Chapter 3 Facelift
Kenneth Hughes, MD
1)What are the factors that result in the aging face?
Referred to as elastosis, this process results in loss of collagen and elastin fibers due to:
a) Extrinsic factors = actinic damage and gravity
b) Intrinsic factors = genetic factors
2)Name three factors which contribute to less than ideal results in facelift?
a) Poor elasticity
b) Heavy actinic damage
c) Deep, coarse facial rhytids
3)Please explain UV light damage?
a) UV light induces photoaging through generation of reactive oxygen species (ROS) that damage enzymes after being absorbed by chromophores. Alpha tocopherol, a superoxide scavenging antioxidant, may counter these effects. The mechanism of dermal damage occurs via induction of three metalloproteinases capable of degrading the dermal collagen matrix.
b) UVB causes direct damage; wavelength: 280 to 315; responsible for most of DNA damage of skin.
c) UVA acts through other active molecules; wavelength: 315-400 nm; causes damage if 100 to 1000X dose of UVB (unfortunately there is considerably more UVA light making it through the ozone).
4) What are the endogenous changes that occur with aging?
a) Glycosaminoglycans and proteoglycans decrease with age – Rationale for use of Restylane and Hylaform
b) Collagen decreases by 6 % per decade resulting in dermal thinning. There is a decrease of Type I collagen. Type I:III ratio actually increases.
5) Discuss various disorders and whether facelift would be contraindicated?
b) Pseudoxanthoma elasticum: occurs in 2 dominant and 2 recessive forms: recessive form (Type II) – entire skin is loose fitting, diagnose by biopsy to differentiate from cutis laxa, surgery may be indicated if do not have severe systemic symptoms
c) Ehlers-Danlos Syndrome (Cutis Hyperelastica): hypermobile joints, very thin, friable, and hyperextensible skin, subcutaneous hemorrhage, may stretch skin up to 15 cm or more and it will shrink back, posttraumatic bleeding, poor wound healing (due to inadequate production of enzyme lysyl oxidase), surgery contraindicated
d) Progeria (Hutchinson-Gilford Syndrome): rare, unknown etiology, autosomal recessive, craniofacial disproportion (due to premature closure of epiphyses), baldness, pinched nose, protruding ears, micrognathia, loss of subcutaneous fat, arteriosclerosis, and cardiac disease, do not reach reproductive age, surgery contraindicated
e) Werner’s Syndrome (Adult Progeria): autosomal recessive, baldness, aged facies, hypo and hyperpigmentation, short stature, high pitched voice, cataracts, mild DM, muscle atrophy, osteoporosis, premature arteriosclerosis, various neoplasms, severe microangiopathy, surgery contraindicated
f) Meretoja Syndrome: systemic form of amyloidosis, excessively lax skin in persons 20 years or older, facial polyneuropathy, amyloid deposits in perineurium and endoneurium of peripheral nerves, facial neuropathy helps differentiate this disease, surgery contraindicated
g) Idiopathic skin laxity disorders (MDE): patchy areas of mid-dermal elastolysis (MDE), localized fine wrinkling, without systemic abnormalities, pathogenesis is poorly understood, surgery contraindicated
6) Discuss the difference between facial soft tissue perfusion over the lateral versus the anterior or central face?
a) Anterior face – perfused by numerous small musculocutaneous perforators;
b) Lateral face – perfused by relatively few but large fasciocutaneous perforators;
c) By virtue of elevating facial flaps a significant portion of the fasciocutaneous perforators are disrupted so that the soft tissue must rely on the central musculocutaneous perforators. Medial dissection thus must be performed conservatively in order to avoid blood flow compromise.
7) What is the cause of the hollowed out look in the cheek region following a facelift during which the malar fat was transposed to its pre-ptotic locale?
The malar fat pad itself may atrophy due to disruption of its blood supply resulting in the hollowed out look of the cheek. The malar fat pad is perfused preferentially by the angular artery musculocutaneous perforators. If this fat is mobilized in the skin layer and aggressively translocated ( > 2 cm), the blood supply can be disrupted. The malar fat pad should be kept in continuity with the SMAS layer. This maneuver preserves its musculocutaneous perforators if requiring greater than a 2 cm lift.
