5. Facial fat components may be useful as subdermal fat, nasolabial fat, or a submalar fat pad or may be detrimental as jowl fat, neck fat, or supraplatysmal fat in the neck area (Fig. 37.2). Liposuction with a 3 mm cannula is the best way to retrieve nonuseful fat compartments, prior to any dissection [1–5].
6. Midline division of platysmal bands is not manda- tory and no incision should be made, except in ex- ceptional neck deformities. Platysmal bands are the consequence of muscle contraction and not of muscular laxity. Midline pull (corset platysmaplas- ty as advocated by Feldman [9]) is a nice technique but is unnecessary in most cases: upward rotation of the SMAS and backward advancement of lateral 37.1
Introduction
Different vectors for skin and superficial musculo- aponeurotic system (SMAS) redraping are useful in order to achieve an efficient and natural face lift. Our technique fulfills the rotation and advancement con- cept described by Millard [16] for cleft-lip repair.
In the cure of a double-chin pelican’s neck, the SMAS is rotated up and inward, the platysma is ad- vanced toward the mastoid area and pulled backwards after being freed.
We have used this technique since 1975, and are greatly indebted to Bruce Connell, John Owsley and Ralph Millard, the last being a magician in skin re- draping (for the time we spent with him in Miami) [21, 22]
37.2 Anatomy
The superficial anatomy we find useful is very simple (Fig. 37.1):
1. In the fronto-temporal area, the SMAS and skin are treated as a composite layer: the dissection is performed below the galea until a frontier placed 2 cm above and parallel to the zygomatic arch.
2. Below the temporal area, skin and SMAS are dis- sected separately.
3. The most useful and solid part of the SMAS is the parotid area; the SMAS is thin and fragile in the anterior cheek area [10, 19, 20]. Dissection below the SMAS without entering the parotid gland is possible in most cases and safe, because the facial nerve runs deep there [14].
4. Platysma and parotid SMAS are in the same surgi- cal layer, thus, a plane of dissection below this complex structure is both possible and safe, while the superficial jugular vein and the great auricular nerve must be carefully preserved. Their exact po- sition is well known and is easy to detect prior to making any incision.
Fig. 37.1. Structural anatomy of SMAS
border of the platysma is generally sufficient to re- drape the neck.
7. Volumetric enhancement during face lift is not achieved by biplanar face lift: only in the zygomat- ic and malar area it is useful [13]. The central parts of the face, perioral, lips, chin, nasolabial folds, have to be separately augmented by any means favored by the surgeon.
8. The strongest attachment of the divided SMAS is in the pretragal area and the subzygomatic line.
Plication of the SMAS in any direction is an elegant trick but with no solid attachment to a fixed point of the face [8, 18, 19, 23, 24].
9. Facial retaining ligaments (as advocated by Furnas [10]) have to be cut in order to have a good facial redraping without distortion; an extended subskin dissection is mandatory.
37.3 Goals
The biplanar face lift has several targets, and as with every technique, it does not fulfill all of them (Fig. 37.3).
37.3.1 Skin Redraping
Skin redraping has to be done on a large scale, from the temporal fossa (thus we always use a high tempo- ral incision) toward the neck and the perimastoid area.
Limited skin dissection (“minilift”) may be useful in limited and well-selected cases:
1. Very young patients with no skin laxity 2. Risky dissection in heavy smokers
3. Imposed quick recovery time by a very demanding patient
4. Early face redo
Extensive skin redraping has the advantage of a good distribution of skin, with no concentration lines by exaggerated pull through scars that are too short.
Fig. 37.2. Fat compartments of the face Fig. 37.3. Targets for face rejuvenation
– SMAS laxity – Skin redundancy
Thus, we use a mild liposuction though a tiny incision in the front of the ear lobe; this liposuction is per- formed below the mandibular line and the submaxil- lary area:
– The upward pull and rotation of the facial SMAS allows the jowl to be lifted up between 2 and 4 cm depending on the case.
