64
If the distance from the lateral canthus to the hair- line at the sideburn exceeds 4 cm, it is considered to be receded and therefore further posterior pulling should be avoided [3] (Fig. 64.1).
The incision is carried out in accordance with the guidelines of Camirand [4] using a no. 11 blade, held at 45°, leaving intact hair follicles distally within the underlying dermis (Fig. 64.2). Hair growth through the scar will follow and make the scar inconspicuous to invisible.
Contrary to what has classically been taught for years, the proper hairline incision should be perpen- dicular, and not parallel, to the hair follicles (Fig. 64.3).
If the incision is made parallel to the hairs, the sub- sequent scar frames the border of the hairline and is visible.
The preferred incision that we suggest is made 1–2 mm inside the hairline and is beveled perpendic- ularly to the hair follicles, keeping a residual dermis abundant with hair follicles in the dermis (Fig. 64.4).
Frequently, patients allow their hair to be styled in a way that exposes the invisible suture line (Fig. 64.5).
64.1 Introduction
Achieving a fresh and natural look, safely, with mini- mal risks and without visible scars, is the key goal of all facial rejuvenation surgery. Some of the unfavor- able stigmata of rhytidectomy are visible scars, ear- lobe malposition, distortion or flattening of the tra- gus, superiorly or posteriorly displaced hairlines, and unnaturally directed wrinkles (lateral sweep) caused by lateral vector tightening of the lower face with downward and inward sagging of the midface [1].
64.2
Incisions: Planning and Execution
Our keys to fine scars are comprehensive preopera- tive planning, particularly regarding the auricular contour, the sideburn, the temporal hairline, and pos- terior scalp hairline, and flap inset with no tension.
Today, our scars are only as long as necessary to directly correct an area that needs improvement. Any facelift incision should preserve the anatomic details of the ear and hairlines. The length, orientation and location of the temporal incision may vary, depend- ing on individual parameters.
In patients with low and anteriorly positioned side- burns, the incision is located within the hair-bearing temporal scalp, proceeding into the temple cephali- cally.
It is important to realize that unless this incision is carried out well beyond the temporal line of adhesion and the periorbital septum (orbital periosteum) re- leased from the orbit, there will be no lifting effect on the temporal area [2].
Carrying the incision up in that direction will only serve to treat the “crowding” and excess of hair-bear- ing scalp created by the vertical pull, thus paying a high cost for a relative poor return. On the other hand, a recessed hairline requires intratrichial inci- sion at the sideburn horizontally, curling up as neces- sary.
Concepts, Tricks and Tips in Facelift Surgery
Michael Scheflan, Tal Friedman
Fig. 64.1. If the distance from the lateral cantus to the sideburn is more than 4 cm, then the incision is made at the hairline, in order to avoid further recession
Fig. 64.2. The incision is carried out in accordance with the guidelines of Camirand [4], leaving intact hair follicles distal to the cut, by holding the knife at a 45° angle
Fig. 64.3. The hairline incision should be oblique and perpen- dicular, and not parallel to the hair follicles
Fig. 64.4. The hairs grow through the scar, making it less conspicuous, as these different close-ups demon- strate a, b
Fig. 64.5. These scars become so incon- spicuous that patients allow the hair to be styled, exposing the scar
Being relatively short, a vertical “zigzag”, or w-plasty incision is made through the hair-bearing scalp, enabling compensation for the incongruent length between the proximal and distal margins, thereby preventing dog-ears, as well as preventing the contracture potential of the linear scar (Fig. 64.6).
Though controversy exists regarding the tragal part of the preauricular curvilinear incision, we pre- fer a retrotragal placement in women. Commonly quoted reasons for avoiding a retrotragal incision are greater likelihood of distortion of external ear anato- my, including blunting the fold anterior to the tragus, tragal distortion due to tension, external auditory me- atal show, and loss of the natural cheek/ear interface [5–7]. A simple through-and-through transtragal su- ture and no tension as described later, maintains its natural appearance. These possible unfavorable stig- mata are rare when using appropriate guidelines and techniques.
After exiting the tragus with a near 90° angle, the incision proceeds anterior to the lobule at the base of the intertragal incisure, and then hugs the inferior as- pect of the lobule, towards the postauricular sulcus.
