CHAPTER 50
50
culo-aponeurotic system (SMAS) tension, the proce- dures suggested in Chap. 36 are suggested. Depend- ing on preoperative cheek fullness, we perform SMAS plication, simple SMAS flaps, snail SMAS flap, or tricuspidal SMAS flap.
By applying tumescent local anaesthesia with adrenaline and fibrin glue at the end of the procedure, we can avoid the drainage, so 96% of our patients were outpatients. The satisfaction of our patients was high (88%) and no major complications have occurred.
Only three out of 200 patients had to undergo revi- sionary surgery.
The way that people of about 60 years of age par- ticipate in public life has changed radically during the last century. In the past they used to withdraw almost completely from public life. Nowadays they are still fully active, mainly on a private level, but also profes- sionally – consuming the fruits of their life’s efforts.
50.1 Introduction
Looking tired is reason enough for many 35–45-year- olds to ask a plastic surgeon for prophylactic rejuve- nation. They want to achieve good and long-lasting effects with harmonious features, small scars, and – as they are still very active in their professional and private lives – a quick recovery is very important for them. We have developed a modification of the short- scar facelift with solid deep support. We call it the MIDI facelift. MIDI stands for Minimal-Invasive, Deep-Intensive.
The technical details are as follows. Two half Z-plasties are performed at each end of modest skin excision, supraauriculary and retroauriculary, to avoid uneven suture edges. By doing so we achieve very unobtrusive scarring. For solid superficial mus-
MIDI Facelift
Dimitrije E. Panfilov
Fig. 50.1. a Tired look of a 43-year-old patient prior to surgery and b look of same patient 3 months postoperatively
Rejuvenation not only creates the mythological illu- sion of eternal life, it has also become a very impor- tant factor for the quality of life.
The outcomes of facelifts dramatically improved over the last few decades. Many details of anatomical understanding (four levels of acting, volume preser- vation and replacement, endoscopy, various traction vectors, restoration of different mimic units) have replaced simple skin traction – with its unpleasant operated look – with harmonious rejuvenation and stable effects.
It is a general observation that more and more younger people are coming to our offices asking for aesthetic surgery. This phenomenon is also occurring in the field of rejuvenation surgery. Our patients say:
“Why should I wait until I am old and ugly before I do something? Now when I am fully active in life I want to benefit from my attractive appearance. If I look tired, people will not believe I have enough energy and fun for life.”
Fig. 50.2. Markings of incisions, presumed excision, vectors of traction, and superficial nerve branches
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Fig. 50.3. Steps of retroauricular skin advancement and resection
Fig. 50.4. The steps of the minimal-invasive, deep-intensive (MIDI) facelift
Fig. 50.5. The youngest patient was 34 years of age. At this age we cannot rejuvenate somebody much, but can beautify and enhance. a Before b and after MIDI facelift and lip augmenta- tion
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Fig. 50.6. A 40-year-old patient a before b and 1 year later
Fig. 50.7. Our oldest female patient, 51 years of age, a before b 3 months after MIDI facelift
Fig. 50.8. a Presumed skin excision and edgy contour of malar region
“edgee line”. b Four weeks after surgery.
Note very fine scarring and the harmo- nious contour of malar region (“ogee line”)
50.2
Materials and Methods
For our patients around 40 years old, we are looking for procedures that require less effort and may be per- formed on an outpatient basis, have fewer complica- tions, smaller scars, shorter recovery, and stable or prolonged effects. The special request of these pa- tients, as they are fully integrated in active lives, is for short recoveries. Another request of our patients is that they remain themselves. They do not want to change their facial expressions, but simply to achieve more freshness, harmony, and youth, and to get rid of features that look tired and pessimistic. The change should not be obvious to everybody.
First, the skin drawings are made. These include incision lines, dotted lines of presumed excision, vec- tors of traction for the cheeks and neck skin, mark- ings of superficial nerve branches, and midline mark- ing of the throat for symmetry control. All drawings have to be made when the patient is upright.
The skin flap release is by tunnelling with a lipo- suction cannula but without suction, or with the spreading-scissor technique – closed scissors are ad- vanced blindly under the skin and then opened.
Hereby, we stay in the proper layer and we can stretch the nerve branches without cutting them. By dividing the skin flap from the underlying tissue, we release McGregor’s malar ligament and other connecting tis- sue septa up to the front cheek and platysma margin.
The perforator vessels should be preserved at this lev- el to keep the skin flap safe.
The incisions have to divide the half Z-plasty markings, beginning in the supraauricular region and ending in the retroauricular region, as shown in Fig. 50.3. Depending on whether a patient has full cheeks or hollow cheeks, we treat the deep SMAS–pla- tysma layer that has to undergo solid traction.