– Skin redundancy is corrected by the periauricular skin resection in the desired amount.
37.3.3 The Neck Area
This is the most difficult part to treat, and the first to relapse when the tissues have lost their good elastic properties. The treatment combines liposuction, pla- tysmal plication or horizontal separation, and skin redraping mostly along a 45° vector directed toward the mastoid and occipital area.
37.3.4 The Malar Area
This area has to catch the light. It is mandatory in or- der to fulfill this goal to relocate the submalar fat pad attached and sitting on the SMAS, below the skin.
The proper vector to do this is to follow the direction of the zygomatic major muscle and to slide the sub- malar fat pad toward the infraorbital area and the bony malar eminence. This is why it is advisable to cut the SMAS until the zygomatic major muscle is visible.
37.3.5 The Zygomatic Arch
This area is scarcely in focus. But we think that it is part of the facial rejuvenation when the SMAS is relo- cated along this structure. Like a curtain detached in the front of a window, the SMAS in some aging pa- tients is falling down, and should be reattached in the zygomatic arch area.
37.3.6 The Temporal Area
In my opinion there is no good face lift which does not include a temporal upward rotation: moving up
37.3.7 The Mastoid Area
There is a new trend in avoiding mastoid scars: this may be considered for some young patients (who would need just a vertical lift with mostly a vertical vector). But only the mastoid incision (horizontal or oblique or Z plasty) allows a perfect neck skin redrap- ing. The scar is more acceptable than residual neck skin redundancy or a neck which appears artificially tight.
37.3.8 Volumes
A biplanar face lift cannot enhance volumes in the central face. Only the zygomatic and malar areas ben- efit from the rotation and elevation of the parotid and cheek SMAS. But nasolabial folds, lips, hollow cheeks, and rhytids are out of the range of simple tissue re- moval. We need to replace there what the aging pro- cess has atrophied.
In the beginning of the 1980s we used SMAS strips.
But with time, some irregularities become apparent because the SMAS is a composite structure with mus- cle fibers, fat cells, and fibrous tissue. Some results are still remarkable and each year some younger authors discover a new trick in SMAS strip grafting. The strips need to be inserted with fat grafts especially in the perioral area and the cheek hollow.
Repeated fat grafts seem to work magnificently;
new fillers are also well tolerated. Polyglactic acid (New-Fill) is difficult to use but is very stable and ef- ficient, despite the pain during injection, even under local anesthesia
37.3.9 Additives
During the face-lift session, and in addition, frown lines in the front and rhytids in the orbicularis area benefit from botulinum toxin A. Nowadays, we rarely perform an endoscopic frontal lift; we simply insert an elevator through tiny incisions into the skin, scratch the corrugator muscles from below, and control the position of the instrument with a finger on top of the skin. Blepharoplasty is performed at the end of the face lift. Perioral wrinkles are no longer treated by us with a CO2 laser, but by dermabrasion: a diamond- covered hand piece inserted in a very high speed rotat-
ing machine. It is a very efficient technique to be re- done 6 months later, if necessary. Chemical peel is performed as a secondary procedure, by a qualified dermatologist, who judges the best way to do it.
37.4
Operative Technique
1. Careful patient selection and information.
2. Black-and-white photographs including present and childhood appearance.
3. Local anesthesia with sedation.
4. Betadine shampoo; no hair removal or even hair tied back: just comb wet hair.
5. Diluted Xylocaine infiltration (approximately 300 ml).
6. Incisions depending on the individual case (Fig. 37.1). Usually intratragal approach and in- side the scalp.
7. Extended skin dissection with a no. 15 blade and very long powerful scissors (designed by Mitz) (Fig. 37.4).
8. Skin undermining may be continuous in the neck area , enter the lips beyond the nasolabial folds (V.
Mitz, personal communication, Madrid), and free the arcus marginalis [19]. The extent of skin un- dermining depends on each case. Limitation of it is a nice trick. But rotation of the skin flap has to be achieved without any distortion.