Retroauricular extension is necessary only when significant neck skin redundancy is present. Other- wise the incision is short, ending just posterior to the lobule.
When active platysmal bands are present or when- ever opening of the neck is indicated, the submental incision is placed anterior to the crease. This helps obliterate and soften the crease.
64.3 The “Deep” Work
Patients age in a slightly different manner. The quan- tity, quality and vector of soft-tissue descent vary, ne- cessitating an individualized approach based on the physical examination and the patients photographs.
The pull vector of the superficial muscolo-aponeu- rotic system (SMAS) and the direction of the redrap- ing of the skin flap must be individually determined, especially when dealing with sun-damaged skin [8].
Skin laxity in the aging face also occurs in differ- ent directions. Using the skin envelope as a handle to re-elevate deep facial structures is not reliable, as it will stretch in an unpredictable way and may lead to inadequate rejuvenation and early relapse and subse- quent facial distortion, especially in individuals with sun-damaged-skin.
We believe that a good result may be obtained by dealing with these two layers individually, utilizing different vectors.
Most patients undergoing rhytidectomy will bene- fit from deep structure tightening prior to skin flap redraping. In essence, tightening or molding of the underlying SMAS is a reliable scaffold for better and longer-lasting results.
We undermine the adipocutaneous flap superfi- cially, under direct vision, leaving cobblestone-like, thin fat globules on the under surface of the semi- translucent skin.
The flap is elevated using direct vision, sharp dis- section in the dense pre- and postauricular areas and blunt dissection in the central third of the face and neck, using the spatulated-tipped dissection scissors, designed by Trepsat [9] (Fig. 64.7).
Fig. 64.6. The intratrichial w-plasty incision produces inconspicuous-to- invisible scar
For the last 5 years, we have performed a direct oblique SMAS trim, or lateral SMASectomy (as intro- duced by Dan Baker from New York), in almost all of our facelift patients, and find this technique rapid, safe, reproducible and long-lasting [10]. In all other (thin and secondary) patients we use direct SMAS pli- cation without trimming.
The axis of SMASectomy is marked, extending on a tangent from the malar eminence to the mandibular angle, directly over to the parotid gland, and caudally along the lateral platysmal border (Fig. 64.8). The SMASectomy is oriented so that the elevation vectors following closure are perpendicular to the vectors of midface and low-face descent.
With forceps, the amount of SMAS laxity is as- sessed and excised. The first suture is placed from the lateral platysma at 2–4 cm below the mandibular bor- der to the fixed preparotid fascia in front of the ear.
The rest is closed directly with interrupted or run- ning 3/0 PDS sutures from above the malar eminence and down towards the parotid fascia.
64.4 Flap Insetting
The redraped skin flap is closed with no tension what- soever except for two anchoring points. The superior fixation suture anchors the cheek flap to the superfi- cial temporal fascia, under moderate to high tension.
A second suture anchors the more caudal portion of the posterior flap, to the mastoid fascia. The rest of the skin surface is sutured with essentially no tension.
To emphasize a natural pretragal crease, a distinct depression is created by a through-and-through su- ture entering the skin of the external auditory canal, through the tragal cartilage, tacking the dermis of the skin flap and exiting back into the external auditory canal (Fig. 64.9).
Together with proper defatting of the skin flap and the pretragal region when indicated, this depression is essential for the natural look of the preauricular region, and also serves as a pivot point allowing an angle change form cheek to ear.
Infraauricular skin is redraped around the lobule with no tension. The flap is inset under the lobule with no skin resection, allowing the lobule to hang tension-free before being sutured into place.
Fig. 64.7. Trepsat spatulated-tipped dissection scissors used for blunt dissection in the central third of the face and neck
Fig. 64.8. The axis of superficial muscolo-aponeurotic system (SMAS)-ectomy is marked, from the malar eminence to the mandibular angle and platysmal border, after excision and before closure
64.5 The Neck
The delineation of the cervicomandibular angle plays an important role in the appearance of the attractive, youthful neck [11, 12]. Occasionally, patients are more concerned with the appearance of their necks than that of their faces. As a direct continuation of the ag- ing process of the lower face, the aging neck is mainly attributed to loss of platysmal tone, loose skin, to- gether with periplatysmal fat deposits.