8) What is the endpoint to each of the described dissection layers in the cheeks?
a) Skin elevation: release of the nasolabial fold
b) SMAS elevation: upturning of the modiolus
9) Discuss some of the differences between the male and female face and implications on facelift?
a) The rate of hematoma (6 to 8%) in the male is twice that of a female.
b) The vascularity of the skin flap, primarily due to the beard, makes hemostasis more difficult.
c) The beard in the male argues in favor of a pretragal incision, as the beard can obscure the light reflex of the anterior scar. Furthermore, a retrotragal incision may produce unwanted hair growth overlying the tragus.
d) The beard and sideburns of the male can be grown longer to mask superior hairline migration.
10) Describe the superficial musculoaponeurotic system or SMAS?
The SMAS was first described by Mitz and Peyronie by 1976. The SMAS becomes attenuated centrally and more fascial over the parotid fascia and over the zygoma region. Understanding the continuity of the SMAS with other facial planes will allow for safe mobilization and will protect all facial nerve branches.
From superior to inferior, the SMAS is continuous with :
a) Galea, frontalis
b) Superficial temporal fascia (STF) or temporoparietal fascia (TPF)
e) Superficial cervical fascia (SCF)
11) Describe the continuity at the tissue plane of the deep temporal fascia?
From superior to inferior:
a) Cranial periosteum
b) Deep temporal fascia (DTF)
c) Parotidomasseteric fascia
d) Deep cervical fascia (DCF)
The DTF splits into two layers, superficial and deep, which surround the superficial temporal fat pad as they extend inferiorly. The superficial layer then becomes the parotidomasseteric fascia.
12) Which of the mimetic muscles are innervated along their anterior surface?
The buccinator, mentalis, and levator anguli oris. All of the other mimetic muscles are innervated deeply.
13) Describe the retaining ligaments and their significance?
a) Osseocutaneous ligaments include the zygomatic and mandibular ligaments. Zygomatic ligaments are responsible for malar fat descent and nasolabial fold deepening.
b) Soft-tissue cutaneous ligaments include the masseteric cutaneous ligaments, which stretch from the anterior border of masseter to the skin and are responsible for jowling.
c) Orbicularis oculi cutaneous ligaments 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 the development of festoons.
14) Describe several of the most common approaches to facelifting?
Most plastic surgeons perform some combination of SMAS and skin relocation. The direction of SMAS pull tends to be vertical as opposed to skin flap redraping, oriented along a more horizontal vector.
a) Skin only: SubQ undermining without addressing SMAS. Safe plane of dissection, but reliance upon only skin tensioning may compromise longevity.
b) SMAS plication: improves facial contour and shape through suture manipulation and is preferred in the thin patient where facial volume is at a premium.
c) Formal SMAS elevation: may allow for better fixation than plication alone which may improve longevity of result.
d) Lateral SMASectomy: popularized by Baker involves excision of a 1 to 2 cm strip of SMAS along the anterior border of the parotid, extending from the mandibular border obliquely to the malar pad. The strip orientation can be altered to influence the vector of SMAS lift. Technique may not be suitable for thin patient.
e) MACS (minimal access cranial suspension): developed by Tonnard – the SMAS is purse-string sutured to the deep temporal fascia with two sutures to correct the neck and the lower third of the face and sometimes an additional suture to address the malar fat pad. The skin flap is elevated through a preauricular and pretemporal hairline incision.
f) Deep plane procedure: advocated by Hamra and Barton – both the skin and SMAS are mobilized in continuity preserving blood supply to the overlying skin. However, differential vectors of the skin and SMAS cannot be created with this technique and facial nerve injury is 4 times as common as with subQ undermining techniques.
g) Subperiosteal face lifting through a temporal or lower lid approach can be useful in the young patient with little skin laxity. Patients with more pronounced skin laxity require more traditional techniques that excise and redrape skin. The technique does not address the lower third of the face or the neck, only the midface.
15) Describe the various nerves and their significance to facelift?
a) Buccal branch: if injured not typically symptomatic since it demonstrates collateral innervation in 70% of patients
b) Frontal or temporal branch: collateral innervation observed in only 15 % patients; found on Pitanguy line from 0.5 cm below tragus to 1.5 cm above lateral eyebrow. The temporal branch of the facial nerve is found within the temporoparietal fascia above the zygoma. Dissection must either be subcutaneous and superficial to the frontal branch or deep to the temporoparietal fascia.. The temporal branch or branches cross the middle third of the zygoma. Below the zygoma, one should stay superficial to the parotidomasseteric fascia to prevent injury.
c) Marginal mandibular branch: travels along mandibular angle; 81 % travel above border of mandible vs. 19 % below body of mandible; damage to this nerve causes loss of depressor anguli oris and depressor labii inferioris function. The platysma can compensate for its role to some extent in cases of MM injury.