We first used liposuction of the submental area only occasionally and noticed that it improved skin retraction. We eventually decided to do it regularly, even if there is no fat to be removed, and we continue to do so.
It is very important to harmonize the skin and deep layers after we have played with the different vectors at the key point, 2–5 cm lateral of the lip com- missures. If we neglect to release this adhesion, we will create a case of the “sofa button” phenomenon, with the unpleasant stigma of an operated look.
To make the skin anchorage sutures, the skin flap is first stretched to its maximum point, then released 2–3 mm. There is the motto in aesthetic surgery:
What ever you do, do not overdo.
The supraauricular and retroauricular anchorage sutures are made first. The skin flap is then cut in the direction of the ear lobe. There has to be no tension
on the ear lobe. We then size the skin that will be su- tured retrotragally and put the third anchorage suture upwards of the tragus.
After the anchorage sutures have been placed, fi- brin glue is applied to the skin that is pulled upwards for 3 min. This is good prevention of swelling and bruising, so our facelift patients rarely need drainage anymore. Intradermal sutures complete the wound closure.
We check the midline to test the symmetry. After the right side has been lifted, the midline deviates to the right. When the left side has been completed, it returns into midposition again. The patient wears a head net bandage for 1 day. The patient can be dis- missed from the clinic the same evening or late after- noon. The patient can be picked up or driven by taxi but cannot drive or use a bus or train alone. The next day we remove the bandage. After 6 days, the intra- dermal sutures are removed. The anchorage sutures are removed after 10 days.
50.3 Results
We have treated 200 patients in 4 years with the MIDI facelift method. The satisfaction rate among the pa- tients is promising: high 88%, moderate 11%, low 1%.
We could not observe any major complications; nerve lesions 0%, skin necrosis 0%. Only in two cases of consecutive bleeding and one case of a postoperative salivary cyst did a patient have to undergo surgical revision (Table 50.1).
The latter did not have to be done: the revision of salivary cysts is not necessary. Table 50.2 shows the adjuvant procedures performed. Figures 50.9–50.11 show some results.
There are some aging patients who do not want to undergo “real” operation. For them we offer alterna- tively the following procedures: autologous fat aug- mentation of facial structures like folds, cheeks, malar prominence, lips, and the possibility of combining it with a handlift.
Seventy-five percent of our patients were between 35 and 45 years of age. If they were older than 50 (women) and platysma bands had already developed, the MIDI facelift was not recommended. Rather, the full facelift, with extended retroauricular skin resec- tion and platysmoraphy, was indicated.
With patients younger than 35, we employed the mini lift that only uses preauricular incisions. In the 19 male patients (9.5% of the total) who underwent MIDI facelifts, we observed that the higher upper age limit was 58 years.
The MIDI facelift is a one-stage operation with
short scars, short recovery, and short operative time
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Fig. 50.10. A 45-year old patient a before and b 6 months after volumet- ric MIDI facelift, with cheek and lip enlargement by autologous fat Fig. 50.9. A 38-year old actress a before and b 2 weeks after MIDI facelift and lower blepharoplasty
Table 50.1. Complications in 200 minimal-invasive, deep-in- tensive (MIDI) facelifts
Percentage
2 consecutive bleedings unilateral 1.0 1 postoperative salivary cyst 0.5 12 postoperative unilateral swellings 6.0 8 cases of prolonged wound healing 4.0 2 hypertrophic retroauricular scars 1.0
Table 50.2. Among 200 MIDI facelifts, these additional surger- ies were done on request
Percentage
8 endoforehead lifts 4.0
35 blepharoplasties 17.5
9 rhinoplasties 4.5
18 partial peels (forehead or lips) 9.0
23 lip augmentations 11.5
42 double-chin liposuction 21.0
3 chin implants 1.5
(90 min on average), which allows outpatient treat- ment and combination with other aesthetic proce- dures.
Modern rejuvenation procedures combine differ- ent methods, creating better and longer-lasting re- sults and with less aggressive surgery than the singu- lar methods. Less aggressive surgery has fewer com- plications, which translates into great safety for both the patient and the surgeon.
The MIDI facelift is easily taught and easily learned (prerequisites are anatomical knowledge and opera-
tive skills). It shows no major complications and serves to the satisfaction of the patient. In four words we can say it is easy, simple, effective, safe.
Bibliography
Please see the general bibliography at the end of this book.
Fig. 50.11. a Before surgery. b Dermographic markings and c 6 weeks after MIDI facelift, upper and lower blepharoplasty, auto- logous fat transfer, and reductive rhinoplasty of a 50-year-old patient