We manage most necks today by combining lipo- suction with lateral muscle tightening and skin re- draping.
When indicated, a medial plication is added, and in heavy necks or with active platysmal bands, a com- plete corset platysmaplasty is undertaken as described by Feldman [13] (Fig. 64.10). Lateral platysma plica- tion helps define the jawline at the mandibular angle and improves contouring in the submandibular re- gion.
We use close suction-assisted lipectomy (SAL) to defat the submental area and jowls, both “close” at the onset and “open” prior to skin redraping. Special at- tention is directed to fat deposits often found between and under the platysmal bands (subplatysmal fat).
This fat cannot be addressed by liposuction and should be treated by direct excision using the electro- cautry needle as it is quite vascular.
Care should be taken to stay conservative when ad- dressing the subplatysmal fat to avoid creating an un- sightly depression under the chin.
As more skin is required to cover a sculpted neck with an acute cervicomental angle than to drape a heavy neck with an obtuse angle, excess skin is rarely a problem in younger patients with good skin elastic- ity. When there is excess skin, along with poor skin elasticity, there is a need for skin excision. In these pa- tients a postauricular, full extent, hairline incision is recommended, in order to accommodate skin excision without distorting the posterior hairline integrity.
Partial submandibular gland excision is fraught with controversy, as is resection of the anterior belly
Fig. 64.9. Creating a pretragal sulcus using an absorbable, through-and- through suture, entering via the external auditory canal to the dermis and back
Fig. 64.10. Face lifting with complete corset platysmaplasty and suture suspension: Left to right: Preoperatively, 10 days post- operatively, 5 years postoperatively
of the digestric muscles [14, 15]. Though the subman- dibular glands are often visible, most cases of promi- nent glands are mild, and patients are unaware of its existence. Nevertheless, we always notify the patients that the fullness created by a visible gland preopera- tively may be more noticeable after rhytidectomy. Our attitude towards the ptotic submandibular glands and digestric muscles is conservative, which means we leave them untouched.
64.6
Volume Replacement
Tight facial skin is not equivalent to youth. The at- tractive young face has smooth, soft and rounded shapes [16]. An integral part of almost every facelift procedure in our practice is volume replacement;
therefore, at present, we perform a facelift and lipo- structure (lipofilling, lipoinjection) in the same op- erative session.
Volume replacement using liposculplture with simple, operating field processing of the fat has be- come an integral part of the daily practice of our fa- cial rejuvenation surgery.
The locations where fat is to be injected are marked on the face, with the patient in the upright position.
We usually harvest fat from the lower abdomen or pertrochanteric region.
64.6.1
Fat Processing for Injection
The volume survival of transplanted fat has proved difficult to estimate and our impression is that more fat “takes” and remains stable when Coleman’s prin- ciples of atraumatic harvesting and transfer are re- spected [17].
There is still no agreement concerning the best way of processing the harvested fat prior to reinjection.
Our experience with “cotton towel processing” is quite encouraging (Fig. 64.11).
The ideal processing technique should provide vi- able adipose tissue, with less subsequent absorption of the injected fat, and should be simple, fast and cheap.
Cotton towel processing utilizes a sterile operating room cotton towel as an absorption surface, separat- ing fat cells from fluids, oil and debris. When com- pared with the closed centrifugation technique, oper- ating field drape technique provided equal or better fat quality (less fibrosis), while there was no differ- ence in fat uptake between the methods [18].
We believe now that centrifugal processing of the harvested fat prior to reinjection may not be neces- sary.
64.6.2 Lipostructure
Rejuvenation of the midface using lipostructure may in our opinion obtain results that are equivalent to those of more aggressive techniques of reshaping those same areas [19].
If volume is restored, the face appears rounded, healthy, attractive and younger. We also believe in the importance of cheek sculpture in the younger patient searching for a fuller malar eminence (Fig. 64.12).
The structures we can improve by fat injections are the lips and perioral area, the periorbital area, the chin, jowls, cheeks, glabellar area and nose. The lips and the lid–cheek junction are the two most difficult regions for lipofilling. Lipostructuring these sites is occasion- ally fraught with significant postoperative swelling, visible grafts and irregularities, and all too often un- predictable survival of the grafted fat particles.