d) Great auricular nerve (GAN): located at 6.5 cm inferior to external auditory meatus as it crosses the anterior belly of the sternocleidomastoid muscle; the nerve runs in close proximity to the external jugular vein and is invested in the superficial fascia of the sternocleidomastoid (SCM)
e) Lesser occipital: innervates superior cranial surface of ear, may be injured at it runs along the posterior border of the SCM
f) Greater occipital nerve: supplying the mastoid area not typically injured as its path is more posterior to the field of dissection
g) Auriculotemporal nerve: supplies the tragus and the root of the helix and can be seen running superficial to the temporoparietal fascia during the subcutaneous elevation of the temporal flap during a facelift
h) Spinal Accessory Nerve: not typically injured as it supplies the SCM from the deep surface
16) Discuss several common ways of dealing with the neck in a facelift?
a) When rejuvenating the lower face and neck, the surgeon must determine if wide subcutaneous undermining to or near the midline through the lateral incisions will allow adequate submental contour or if a submental incision must be employed.
b) Indications for a submental incision may include patients with extensive neck fat, moderate to severe skin laxity, a lax decussation of the platysma, or to improve visualization in dealing with platysmal bands, subplatysmal fat, full anterior digastric muscles, and prominent submandibular glands. A platysmaplasty, such as Feldman corset platysmaplasty or some medial plication variation, is commonly used to address a lax platysma.
c) Suction lipectomy is most effective in those patients with no, mild, or moderate skin laxity but can serve as a useful adjunct to other manuevers.
d) Fat removal at any level should be conservative to avoid contour abnormalities and the “dug-out” neck deformity.
17) Discuss the complications of rhytidectomy?
a) Hematoma: most common complication at 3% in females; more common in men averaging 6 to 8 %; associated with systolic blood pressure of 150 or greater. Stop meds with anticoagulant effect, such as aspirin, Plavix, Coumadin, NSAIDS, ginkgo, garlic, and vitamin E at least 1 week prior to surgery.
Avoid vomiting, coughing, anxiety, or pain as these are contributing factors. Drains do not prevent hematomas The treatment of a hematoma is evacuation.
b) Postoperative hypertension, which can lead to hematoma. To avoid this, may prophylax with chlorpromazine 25 mg 1 hr before completing surgery and again 3 hours after surgery; repeat dose at 4 hr intervals for 24 hours if SBP > 150; may also use po clonidine or clonidine patch
c) Nerve injury: buccal branch most often injured but is asymptomatic; GAN: second most common nerve injury (the most common symptomatic nerve injury); Marginal mandibular nerve is injured more often than frontal branch nerve due to advent of platysmal slings that has resulted in an increased incidence of transient marginal mandibular deficits
d) Skin dehiscence or skin slough : associated with aggressive medial dissection of the skin flap, tension at the closure, and cigarette smoking; nicotine known to trigger release of epinephrine and increase platelet adhesion; nicotine retards wound healing; treatment is local wound care, healing by secondary intention; scar revision as needed, and frequent visits for reassurance
e) Alopecia: the tension of the closure is usually the culprit (facelift should be a redraping more than a tensioning procedure); electrocautery at the level of the hair follicle, rough tissue handling, and poor scalp flap design may all contribute. Beveling the temporal incision cuts through the hair root at variable levels and preserves the hair root to a small extent. The healing scar may produce a variable amount of hair.
f) Wide scars or cross hatched scars – frequently due to excessive tension at closure. One should use fine sutures (5-0 or 6-0) that are removed in 5 days.
g) Displacement of the sideburn and temple hair can be avoided by a hairline incision
h) Noticeable postauricular scar – these incisions should always be placed in the auriculomastoid sulcus to obscure visibility.
i) “Double chin” – A submental incision placed directly in the submental crease can accentuate a "double chin". Placing the incision 1 to 2 cm inferior to the crease allows undermining in the area and the scar is hidden in the mandibular shadow.
j) Pixie and loving cup ear deformities – there should be no tension when insetting the earlobe to avoid these two deformities.
k) Infection: RARE, less than 0.5% after facelift
Click on the links below to view a few of the chapters written by Dr. Hughes
Chapter 2: Photography in Plastic Surgery
Chapter 3: Facelift
Chapter 4: Fat Grafting
Chapter 5: Fillers
Chapter 6: The Role of Dermal Matrices in Breast Augmentation
Chapter 7: Scar Revision in Plastic Surgery
Come to Hughes Plastic Surgery in Los Angeles and Beverly Hills. You will be glad that you did.