9. Entering the SMAS is done through a tiny hole in the pretragal infrazygomatic space. Scissor dis- section above the parotid fascia is done if the SMAS test is positive: elevating the SMAS with forceps with a 2 cm excursion is a good sign of SMAS laxity. If no laxity is found, a horizontal SMASectomy below the zygoma is performed. If the SMAS is perfect (5% of our cases), we just per- form a skin lift. The SMAS is dissected horizon- tally until the zygomatic muscles area is reached (Fig. 37.5). The SMAS flap is cut vertically along the tragus down to the anterior border of the ex- ternal jugular vein. The platysma is freed in front of the vein, and is transected horizontally 7 cm below the mandible with control that the anterior border of the platysma has been reached and will be cut.
10. Hemostasis is extensive.
11. The SMAS and the platysma are dealt with using different vectors
– Upper and inside rotation to enhance the ma- lar and zygomatic area (Fig. 37.6)
– Relocation of the submalar fat pad
– Posterior pull of the platysma sutured to the sternocleidomastoid fascia (Fig. 37.7); all deep sutures are made with inverted knots of nylon 3/0
Fig. 37.4. Lines of SMAS surgical division
Fig. 37.5. Malar SMAS and fat pad rotation
12 Drainage on both sides.
13 Skin suturing with two planes – Absorbable polylactic acid 3/0
– 5/0 nylon around the ear; staples in temporal and mastoid area
14 No coverage of the face. But hair shampoo to re- move the blood clots with saline water. No dress- ing at all. Clean sheets on the bed with a roll put behind the back part of the neck.
15 One overnight stay in hospital. Removal of the drains one day later. Hand shampoo before leav- ing the hospital.
16 Then aftercare routine at home and removal of stitches.
ic area SMASectomy
– When the planned procedure is a graft to the naso- labial folds (which is done through an intranasal approach), you should not undermine the skin in the nasalfold area.
– Use suction drains. These may be responsible for iatrogenic hematomas but at least they take out 20–60 ml of lymph and blood on each side.
– Do not use fibrin glue.
37.6 Complications
We share the same number of complications and inci- dents as other medical colleagues.
Among them, here are a few points:
– Hematomas: Giant hematomas occur in 2% of our cases: agitation, hypertension, error in positioning the suction drain, and postoperative skin massag- ing are the main causes. I do not agree with Pitan- guy’s opinion that aspiration of the hematoma and compressive bandage may cure this. I would prefer to reoperate in the operating room, reopen the wound, and wash and coagulate a small perforat- ing vessel often found in the temporal, jugal, or mastoid area.
– Skin slough: Always use conservative treatment, and make no effort to excise or suture again. The best surgeon is the one who is prepared to allow time handle the problem.
– Frontal or buccal branch palsy: No treatment for 6 months: 95% of patients recover spontaneously. If there is still a problem, deal with it by standard treatment: botulinum toxin in the opposite side.
Fig. 37.6. Platysmal back pull toward the sternocleido-mastoid aponerosis
Fig. 37.7. Mitz sissors
– Facial fasciitis: we described this condition as a subcutanous fibrous contraction, like Dupuytren disease. It disappears within 2–4 months. Fre- quently it is associated with a depressive character and a kind of automanipulation. Steroid injections may be useful in selected cases if this condition persists too long.
– Early deterioration of the result. Five percent of our patients have a significant recurrence of skin dete- rioration. We accept a touch-up after 1 year post- operatively; sometimes with minimal fees, when the deterioration is of low grade in order to make the patient know that the skin situation is unpre- dictable.
37.7 Results
Most of the surgeons doing face lift use a biplanar- like type of face lifting procedure.
Our results have been rewarding in the last 25 years (Fig. 37.8); the number of patients is growing and our students now regularly perform this procedure; out of many cases only one patient was not happy.