Owing to different soft-tissue properties, motion and underlying structures, a different survival rate in different anatomical areas of the face is observed, and the incidence of secondary surgery and touch-ups varies with recipient site.
It has been our personal experience that only 60%
of the patients having lipofilling of the lips are satis- fied with one procedure, while 20% require a second procedure, 18% a third, and 2% need more than three interventions to achieve a satisfactory and stable re- sult.
Fig. 64.11. Processing utilizes a sterile operating room cotton towel as an absorption surface, separating fat cells from fluids, oil and debris
The second most difficult area to graft fat in is the cheek–eyelid junction. In this thin and delicate soft- tissue area, 80% of the patients are satisfied with one procedure, 10% with two, 8% with three, and 2% with more than three interventions. The main problem in this area is hiding the fat “parcels” under the thin cov- erage.
Other areas such as the malar, submalar, glabelar, perorbital, frontal, mental and mandibular regions are more favorable. In those areas, when injecting di- rectly over the bone, 95% of the patients are satisfied with one procedure, and 5% with two.
Fig. 64.12. Lipostructure helps shaping and restoring depleted facial fat
64.7 Conclusions
Well-planed and carefully executed rhytidectomy incisions are practically invisible. Incision placement should be individualized to fit the needs, desires and specific anatomic characteristics of the patient. Sim- ple and safe manipulation of the SMAS and the pla- tysma is adequate and long-lasting in all patients [20].
Liposuction along with lipostructure helps in shaping and restoring present and missing fat deposits.
References
1. Owsley J.Q. Face lifting: problems, solutions, and an out- come study. Plast Reconstr Surg 2000; 105:302–313.
2. Moss C.J, Mendelson B.C., Taylor G.I. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000; 105:1475–1490.
3. Baker D. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy. Aesthetic Surg J 2001; Jan/
Feb:68–80.
4. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when per- forming a face lift. Plast Reconstr Surg 1997; 99:10–15.
5. Cardoso de Castro C. Proper incision planning can avoid facelift stigmata. Aesthetic Surg J 2004; Jan/Feb:75–78.
6. Brink R.R. Auricular displacement with rhytidectomy. Plast Reconstr Surg 2001; 108:743–749.
7. Gradinger G.P. The pretragal incision in rhytidectomy.
Aesthetic Surg J 2001; 21:564–568.
8. Stuzin J.M., Baker T.J., Gordon H.L., Baker T.M. Extended SMAS dissection as an approach to midface rejuvenation.
Clin Plast Surg 1995; 22:295–311.
9. Trepsat F. Volumetric face lifting. Plast Reconstr Surg 2001; 108:1358–1370.
10. Baker D. Rhytidectomy with lateral SMASectomy. Facial Plast Surg 2000; 16:209–213.
11. Ellenbogen R, Karlin J.V. Visual criteria for success in restoring the youthful neck. Plast Reconstrc Surg 1980;
66:826–837.
12. Ramirez O.M., Robertson K.M. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg 2001; 17:129–
13. Feldman J.J. Corset platysmaplasty. Clinc Plast Surg 1992; 140.
19:369–382.
14. Singer D.P. Submandibular gland I: an anatomic evalu- ation and surgical approach to submandibular gland re- section for facial rejuvenation. Plast Reconstr Surg 2003;
112:1150–1154.
15. Pompeo de Pina D., Quinta W.D. Aesthetic resection of the submandibular salivary gland. Plast Reconstr Surg 1991; 88:779–787.
16. Little J.A. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg 1999; 105:252–263.
17. Coleman S.R. Facial reconturing with lipostructure. Clin Plast Surg 1997; 24:347–367.
18. Ramon Y., Shoshani O., Peled I.J., Gilhar A., Carmi N., Fodor L., Risin Y., Ullmann Y. Enhancing the take of in- jected adipose tissue by a simple method for concentrating fat cells. Plast Reconstr Surg 2005; 115:197–201.
19. Ellenbogen R, Youn A., Svehlak S., Yamini D. Facial re- shaping using less invasive methods. Aesthetic Surg J 2005; Mar/Apr:144–152.
20. The twins face lift study–10 years later. The Aesthetic Meeting 2005, New Orleans.
