62 Cosmetic Surgery for the Aging Neck & Face Flashcards
What is a facelift?
What is a facelift?
Facelift, or cervicofacial rhytidectomy is a surgery that elevates the skin and soft tissues of the lower third of the face and neck. The procedure involves elevating a skin flap around the ear, drawing the deeper tissues up superiorly and fixating them to strong fascia. This is generally considered a cosmetic procedure and is performed in the outpatient setting.
What type of anesthesia is required?
What type of anesthesia is required?
Facelift can be performed under general anesthesia, IV sedation, or with local anesthesia only.
What aging stigmata are addressed with facelift?
What aging stigmata are addressed with facelift?
When examining the aging-face patient interested in facelift, it is useful to know what areas can be corrected with this procedure. The following aging issues can be addressed:
- Sagging neck skin
- Platysmal bands
- Jowls
- Excess cervical fat
A combination of facelift, liposuction, and platysmaplasty (see later) are used to correct these problems. Fine wrinkles are not treated by facelift.
What is the SMAS?
What is the SMAS?
The superficial musculoaponeurotic system (SMAS) is a continuous layer of the face that contains the muscles of facial expression. The SMAS layer is connected to the dermis, which allows these muscles to move the skin and convey emotion. These are the only muscles in the body that attach directly to skin, which highlights the importance of facial expression in social species such as our own.
What is the most common complication of facelift and what are some risk factors?
What is the most common complication of facelift and what are some risk factors?
The most common complication is hematoma and the reported incidence is 5% to 10%. This can range from major postoperative hematoma requiring emergent surgical evacuation to minor hematomas that are aspirated in clinic. Hematoma is more common in men due to differences in skin vascular perfusion around facial hair. Another significant risk factor is uncontrolled hypertension. When blood pressure is above 150/100 mmHg at admission, hematoma is 2.6 times more likely than in normotensive patients.
What is the most commonly injured nerve in facelift surgery?
What is the most commonly injured nerve in facelift surgery?
The great auricular nerve—a sensory nerve originating from spinal levels C2 and C3—is the most commonly injured nerve. It innervates to the lower ear and periauricular skin and is found 6.5 cm below the external ear canal on the belly of the sternocleidomastoid muscle. Injury to this nerve occurs in around 7% of cases.
What is the most commonly injured motor nerve in facelift surgery?
What is the most commonly injured motor nerve in facelift surgery?
The marginal mandibular nerve—a motor nerve to the depressors of the oral commissure. Injury to the marginal mandibular nerve is thought to occur in less than 1% of cases and depends greatly on the facelift technique utilized.
What are other complications of facelift surgery?
What are other complications of facelift surgery?
- Skin necrosis can occur in the preauricular (most common) and postauricular (second most common) skin.
- Cobra-neck deformity describes over-prominence of the platysmal bands due to overly aggressive removal of submental fat (see below).
What are the some popular facelift techniques?
What are the some popular facelift techniques?
- Skin-only: The skin-only facelift technique is the earliest described technique, and is safe and reliable for the beginning surgeon. This technique employs subcutaneous dissection only. The skin is elevated off the underlying SMAS to a variable extent around the ear. Excess skin is trimmed and the incision is closed. The skin-only technique has the advantage of having minimal risk to the facial nerve. The main drawback of this technique is a lack of longevity, which is greatly improved with the SMAS techniques described below.
- SMAS plication: Plication describes folding the SMAS over on itself near the ear and securing it with sutures. A subcutaneous flap is elevated, but no sub-SMAS dissection is performed. The SMAS plication is performed with resorbable or permanent sutures.
- MACS lift: The minimal access cranial suspension (MACS) lift is a plication technique that utilizes only a preauricular incision and a limited skin flap dissection. Suspension sutures are used to elevate the underlying SMAS tissue vertically. These sutures pass down to the neck, jowls, and malar fat pad in a purse-string manner to achieve elevation. The main difficulty with this technique is contour irregularities from the bunching of the SMAS, though these typically flatten with time.
- Extended SMAS: Extended SMAS dissection has been purported to improve facelift results at the nasolabial fold. The SMAS is incised near the ear and elevated off of the parotid gland, where the facial nerve is protected. The SMAS is released from the upper lateral border of the zygomaticus muscle and medially to release the zygomatic retaining ligaments. As the facial nerve branches exit at the anterior border of the parotid gland, they course directly beneath the SMAS. An increased risk of facial nerve paresis has been reported with this technique.
- Deep plane: The deep plane technique is perhaps the most invasive facelift technique. It was developed to further improve the results at the nasolabial fold and the ptotic malar fat pad. This procedure begins with an extended SMAS procedure. Dissection then continues anteriorly and the surgical plane is transitioned from a sub-SMAS plane to a supra-SMAS plane to avoid injuring the facial nerve. The anterior extent of the sub-SMAS dissection is the facial artery. In the deep plane technique, the facial nerve branches are protected because they enter muscles on their undersurface.
What are some important reference angles and points with regards to facelift?
What are some important reference angles and points with regards to facelift?
- Lower Face-Throat Angle (90–105 degrees): The lower face-throat angle (LFTA) describes the extent to which the submental tissues are tucked beneath the chin. It is the angle formed by connecting a line from the cervical point (posterior most point in the submental area) to the menton (inferior most point of the chin), with a line from the subnasale (junction of the columella and upper lip) to the pogonion (anterior most point of the chin in the midline). The intersection of these lines is a virtual point called the gnathion (see figure on front).
- Mentocervical Angle (80–90 degrees): The mentocervical angle (MCA) takes into account a broader area of the face and therefore better describes the relationship of the neck to the face. The MCA is formed by the intersection of a line from the cervical point to the menton with a line from the glabella (anterior most point between the eyebrows) to the pogonion (see below).
What anatomic structures limit the improvement of the LFTA and the MCA?
What anatomic structures limit the improvement of the LFTA and the MCA?
The values of the MCA and LFTA are reliant on the relationship of the hyoid bone to the mandible. The relative position of these two entities to one another represents the limiting factor in any attempt to surgically manipulate the neckline.
What can be done about platysmal bands?
What can be done about platysmal bands?
The “corset platysmaplasty” is the most popular technique to address plastysmal bands. The medial bands of the platysma are identified via a submental crease incision. They are then trimmed, incised at the hyoid bone, and imbricated together across the midline.
SMAS plication versus deep plane facelifts?
SMAS plication versus deep plane facelifts?
Controversy
In recent years, the pendulum has swung back toward less invasive facelift techniques. This is in part due to less risk of complications, but perhaps more to a failure to realize the improved results touted by more extensive dissection techniques. Certainly, excellent results can be seen with any technique in the hands of an experienced surgeon. However, many very experienced surgeons now perform limited SMAS elevating techniques or plication in favor of extensive deep plane dissection.
Drains and/or compression dressings?
Drains and/or compression dressings?
The use of subcutaneous drains is controversial. Hematoma is the most common complication of this surgery and can even be life-threatening. Preventing this complication is foremost in the surgeon’s mind. However, drains are uncomfortable and not necessary in the majority of patients. Compression dressings wrapped around the head may reduce the risk of hematoma, but they increase the risk of focal skin necrosis. Also to be considered is the gender as well as the particular facelift technique employed, as more skin undermining tends to increase bleeding.
