51
in a prominent area. To avoid an unsightly yawning of the meatus acusticus, the small flap eventually cover- ing the tragus will have to be thoroughly defatted and shaped generously in order to avoid forward traction (Figs 51.2, 51.3).
Another important point is the design of the hori- zontal incision. Beyond the orbital rim, the incision should be directed upwards, following one of the up- per crow’s-feet folds, thus reaching the hair-bearing area in a lazy curve. From there, the incision follows the scalp border to the preauricular area (Fig. 51.4).
Pinching the skin over the zygomatic arch, one can get a rough idea of how much skin can be removed there. Having already drawn the upper incision line, the estimated amount of removable skin can now be marked below this line (Fig. 51.5). The estimated re- section line can now be drawn, starting at the inner canthus and delimiting a slender triangle of which the long sides have a similar curved pattern. The maxi- mum width is situated just before the hairline and usually measures between 20 and 30 mm.
51.1 Introduction
The last 50 years has been a period of intense diversi- fication of facial rejuvenation surgery. Face-lifting procedures have been developed further, becoming more extensive in all dimensions as the mechanisms generating the visible signs of aging became better understood.
Parallel to the trend that favored more invasive and often more traumatizing techniques that promised better and longer-lasting results, there were always tendencies where one would try to achieve with a light, precise and well-aimed surgical gesture a favor- able result in a given situation.
If one agrees that in the face and neck unsightly signs of aging are mainly due to skin alteration and associated soft-tissue shifts, there are a series of small- er procedures available if one accepts a fine incon- spicuous scar in a visible area.
A good understanding of the vectors implied in re- positioning surgery of the face helps to determine the required tissue shift.
51.2
Temporo-canthal Rhitydectomy
After repeated facelift procedures implying vertical soft-tissue repositioning and diagonal skin traction, a more vertical skin shift including the subjacent soft tissue becomes necessary in most cases. Such an up- ward advancement brings redundant skin to the in- frapalpebral area as well as to the malar and temporal area. Incisions at the border of the hair-bearing area can take care of the skin abundance in the latter re- gion. As a lower blepharoplasty will then also be re- quired, it makes sense to use what we call the tempo- ro-canthal incision [1], which starts at the inner canthus and goes all the way to the fossa supratragica (Fig. 51.1). From there, the incision can be carried downwards behind or in front of the tragus, depend- ing on the convictions of the surgeon. We favor the retrotragal incision that does not leave a telltale scar
Skin Resection Rhytidoplasty
Ulrich K. Kesselring
Fig. 51.1. The temporo-canthal incision makes sense since in most cases a lower blepharoplasty has to be performed
375 51 Skin Resection Rhytidoplasty
This resection pattern minimizes the risk of creat- ing an ectropion. To be even more on the safe side, the orbicularis oculi muscle can be attached in the lateral canthal region to the orbital rim periosteum with an absorbable 5/0 suture (Fig. 51.6).
Once the initial incisions have been made, the sur- geon will decide how to intervene on the subjacent structures. All options are possible and all planes eas- ily accessible (Fig. 51.7).
The advantage of this and other, related incision patterns resides in the fact that the skin shift vector points in the right direction and we can achieve a considerable tissue lifting and tightening effect down to the mandibula-neck angle without displacing the scalp (Fig. 51.8).
Fig. 51.2. The defattening of the small
“peninsula flap” which will cover the tragus is essential. It will allow the skin to smoothly adhere and reproduce the cartilaginous structure
Fig. 51.3. If required, the removed fat can be grafted into the
tear troughs or the lips Fig. 51.4. After following one of the crow’s-feet folds, the tem- poro-canthal incision curves down in front of the hair-bearing area to reach the fossa supratragica
Fig. 51.7. As this incision gives a generous access and view of the deeper layers, any technique can be used at that level Fig. 51.6. The orbicularis oculi muscle, which is attached to
our skin/muscle flap, will be attached to the orbital rim perio- steum with one suture
Fig. 51.5. Pinching the skin above the zygomatic arch gives an indication of how much skin can be removed at that level
377 51 Skin Resection Rhytidoplasty
51.3 The Difficult Neck
A crucial telltale area that can be addressed separately also is the neck area, if there is a significant redun- dancy of skin and platysma with or without excessive fat tissue.
This symptomatology is usually dealt with during a comprehensive facelift, combined with a minimal incision submental procedure. There are, however, patients who do not wish to undergo such extensive surgery, e.g., the typical male patient who just wants to be able to close his collar button to wear a tie rather than to hide his turkey gobbler neck behind a John Wayne neckerchief.
For these cases we use a midline multiple w skin resection [2], which gives excellent access to the sub- jacent structures (Fig. 51.9) that can now be surgically modified and rearranged as necessary. It is also a nice approach to do a first-time Connell [3] or a Feldman [4] procedure with an anatomical view of the layers involved. Precise skin approximation and suturing are imperative and make all the difference in the final appearance of the scar (Fig. 51.10). In an aged, atro- phic skin, one or two simple Z-plasties instead of a long W-closure may be a valid alternative (Fig. 51.11).
This operation is not suitable for patients with drooping jowls as the forward repositioning of the neck skin can accentuate that problem.
51.4
Drooping Lip Commissures
Downward drawn mouth angles give the face a bitter, disapproving expression. The multifactor etiology includes lower-lip retraction through soft-tissue loss, cheek ptosis and chronic mimic activity.
The problem has been addressed in various ways, surgically, with fillers or with Botox. Austin and Weston [5] reported a simple skin resection above the commissures (Fig. 51.12). We added to this technique the subtotal transection of the m. depressor anguli oris, folding its stump upon itself and keeping this pad in place with a 6/0 absorbable suture (Fig. 51.13).
With this procedure we reposition the angles of the mouth cranially, we weaken significantly the active downward pull and we fill the subangular depression with our pad.
The scar, which lies some 10 mm along the upper vermilion border and reaches 10 mm into the adja- cent cheek skin, is very inconspicuous and always well accepted by the patients (Fig. 51.14).
References
1. Kesselring, UK: Die temporo-canthale inzision beim Face- lift. Congress of the German Plastic Surgeons, Düsseldorf 1989.
2. Kesselring, UK: Direct Approach to the Difficult Anterior Neck Region. ISAPS course, Tokyo 1991.
3. Connell, BF, Shamoun, IM: The significance of digastric muscle contouring for rejuvenation of the submental area.
Plast Reconstr Surg 99: 1586, 1979.
4. Feldmann, JJ: Corset platysmaplasty. Plast Reconstr Surg 85: 333, 1990
5. Austin, H, Weston, G: Rejuvenation of the Aging Mouth.
Clin Plast Surg 19:511, 1992.
Fig. 51.8. Case: 81 year old lady, secondary face lift, pre-op and 3 months post-op
Fig. 51.10. Precise skin approximation is essential to produce an inconspicu- ous scar
Fig. 51.9. The vertical multiple w skin resec- tion in the neck gives excellent access to the subjacent structures
379 51 Skin Resection Rhytidoplasty Fig. 51.11. Case: 59 year old patient, pre-op and 6 months post W-neck plasty
Fig. 51.14. Case: 51.14 67 year old patient, pre-op and 14 months after lip commissure plasty Fig. 51.12. The lozenge skin resection along the upper vermil-
ion border reaches beyond the commissure and gives access to the depressor muscle
Fig. 51.13. Under direct view the muscle is transected cranially and the stump folded and sutured upon itself. The resulting pad efficiently fills the infraangular “bitterness troughs”
