Jowls
  • Mandibular progection & dental occlusion.
19
Q

Please examine this patient’s face (neck)

A

Neck

  • loss of definition of mandibular border
  • blunted cervicomental angle (normally 105-120 degrees)
  • excess fat
  • platysmal bands and divarication
20
Q

What do you propose for this patient?

A

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).

21
Q

Name the features of facial ageing.

A

Diagram pg 536

22
Q

How do you counsel a patient for facelift surgery?

A

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

23
Q

What are the complications of facelift surgery?

A

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.
24
Q

How do you classify the different techniques of facelift surgery?

A

Subcutaneous

  • skin only
  • traditional SMAS dissection
  • extended SMAS dissection
  • SMASectomy
  • SMAS plication
  • MACS suture suspension (minimal access cranial suspension)

Sub-SMAS (‘deep-plane’)

Subperiosteal

25
Q

Can you tell me about facelift surgery involving SMAS manipulation?

A

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)

26
Q

Tell me about MACS facelift

A

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).

27
Q

What is a sub-SMAS facelift?

A

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)

28
Q

What is a subperiosteal facelift?

A

Tessier
Craniofacial incisions originally: coronal, lower eyelid, upper buccal sulcus. (Endoscopic)
Advantages: CN VII protected.
Disadvantages: does not address skin excess and laxity.

29
Q

What procedures can be done for the malar fat pad?

A

Elevation of malar fat pad restores fullness, via

  1. Temporal incisions
  2. Lower eyelid incisions
  3. Classic facelift incision

Tear trough deformity - fat grafting.

30
Q

How can the neck be improved?

A
  • 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!)

FRCS Plastic Surgery (63 decks)

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