This patient asked to have an operation that no- body in her family would notice. After 2 years, her son said that there is not enough difference which could be seen for the money that had been paid; the patient decided to recover her fees instead of being reoperated on.
A face lift procedures in our hands takes no longer than 2.5 h. Most of our patients are still very happy with their result even after 10 years.
37.8 Conclusions
The biplanar face lift procedure including skin un- dermining and a SMAS platysma flap treated as sepa- rate layers is still our procedure of choice.
The concept of rotation advancement is of valuable interest in both layers dealt with different vectors in order to relocate in depth and redistribute in the sur- face.
Complications may still arise and good results can be achieved with this precise, difficult, and lengthy procedure compared with the result which can be achieved from the minimal lifts advocated today. But who knows the most can accomplish the least.
References
1. Cardoso de Castro C. The anatomy of platysma muscle.
Plast. Reconstr. Surg. 66:680, 1980
2. Cardoso de Castro C. The role of the superficial musculo- aponevrotic system in face lift. Ann. Plast. Surg. 16:279, 3. Cardoso de Castro C. Superficial musculo-aponevrotic 1984 system platysma. A continuous study. Ann. Plast. Surg.
26:201, 1991
4. Cardoso de Castro C. The superficial musculo-aponev- rotic system in rhytidoplasty. Oper. Tech. Plast. Reconstr.
Surg. 2 1995
5. Cardoso de Castro C. The changing role of platysma in face lifting. Plast. Reconstr. Surg. 105: 764, 2000
6. Connell B.F. Cervical lifts: the value of plastysma flaps.
Ann. Plast. Surg 1:32, 1978
7. Connell B.F. Contouring the neek in rhytidectomy by li- pectomy and muscle sling. Plast. Reconstr. Surg. 61:376, 8. Connell B.F, Semalcher R.A. Contemporary deep layer fa-1978
cial rejuvenation. Plast. Reconstr. Surg. 100:1513, 1997 9. Feldmann J.J. Corset platysma plasty. Clin. Plast. Surg
19:369, 1992
10. Furnas D.W. The retaining ligaments of the cheek. Plast.
Reconstr. Surg. 83:11, 1989
11. Goulian D. The need for extensive undermining in face lifting operations. Br J Plast. Surg. 26:387, 1973
12. Guerrerosantos J. The role of the plastysma muscle in rhytidectomy. Clin. Plast. Surg. 5:29, 1978
13. Little. J.W. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast. Reconstr. Surg.
105:252, 2000
14. Mackinney P. Parotid fascia and face lifting. Plast. Recon- str. Surg. 75:439, 1985
15. Matarasso A., Elkwood A., Rankin M., Elko Witz M. Na- tional plastic surgery survey face lift techniques and com- plications. Plast. Reconstr. Surg. 106:1185, 2000
16. Millard D.R. Refinements in rotation advancement cleft lip technique. Plast. Reconstr. Surg. 33:26, 1964
17. Millard D.R. Cleft craft. Little Brown, Boston, 1976 18. Mitz V. Current face lifting procedure: an attempt of eval-
uation. Ann. Plast. Surg. 17:184, 1986
19. Mitz. V. Use of deep planes in surgery of rejuvenation of the face. Chirurgie 117:278, 1991
20. Mitz V., Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast. Re- constr. Surg. 58:80, 1976
21. Owsley J.Q. A preliminary report. Platysma-facial rhytid- ectomy. Plast. Reconstr. Surg. 60:843, 1977
22. Owsley J.Q. Lifting the malar fat pad for correction of prominent nasalabial folds. Plast. Reconstr. Surg. 91:462, 23. Pitanguy I. Consideracoes sobre nossa experiencia com 1993 dissecçao e plicatura do SMAS em meloplastia. Rev Bras Cir 71:57, 1981
24. Stuzin J.M., Baker J.J. Gordon H.L., Baker T.M. Extended SMAS dissection as an approach to mid face rejuvenation.
Clin. Plast. Surg. 22:295, 1995
Fig. 37.8. Continued
